Events that took place this past holiday season have set me to thinking not just about the awful nexus that takes place when illness, addictive drugs, and the American medical system meet, but also about the nature of observation-based (as opposed to controlled-study-based) science and the relationship between the practice of this science and the giant corporations that have an interest in this practice. In short, I’ve been thinking about how failures in the world of medicine look very similar to failures in the world of finance.
What happens in an environment where data is important, but its interpretation is necessarily imprecise, and there are corporations whose goal is to profit off of any structural weaknesses in the methods used to interpret the data? The combination of weak antitrust enforcement that has placed immense power in the hands of a very small number of corporations and a corporate focus on shareholder value rather than stakeholder value means that there simply aren’t that many influential corporations left whose core business strategy is to serve those who buy their products to the best of the corporation’s ability.
In finance this means that clients are often treated as “the mark”, and client losses are justified by those who generate them on the Darwinian principle that good things will happen when dumb or uneducated people lose money. Financiers know that the nature of the data ensures that they can almost always come up for some kind of an explanation for why the product they use to garner some “dumb money” is in some way beneficial and should not be banned. (e.g. “in an efficient market, only people who need product X will buy product X, so we don’t need to worry about the losses of the “dumb money,” which exists to make the market more efficient.”) The tools of the academics are used, not for the purpose for which they were invented, but to make the world a worse place to live in.
Unfortunately I’m beginning to suspect that our drug companies function on the same principles as the financial industry. It seems to me that doctors have been trained not to listen too closely to patient complaints about side effects. Now there are probably good reasons for this: if the doctor is conservative about prescribing medicine so that you really need the medicine when you get it, then the side effects will need to be quite severe in order for them to outweigh the need for the medication. And it is true that doctors almost certainly receive many complaints about perceived side effects that are in fact due to other causes. In short, doctors have a very hard job.
It seems to me that pharmaceutical have turned the challenge of medicine into a profit opportunity through two mechanisms. First, they work aggressively to get doctors to prescribe their medications for minor ailments that could be addressed through over-the-counter or non-pharmaceutical means. When the pharmaceutical companies are successful, doctors end up prescribing drugs that are net “bads” for their patients, and frequently choose to address side effects not by taking the patient off the medication, but by prescribing another medication to address the side effect. A patient with a minor complaint can end up on a cocktail of drugs that causes far more damage to the patient’s health than the minor complaint itself. Who has not heard a doctor state when the patient questions whether her growing health problems are not in fact being caused by the cocktail of medication that “It’s not cause and effect,” pooh-poohing the patient’s concerns? While there are certainly very good doctors out there (and I recommend that you seek them out), the medical profession has done far too little to offset the nefarious influence of drug company incentives.
Secondly, it appears that drug companies have learned that addictive drugs are some of the most profitable. In my view this is likely to be due to the fact that these drugs often have the side effect of causing the malady they are prescribed to cure. That is, once you have become addicted to the drug, trying to get of the med will often cause you to experience the illness that you took it to address — but even worse than before you took it. It’s not unusual for patients to get into a pattern where the doctor keeps prescribing higher and higher doses of these medications and that the patient ends up facing very strong disincentives to go off the medicine. A profit-maximizing pharmaceutical company will likely prefer to develop this type of medicine than a medicine that can treat the ailment, but that is non-addictive. That is, the profit motive is very much adverse to what is in patients’ best interests. When you add to this dynamic the tendency of many doctors to pooh-pooh patient concerns about side-effects and in particular concerns that the medication may be worsening the condition (“It’s not cause and effect. Your symptoms are probably just the progression of your ailment.”), it hardly surprising that the way these medications are being used is often toxic.
Overall, when I hear complaints about how too much of the public doesn’t believe in science anymore, I can’t help wondering: Well, what is their experience of how science is applied in the modern world?