Friday, August 5, 2016

Phishing for phools

Doctors, I fear, are positioned to be the most powerful phishers in that they are dealing with things that matter hugely (life, death, disease, pain, birth) and with customers almost all of whom are phools in that it’s almost impossible for them to know whether the doctors are being truthful about their offering. And there’s no better place to phish than with the dying; that deep instinct to stay alive distorts people’s decision making more than any other psychological flaw.

I thought here of how Seamus O’Mahony in his marvellous book The Way We Die Now tells two stories of phools being phished, and these two phools were extremely clever people: Christopher Hitchens and Susan Sontag.

Hitchens was a highly successful writer and iconoclast, who had dared even to debunk Mother Theresa. O’Mahony describes him as being in “the premier league of celebrity atheist intellectuals.” As he drank and smoked heavily it wasn’t surprising when he was diagnosed with stage IV oesophageal cancer. Yet the great debunker was a phool when it came to what medicine could offer. He was, writes O’Mahony, “childlike in his enthusiasm for American oncology.” He pursued an “immunotherapy protocol,” the possibility of having a whole new oesophagus created from “tissue engineering,” and having his genome and his tumour sequenced. A correspondent advised that he have himself frozen for when a magic bullet became available. Neither he, his wife, nor his great friend the writer Martin Amis seemed to know that death was imminent, all thinking he would live for years when months are usual. He didn’t last for years.

Sontag, a great American intellectual and author of Illness as Metaphor, had survived two cancers before she developed myelodysplastic syndrome. A non-phishing doctor told her nothing could be done, but two others offered a bone marrow transplant even though they must have known the chances of success in a 71 year old were minuscule. The original doctor was savaged by Sontag—rather as a company refusing to play on human weakness loses business to one that will. Sontag wouldn’t accept that she was dying, and her son described in a book after her death his grief at never being able to have a proper conversation with her about what was happening.

These were two powerful phools who desperately wanted to be phished, and as such are perhaps like the phools who buy cigarettes and excessive amounts of alcohol even though they know they will be harmed. The phishers here weren’t fishing for money, and doctors—like politicians—are not mostly phishing for immediate rewards of money, although in a fee for service health system they may be. They are phishing to build up the reputations of themselves and their specialty—or for the sheer joy and satisfaction of phishing rather as fishermen do. In the long term, of course, they do build up their incomes—because we need more oncologists and cancer researchers.

We know that doctors as a profession and as individuals overpromise, overdiagnose, and overtreat. This, I suggest, is phishing no different from the phishing of the banks who caused the financial crisis. Ironically, the suffering caused by the phishing of doctors is less visible as it happens individual by individual, although the cumulative effect (with the ever climbing proportions of GDP devoted to healthcare) is to crowd out other activities and eventually to bankrupt the states or businesses that pay for healthcare.

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