The Hubris of Man
Instapundit directs me to this report advising which patients should be given care in the event of a massive pandemic where medical resources must be conserved. I want you to think about this for a second because this is the same kind of reasoning we see in global warming.
A groups of experts, who have no actual experience working in a massive pandemic flu, have posited a set of outcomes, developed a set of guidelines for operation in those hypothetical outcomes, and then argue these guidelines should be applied to all hospitals that serve the 300 million or so people of this country. Can you imagine the kind of pride it takes to earnestly make these suggestions.
First, these so-called experts have no actual experience with a national or global pandemic. It’s simply assumed they do because their ‘expertise’ in some field appears to have some vague association with determining hospital policy during a catastrophe. However, given the fact that not a single one of them have ever actually been in a national or global pandemic, its hard to really see how their current expertise, whatever that may be, is more useful in foreseeing the events of such a pandemic, or that they would have more insight in setting policy then just a typical mix of people forced into that situation.
Its bad that these experts are riding on the coat tails of an association between their expertise and a perception that they are qualified prognostications, but then they suggest guidelines in which the entire medical system should be behave in this situation. Instead of taking a position that each facility should set it’s own policy so as to adapt to the conditions it finds itself in, these ‘experts’ wish to apply a set of rubrics that all facilities across the whole country, if not the world should follow. Its in this suggestion that their hubris becomes manifest. It’s one thing to shoot the shit with your colleagues about how the medical system will behave in a pandemic, but an entirely different thing when you actually argue for setting policy based on your prognostications. These experts think their conjecture is so likely to be true, that it’s best to advise how thousands upon thousand of medical facilities should respond to some future catastrophe.
It’s even worse than that. These same experts believe that the application of their rubrics will result in a better outcome than the collective action of all the medical professionals in the actual pandemic adapting their decisions to match the context of the local community. These experts are suggesting a command economy approach to managing a pandemic will be superior to a free market approach. History has really shown that to be true.
These experts know what no one can possibly know and believe their rubrics will be superior to managing the pandemic then medical professionals that develop an intimate understanding of of the catastrophe and adapt as context demands. Such belief is the very definition of hubris.
May 5th, 2008 at 11:46 am
It’s almost as if nobody alive today has experience in dealing with a worldwide flu pandemic, and these doctors are simply trying their best to plan for such a disaster.
May 5th, 2008 at 12:54 pm
“History as really shown that to be true”
I suspect you meant _rarely_…
May 5th, 2008 at 2:18 pm
Um, did you bother to read the suggestions? Because they’re spot on.
If such an event hits, yes individual doctors will have to make decisions on the spot. So, how many doctors do you think will have thought about all this before hand? How many hospitals will have piece of shit lawyers nattering about anti-discrimination laws, and how the physicians must do these stupid things because “the law requires it”? And when that happens, do we want the doctors to be able to say “hey, it’s real world time, now, not fantasy lawyer time, so STFU and get out of my face, I’ve got work to do”? I do.
And they’re more likely to be able to do that thanks to this report.
May 5th, 2008 at 2:58 pm
I just want to posit that the analogy to GW would be more apt of they said “A disaster will happen in the future, we’re sure of it, so lets ration care based on these standards right now”.
Now, I think it’s unfair to chastise them for lack of experience, b/c, well, who really does have that experience? You go to the experts you have, not the ones you want.
I should add that I think the guidelines are a bit silly though, as they really need to be formed ad hoc when hospitals know what they’re dealing with and what resources they have. I think these guidelines are more just to provide ass-covering in the event of a catastrophe, so nobody (at the time) has to take direct responsiblity for making the damned-if-you-do-damned-if-you-don’t decisions.
May 5th, 2008 at 4:24 pm
Steve, you’re making to much out of this. It seems like pretty basic triage to me, and I’m sure that if the shit really does hit the fan, doctors and nurses will do everything they can to save as many people as possible.
May 5th, 2008 at 5:45 pm
I’m surprised so many commenters have such touching faith in bureaucracy. That scares me more than the machine-like triage prescriptions.
Consider:
If these were to become policy (so thinking was no longer necessary or even encouraged), they would be likely to be rigidly followed throughout the country even though the pandemic would be unlikely to be the same all over. Think not? Look at airport security.
This also seems like a great way for the eugenicists to get what they want without having to do the political persuading they would otherwise have to do. Yes- there probably will be a pandemic one of these days. When it happens, we can, for example, fix the social security system by eliminating all those expensive baby boomers. What a silver lining in that black cloud!
When I see more effort and money going into avoiding the “sooner or later” pandemic than in eagerly deciding who to off when it happens, I’ll start thinking about trusting these bastards.
May 5th, 2008 at 6:48 pm
This from the guy that supports the current war under the notion that a “failure to act” could result in more terrorism in the future.
May 5th, 2008 at 7:07 pm
The problem with adopting a slate of “suggestions” is that they add, rather than subtract, uncaring bureaucratic middle-men to the gut-wrenching decision doctors would have to make as to whom to let die.
The real way to “solve” this unsolvable problem would be to allow doctors to make their own decisions to allocate their imperfect time and resources as they think will best help.
In other words, re-legalize medical imperfection and put the ambulance chasers out of business for the duration of the emergency. Declare non-malicious medical malpractice null/void and suspend guidelines that restrain doctors from making hard decisions while the State of Emergency is in effect.
May 5th, 2008 at 7:57 pm
Sorry, you can’t/shouldn’t adopt a free market approach during a pandemic.
Asha Devereaux does have some experience with this. We ran into this problem on a small scale in san diego during a flu outbreak. At that time the local hospitals were running out of ventilators, so they asked the Navy to help out. We emptied the ships of their ventilators to give to the civilian hospitals. This paper is an attempt to decide where those assets will go in an emergency.
It is silly to imagine that all the hospitals will just function autonomously and give the best possible care. In that situation perhaps you have an inner city hospital full of little dying children, and a large suburban one full of eighty year old demented patients getting all of the additional assets.
There may be no world experts on pandemics with real-life experience, but I can tell you these particular experts know more about it than you do.
May 5th, 2008 at 8:35 pm
“He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.”
This is reasonable in principle, but ironically, the 20th century pandemic that caused the most deaths/year (Spanish Flu) killed off many healthy young people (see graph). Clearly, the variability of one epidemic to another call into question estimates of patient survivability that cannot take into account particulars of disease. Hopefully they would adapt the recommendations to individual diseases.
http://upload.wikimedia.org/wikipedia/en/7/70/W_curve.png
Despite that, I think you are on very, very shaky ground trying to suggest that command economy approaches are historically less effective at managing pandemics. In the case of the influenza epidemic for example, the Japanese government instituted a variety of policies including severe restrictions on maritime travel that reduced the total mortality rate below .5%, much less than other Asian countries, and a lower death rate than that suffered in New Yorkers in a single week during the peak of the epidemic.
That said, I’m uncomfortable with the specific suggestion of putting a panel of three people in charge of these decisions. Inevitably, they are going to protect their friends because they are human, and they might even be subject to threats and intimidation at the hands of people trying to bump family members onto ‘the list’.
Broadly, my position is that some government policies for crisis management are good and some are bad. This particular example might fall into the latter category, but you are going way too far when you suggest that large-scale organization is always less effective than an ad lib approach of letting each medical practitioner do their own thing.
For free-market competition to work, the less competitive producers have to suffer reduced market share. In the context of a pandemic outbreak, I really don’t see that happening fast enough.
By the way Steve, what do you think of the government using coercion to protect licensed medical doctors from free-market competition at the hands of unlicensed quacks?
May 5th, 2008 at 9:53 pm
Triage is a time-tested thing in the military which is used because it works. It helps the largest number of people with the minimum waste of valuable resources (and in a medical emergency time is often the most important resource). I’m willing to bet that any hospital in a medium or large city has a plan for care in a mass casualty emergency. And that plan likely includes leaving people to die so that others can be cared for. That a panel has put forth a plan that brings these ugly, but necessary, steps to light doesn’t mean it’s not a good idea to be thinking ahead for it.
May 6th, 2008 at 9:21 am
So, are you being disingenuous and pretending to be this stupid in order to bootstrap a wholly-unearned slap against climate-change skeptics, or are you just that ignorant?
Pandemic planning is incommensurate with the GW alarmists’ Laputan plans for aerial castellation. Pandemics have happened in the past, minor epidemic outbreaks occur on a reasonably frequent basis to allow extrapolation from experience, and epidemic dynamics are simple enough to allow modelling of a certain degree of accuracy. None of those are true of the alleged climate change crisis.
May 6th, 2008 at 3:29 pm
The main issue here isn’t equality and it isn’t god-like power to a select few, it’s just a numbers game – maximize the number of lives saved. Several people have already stated this. Hard decisions need to be made when there isn’t enough supply for the demand. I think the recommendations outlined here would be in line with what most medical professionals would suggest. Having a committee to back them up on these necessary and difficult decisions will allow the physicians to do their job quickly and effectually without unnecessary guilt or debilitating emotion. Having these guidelines standardized among hospitals would also allow the hospitals to work as a cohesive unit without deteriorating into chaos in the face of disaster. When you let emotion and the personal prejudice and ethics of individual doctors rule who lives and who dies - then you have disorder and mistakes are made. In addition, I think the idea that this would become policy is just ludicrous. They already stated in the article that these are merely guidelines and hospitals are welcome to redesign the rubric to better suit their individual needs. These men were faced with the very difficult job of objectively evaluating what would by an interpretation be a highly emotional and devastating disaster. They made the hard choices so that others don’t have to. I can do nothing but commend them. They are not forcing their recommendations on anyone and have taken the weight of guilt and emotional entanglement off the shoulders of those that will need to keep their heads if and when a disaster should ever occur.