On Priority-Setting in Mental Health Research

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Bill Gardner over at The Incidental Economist has a thoughtful post on a NY Times op-ed that appeared last Friday.  The op-ed pointed out that for all of our considerable investment in basic neuroscience, we have not gained many significant clinical psychiatric interventions over the past 20 years.

Gardner points out that there are a number of evidence-based psychotherapeutic interventions, and concludes that “the National Institute of Mental Health (NIMH) should be funding more research on psychotherapy!” But, he cautions, it does not follow that we should reduce funding for neuroscience research:

The brain is the most important yet least understood organ in the body. Eventually, we will understand the brain. When that day comes, that understanding will be transformative.

Now, given that one of my central areas of scholarship within public health ethics is on priority-setting, I found myself wondering if we can really avoid difficult allocative decisions simply by increasing absolute levels of funding.  So, I asked Bill on Twitter, what happens if we cannot do the latter? What if we have to make a decision regarding whether to reduce funding levels for basic neuroscience in order to increase funding levels for psychotherapy research? Which is our priority, and why?

Bill replied:

Believe it or not, I was actually not trying to be cheeky here! These kinds of questions are literally core to my research.  Of course, as I argue in lots of places, we want to avoid the false choice fallacy.  That is, we do not need to do either A or B or Q.  We can pursue all of them.  But, as I responded to Bill:

We can do lots of different things, but given scarce resources, we cannot do them all at the same level of investment.  Even if we were to increase the size of the pot for research, we would still be faced with the same kinds of allocative questions: should funding for basic neuroscience be maintained at the same proportion relative to that allotted for psychotherapy research? Should we change the ratio of funding? Why or why not?

Bill argued that given the constriction of research funding for NIH in general, let alone NIMH, trying to make these kinds of priority-setting assessments would be distorted:

Here, I want to respectfully disagree with Bill.  There is nothing “false” about making difficsouth-park_1ult decisions of priority-setting in times of scarce resources.  Although fighting for the world we want to see is of great moral significance, as I often remark to my students, sometimes we cannot escape difficult moral problems in the here and now.  We are, as they say, in the s*it.

The world we inhabit is one in which we have scarce resources for mental health research.  We are faced with a dilemma as to how best to allocate those resources.  Although we can choose to sponsor research in a variety of areas, we can nevertheless not avoid the question of which area we should invest relatively more or less of our resources.

Finally, as I remarked to Bill, we should also pay heed to the fact that the world we live in is one in which, as Nikolas Rose & Joelle Abi-Rached put it, the neuromolecular gaze dominates (see also Stephen Casper’s wonderful scholarship on the neuro-turn).  As such, even if we were to increase absolute levels of funding, we would have as a sociological matter every reason to suspect that the lion’s share of increased funding would go to basic neuroscience research.  If this is correct, and we have little reason to suspect otherwise given current neuromania, increasing absolute levels of funding would inspire little confidence that we would substantially improve the dearth of resources currently allocated to psychotherapy research.*

Thoughts?

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*James Coyne has argued in many fora that the quality of the evidence base supporting much psychotherapy leaves much to be desired (to put it mildly).  I offer no opinion on that here — indeed, I’m no methodologist so am not really qualified to weigh in on many of the technical issues in this vein — but it is worth noting.

On the Pharmaceuticalization of (Global) Public Health

(In which he emerges from his dogmatic slumber . . . )

Regular blogging is obviously not my thing, but every now and then something arises that I can’t easily discuss in 140 characters on my beloved Twitter, so here we go.

A new article in PLoS Medicine flashed in my Inbox this afternoon, entitled “A Global Biomedical R&D Fund and Mechanism for Innovations of Public Health Importance.”  This really grinds my gears.  Perhaps surprisingly, this irritates me not because I am opposed to establishing a “biomedical R&D fund and mechanism for innovations of public health importance.”  Not at all — if we can find better ways of generating pharmaceutical products for which robust evidence shows important impact on population health especially in emergent public health scenarios, that sounds fine with me.

What is not fine with me is the way in which public and population health continually seems to be captured by biomedical culture and biomedical interventions, the most prominent of which, of course, is pharmaceuticals.  I am referring here to the medicalization of global health policy.  Such is bad for any number of reasons.  First, overwhelming evidence shows that substantial improvements in overall population health and in the compression of existing health inequities (global or otherwise) are extremely unlikely to flow from acute care services, including but not limited to drugs.  There is virtually no question that collective action on upstream, macrosocial determinants of health are vastly more likely to improve overall population health and to compress inequities, which matters because these two criteria are core to any adequate theory of justice in population health.

The concern, as I have written about independently here,* and as Joe Gabriel and I discuss here, is that the frame of the debate about how best to improve global health is cast on the geopolitical scale in terms of how best to ensure access to pharmaceuticals.  To the extent that the frame obscures an unquestionably more important discussion — intervention on fundamental causes of disease — it is ethically suboptimal.

Second, as Vicente Navarro has pointed out, the perpetual tendency to focus myopically on biomedical interventions for social problems — make no mistake, health is a social problem — has actually had the historical tendency to weaken larger public health and social welfare systems, especially in the global South.  The emphasis on magic bullets tends to absorb resources that could be better allocated to interventions that act on structural determinants of health outcomes, on the amelioration of structural violence, etc.  So even, as Navarro points out, as the eradication of smallpox is unquestionably a good thing, it nevertheless resulted in a substantial weakening of larger health and social welfare systems in some of the most resource-poor settings on the planet.  This is Bad.

Biomedical interventions supported by robust evidence of population health impact obviously have a role to play in improving global health, and in responding to acute public health emergencies.  But we are not going to resolve our health problems, nor compress the staggering global inequities in health, via pharmaceuticals.  Social problems rooted in adverse and deeply rooted social structures must be resolved at the level, or not at all.

Thoughts?

*This paper is essentially an article-length exposition of many of the themes of this blog post.

On the Modern Rise of Hedonism: Changing Views Towards Pleasure, Pain & Suffering

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John Yamamoto-Wilson, an early modern historian who has published a recent book on pain and suffering in 17th c. England, has a fascinating blog post examining some of Olivia Weisser’s forthcoming work on pain, suffering, and gender in early modern England (go Wes!).

(Historians of pain are eagerly awaiting Dr. Weisser’s forthcoming book!)

I am interested in Dr. Yamamoto-Wilson’s conclusion, but I do want to first note the posture in which I approach this subject.

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On What is Owed to Whom: History of Medicine as “Moribund” & Enterprise Justification (II) (Comment from Andrew Ruis)

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First, thanks to all readers for engaging the first post in this series.  I think it might already be the most widely-read post in the very short history of this blog.

Andrew Ruis, an historian of medicine and public health at the University of Wisconsin-Madison, left on my post a comment that was so excellent I immediately requester permission to bump it up the post level.  Andrew graciously consented, so here it is, reprinted verbatim, with paragraph breaks added only to ease readability:

“The issue that always floors me with characterizations like Horton’s is that utility is a useful metric for, say, skills, but a poor one for knowledge generation, where utility (beyond statements like “all knowledge is useful”) can only be assessed retrospectively (historically!), to the extent that it can be assessed at all. Research in history of medicine is no different than bench research in biomedicine or any other basic research endeavor, if using utility as yardstick, because no one can predict the future.

I worked for several years at a genomics company where we learned a lot about cancer biology, but whether that knowledge was useful or not was impossible to determine except insofar as knowledge is useful for its own sake. Even evaluating it comparatively–was that knowledge more or less useful than my historical work on children’s nutrition programs?–is impossible to gauge, unless you have some magical Aristotelian formula that assigns precise values to potentiality. Arguments like Horton’s are not about utility per se but about values. He’s basically implying that he (and I think it’s no great stretch to suggest that he purports to represent a far larger group of medical professionals) values biomedical research intrinsically (biomedical = good, for surely he would not declare biomedical research “moribund”), but he values history of medicine only insofar as he can perceive an immediate and obvious use for it (HoM = good iff useful to me right now). That’s not a statement of logic, it’s a statement of belief. What’s worse, it is a shockingly naive view of utility, as if things like epistemological perspective or the way historians frame, investigate, and answer questions isn’t potentially “useful” even if the outcome of any specific research endeavor may not be in some particular context.

The problem, as Carsten, you, and others suggest, is that values, whether well-founded or no, are powerful when shared by people in positions of power. I fully agree with your assessment–that valuation should not be tied to utility–and it seems the most significant challenge historians of medicine face is not convincing medical professionals and the biomedical-industrial complex that we (and our work) are useful but that there is no real way of assessing the utility of our work except, ironically, historically.

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(I may have an additional post on this tomorrow or the day after, engaging some conversation Mark Weatherall and I have been having on the Twitterz).

On What is Owed to Whom: History of Medicine as “Moribund” & Enterprise Justification

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anton_ego_motivation_by_keep_me_posted-d4t0y6vHo hum.  Another day, another person doubting the worth of [insert humanities field here] history.  Most recently, we have Richard Horton, an editor of The Lancet, writing a commentary in which he declares that

Most medical historians, it seems, have nothing to say about important issues of the past as they might relate to the present. They are invisible, inaudible, and, as a result, inconsequential.

*Pauses to note irony of editor of THE LANCET proclaiming the history of medicine moribund*

Horton is not disdainful of the field itself; he is really lamenting a Golden Past, itself a common historiographical narrative:

Medical historians have made critically important contributions to public debates about health, health services, and medical science.

*Pauses again for irony*

Horton goes on to list a number of texts that he thinks provide such a contribution, but opines that

for almost two decades, medical historians have produced little that has provided truly fresh insights into our understanding of health and disease . . . it seems fair to conclude that medical history is a corpus of activity lying moribund on its way to the scholarly mortuary.

Goodness me . . . glad I’m not involved in any corpse animation such endeavors . . .

Carsten Timmermann at Manchester and Simon Chaplin of The Wellcome Library (The Happiest Place on Earth for historians of medicine & public health) issued excellent responses.  Given that Horton professes, at least, to see the value in the history of medicine per se, the most direct response is to declare that the critic’s opinion is mistaken, and point to just a few of the large number of examples of meritorious works.

I endorse these rebuttals wholeheartedly.  But part of me wonders whether engaging on these terms itself cedes too much ground.  That is, Horton’s view of the value of the history of medicine as a field of inquiry is entirely instrumental.  It is of value only to the extent that it provides contributions to ongoing debates about public debates on health, health services, and medical science.  The contrapositive proves the rule, which means that insofar as the history of medicine and public health is not providing such contributions, it lacks value.

Because I do public health law/policy/ethics AND the history of medicine/public health, I spend an inordinate amount of time thinking about the advantages and drawbacks to thinking about the latter fields in this instrumental sense.  I’ve presented on it (slides here; precis here), blogged about it, and discussed it with other historians in person and on social media.  I actually do not think it is as tricky as it seems.

The only problem with reductionism is that it is reductionist.  What I mean is that the problem with saying that the history of medicine/public health is valuable because of the light it sheds on contemporary issues in health and medicine is absolutely not that the proposition is false.  It is most assuredly true.  As Drs. Timmermann and Chaplin note, there are no shortage of outstanding recent works in the field that are indisputably relevant to public conversations in health and medicine.

But what if there weren’t?

That is, let us assume for the moment that a key premise of Horton’s critique is true, that it accurately reflects the state of the world — that, in point of fact, there have been precisely no recent works in the history of medicine and public health that can inform contemporary public conversations on health and medicine.

Horton’s conclusion — that the fields are moribund — would nevertheless be invalid.  It does not follow even if we grant his factual premise.  This is because of the central unstated premise in Horton’s position: that history, or at least, certain subfields, is of value only insofar as it is useful in illuminating contemporary problems.

I think we should reject this premise with extreme prejudice.  We ought to study history — or anything else for that matter — because it is of inherent worth, because understanding how things happened, how people acted, and what may have motivated them is inherently valuable.  As I have remarked, reducing history to its (very real) instrumental value is enough to bring Clio’s wrath down upon all of our heads . . .

What I’m interested in here is the idea of enterprise justification.  That is, Horton, and critics like him, are not, IMO, simply asking for an accounting of the value of the field.  Such is relatively easy to provide, although in saying as such I do not mean for a moment to denigrate the time and energy expended by those noble souls who deliver such.  Rather, I think what the critics are seeking is a justification for the entire enterprise.  It reminds me of the rasha, the “wicked” son in the emblematic Passover story of The Four Sons:

The Haggadah explains that the “wicked” son looks around at all of the participants engaged in telling their stories, relating their shared history, and says, “What does all of this mean to YOU?” The Haggadah instructs that by phrasing the question this way, he has excluded himself from the community of storytellers.  He is, in essence, challenging the justification for the entire enterprise.

I guess the point — there’s a point! — of all of this is to suggest that while responding to critics like Horton by detailing some of the outstanding works that do in fact have great relevance for contemporary discussions of health and medicine is — while important and worthwhile — to some extent still playing in the critic’s dojo.  At the same time the challenge is and should be met on the critic’s terms, I think it is also important to destabilize the assumed framework for the contest: the justification for studying the history of medicine and public health is not (exclusively) the insights it provides for contemporary policy and practice.

Even where we historians of medicine & public health ought to highlight and lionize the significance of those insights, history ought never be reduced to its instrumental value.

Thoughts?

A Short Critique of Narrative Medicine

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From Joanna Bourke’s stunning new book on the history of pain (p. 269):

But the narrative medicine that is promoted by many concerned commentators in the medical humanities is also infused with a particular class-based ideology that assumes the speech and writing is redemptive.  Like the ‘men of feeling’ of the eighteenth century, linking sympathy with narrative medicine was and is highly dependent upon the statements by articulate and often elite patients.

Discuss.

 

On “Managing” Conflicts of Interest: A Response to Aaron Carroll

Over at the best health care policy blog around, The Incidental Economist, the fabulous Aaron Carroll has a post arguing in favor of an approach to conflicts of interest that focuses on managing such conflicts (rather than seeking to eliminate them).

I have enormous respect for Dr. Carroll, but I’d like to examine his points and offer some alternative perspectives.

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On The Risks & Benefits of Participation in HS Football — Reading the Case in “Virtual Mentor”

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For those unaware of it, Virtual Mentor is the American Medical Association’s green open-access medical ethics journal.  IMO, it is quite good, and it has an extensive library of cases with expert commentary that is extremely helpful in teaching ethics in medical and health professional education.

The July 2014 issue addresses the theme of Ethical Issues in the Physician-Patient Relationship, and includes a case entitled Evaluating the Risks and Benefits of Participation in High-School Football.  Commentary is provided by Michael J. O’Brien & William P. Meehan III.

The case involves 15-year-old Jesse, who wants to play high school football.

Jesse’s mother speaks up. “I’ve read that they’ve started placing sensors in players’ helmets, and they show that a lot of these boys are taking pretty hard hits. They say that concussions are actually more harmful than we knew about back in our day, and that over time all these head injuries could really cause damage to the brain. I’m worried, because Jesse’s already had one or two concussions in the past. Should we really let Jesse play football?”

Jesse’s father does not seem to share his wife’s concern:

Jesse’s father shakes his head and interjects: “Jesse’s brothers played high school football, and they got banged up pretty bad, but they’re fine. One of them has a scholarship to a good university, and he’s still playing football. I played the game myself when I was in school and it taught me a lot of important life skills—skills that served me as a unit leader in the Army and that I still use in running my business. I want Jesse to have the chance to play on a team and learn the value of sportsmanship. More important, I don’t want him hanging around after school with these other kids who are doing drugs and getting into trouble.”

The case and the analysis are detailed, thoughtful, and well-worth reading.  Naturally, I disagree with the reasoning and the conclusion completely, so let’s take a look.

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Some Preliminary Thoughts on the Revised NFL Concussion Litigation Settlement

The parties to the class action NFL concussion litigation filed a revised settlement proposal in the Federal District Court for the Eastern District of Pennsylvania.  Recall that in January, the Court ordered the parties back to the settlement drawing board, largely over concerns that the proposed $765 million cap on awards was simply too little to cover the costs and damages incurred by players suffering from neurological disease over decades.

I cannot seem to locate a copy of the revised settlement proposal; I do not have access to PACER and cannot seem to find it on the E.D. Pa web site.  But I’ll offer some quick preliminary thoughts here on the major changes to the settlement as is being reported in the media.  I’ll try to come back around and update the post if and when I am able to read the entire proposal.

(Bear in mind, I am fortunate to have practiced some mass tort litigation for a few years — on the defense side only — so while it has been some time, and while I was never an expert, I have a bit of a window into some of tactical and strategic issues at play in mass tort settlement negotiations).

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Some Preliminary Thoughts on Merlin Chowkwanyun’s Response (“The Taxonomy Fetish”)

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Merlin Chowkwanyun has a fantastic post responding to a guest post of mine at the U.S. Intellectual History Blog.  My post is entitled Diagnosis – Intellectual Historian, and Merlin’s response is entitled The Taxonomy Fetish: Another View on the Intellectual History in the History of Medicine and Public Health.

I have so much respect and admiration for Merlin’s work, that if he thinks I am way off about something, I am generally tempted simply to express thanks and take the correction.  This sounds gratuitous, but I am absolutely serious.  And indeed, I do generally take the ultimate point regarding the dangers of fetishizing taxonomy.  Along the way, however, I do have some items of disagreement that might be worth noting in the interests of continuing a fascinating and productive exchange.

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