Tag: medicine

A Lesson in Credulity

Last week I made a claim that, on review, might be untrue. This was bound to happen sooner or later. I do research these posts, but except for the posts where I actually include a bibliography, I’m not fact checking every statement I make. 


One of the dangers of being smart, of being told that you’re smart, and of repeatedly getting good grades or otherwise being vindicated on matters of intelligence, is that it can lead to a sense of complacency. I’m usually right, I think to myself, and when I think I know a fact, it’s often true, so unless I have some reason to suspect I’m wrong, I don’t generally check. For example, take the statement: there are more people that voted for republicans in the last election living to the south of me than to the north. 

I am almost certain this is true, even without checking. I would probably bet money on it. I live north of New York City, so there aren’t even that many people north of me, let alone republican voters. It’s objectively possible that I’m wrong. I might be missing some piece of information, like a large population of absentee Republicans in Canada, or the state of Alaska. Or I might simply be mistaken. Maybe the map I’m picturing in my head misrepresents how far north I am compared to other northern border states like North Dakota, Michigan, and Wisconsin. But I’m pretty sure I’m still right here, and until I started second guessing myself for the sake of argument, I would have confidently asserted that statement as fact, and even staked a sizable sum on it. 

Last week I made the following claim: Plenty of studies in the medical field have exalted medical identification as a simple, cost-effective means of promoting patient safety. 

I figured that this had to be true. After all, doctors recommend wearing medical identification almost universally. It’s one of those things, like brushing your teeth, or eating your vegetables that’s such common advice that we assume it to be proven truth. After all, if there wasn’t some compelling study to show it to be worthwhile, why would doctors continue to breath down the necks of patients? Why would patients themselves put up with it? Why would insurance companies, which are some of the most ruthlessly skeptical entities in existence, especially when it comes to paying for preventative measures, shell out for medical identification unless it was already demonstrated to be a good deal in the long run?

Turns out I may have overestimated science and economics here. Because in writing my paper, I searched for that definitive overarching study or meta analysis that conclusively proved that medical identification had a measurable positive impact. I searched broadly on google, and also through the EBSCO search engine, which my trusty research librarian told me was the best agglomeration of scientific and academic literature tuition can buy. I went through papers from NIH immunohematolgy researchers to the Army Medical Corps; from clinics in the Canadian high arctic to the developing regions of Southeast Asia. I read through translations of papers originally published in French and Chinese, in the most prestigious journals of their home countries. And I found no conclusive answers.

 There was plenty of circumstantial evidence. Every paper I found supported the use of medical identification. Most papers I found were actually about other issues, and merely alluded to medical identification by describing how they used it in their own protocols. In most clinics, it’s now an automatic part of the checklist to refer newly diagnosed patients to wear medical identification; almost always through the MedicAlert Foundation.

The two papers I found that addressed the issue head on were a Canadian study about children wearing MedicAlert bracelets being bullied, and a paper in an emergency services journal about differing standards in medical identification. Both of these studies, though, seemed to skirt around the quantifiable efficacy of medical identification and were more interested in the tangential effects.

There was a third paper that dealt more directly as well, but there was something fishy about it. The title was “MedicAlert: Speaking for Patients When They Can’t”, and the language and graphics were suspiciously similar to the advertising used by the MedicAlert Foundation website. By the time I had gotten to this point, I was already running late with my paper. EBSCO listed the paper as “peer reviewed”, which my trusty research librarian said meant it was credible (or at least, credible enough), and it basically said exactly the things that I needed a source for, so I included it in my bibliography. But looking back, I’m worried that I’ve fallen into the Citogenesis trap, just  this time with a private entity rather than Wikipedia.
The conspiracy theorist in me wants to jump to the conclusion that I’ve uncovered a massive ruse; that the MedicAlert Foundation has created and perpetuated a myth about the efficacy of their services, and the sheeple of the medical-industrial complex are unwitting collaborators. Something something database with our medical records something something hail hydra. This pretty blatantly fails Occam’s Razor, so I’m inclined to write it off. The most likely scenario here is that there is a study lying around that I simply missed in my search, and it’s so old and foundational that later research has just accepted it as common knowledge. Or maybe it was buried deep in the bibliographies of other papers I read, and I just missed it. 

Still, the fact that I didn’t find this study when explicitly looking for it raises questions. Which leads me to the next most likely scenario: I have found a rare spot of massive oversight in the medical scientific community. After all, the idea that wearing medical identification is helpful in an emergency situation is common sense, bordering on self-evident. And there’s no shortage of anecdotes from paramedics and ER doctors that medical identification can help save lives. Even in the literature, while I can’t find an overview, there are several individual case studies. It’s not difficult to imagine that doctors have simply taken medical identification as a logical given, and gone ahead and implemented it into their protocols.

In that case, it would make sense that MedicAlert would jump on the bandwagon. If anything, having a single standard makes the process more rigorous. I’m a little skeptical that insurance companies just went along with it; it’s not like common sense has ever stopped them from penny-pinching before. But who knows, maybe this is the one time they took doctors at their word. Maybe, through some common consensus, this has just become a massive blind spot for research. After all, I only noticed it when I was looking into something tangential to it. 
So where does this leave us? If the data is really out there somewhere, then the only problem is that I need a better search engine. If this is part of a blind spot, if the research has never been done and everyone has just accepted it as common sense, then it needs to be put in the queue for an overarching study. Not that I expect that such a study won’t find a correlation between wearing medical identification and better health outcomes. After all, it’s common sense. But we can do better than just acting on common sense and gut instincts. We have to do better if we want to advance as a species.

The other reason why we need to have hard, verifiable numbers with regards to efficacy, besides the possibility we might discover our assumptions were wrong, is to have a way to justify the trade off. My whole paper has been about trying to prove the trade off a person makes when deciding to wear medical identification, in terms of stigma, self perception, and comfort. We often brush this off as being immaterial. And maybe it is. Maybe, next to an overwhelming consensus of evidence showing a large and measurable positive impact on health outcomes, some minor discomfort wearing a bracelet for life is easily outweighed. 

Then again, what if the positive impact is fairly minor? If the statistical difference amounts only to, let’s say, a few extra hours life expectancy, is that worth a lifetime of having everyone know that you’re disabled wherever you go? People I know would disagree on this matter. But until we can say definitively the medical impact on the one hand, we can’t justify it against the social impact on the other. We can’t have a real debate based on folk wisdom versus anecdotes. 

On Hippocratic Oaths

I’ve been thinking about the Hippocratic Oath this week. This came up while wandering around campus during downtime, when I encountered a mural showing a group of nurses posing heroically, amid a collage of vaguely related items, between old timey nurse recruitment posters. In the background, the words of the Hippocratic Oath were typed behind the larger than life figures. I imagine they took cues from military posters that occasionally do similar things with oaths of enlistment. 

I took special note of this, because strictly speaking, the Hippocratic Oath isn’t meant for nurses. It could arguably apply to paramedics or EMTs, since, epistemologically at least, a paramedic is a watered down doctor, the first ambulances being an extension of the military hospitals and hence under the aegis of surgeons and doctors rather than nurses. But that kind of pedantic argument not only ignores actual modern day training requirements, since in most jurisdictions the requirements for nurses are more stringent than EMTs and at least as stringent as paramedics, but shortchanges nurses, a group to whom I owe an enormous gratitude and for whom I hold an immense respect. 

Besides which, whether or not the Hippocratic Oath – or rather, since the oath recorded by Hippocrates himself is recognized as being outdated, and has been almost universally superseded by more modern oaths – is necessarily binding to nurses, it is hard to argue that the basic principles aren’t applicable. Whether or not modern nurses have at their disposal the same curative tools as their doctorate-holding counterparts, they still play an enormous role in patient outcomes. In fact, by some scientific estimates, the quality of nursing staff may actually matter more than the actions undertaken by doctors. 

Moreover, all of the ethical considerations still apply. Perhaps most obviously, respect for patients and patient confidentiality. After all, how politely the doctor treats you in their ten minutes of rounds isn’t going to outweigh your direct overseers for the rest of the day. And as far as confidentiality, whom are you more concerned about gossiping: the nerd who reads your charts and writes out your prescription, or the nurse who’s in your room, undressing you to inject the drugs into the subcutaneous tissue where the sun doesn’t shine? 

So I don’t actually mind if nurses are taking the Hippocratic Oath, whether or not it historically applies. But that’s not why it’s been rattling around my mind the last week. 

See, my final paper in sociology is approaching. Actually, it’s been approaching; at this point the paper is waiting impatiently at the door to be let in. My present thinking is that I will follow the suggestion laid down in the syllabus and create a survey for my paper. My current topic regards medical identification. Plenty of studies in the medical field have exalted medical identification as a simple, cost-effective means of promoting patient safety. But compelling people to wear something that identifies them as being part of a historically oppressed minority group has serious implications that I think are being overlooked when we treat people who refuse to wear medical identification in the same group as people who refuse to get vaccinated, or take prescribed medication.

What I want to find out in my survey is why people who don’t wear medical identification choose not to. But to really prove (or disprove, as the case may be, since a proper scientific approach demands that possibility) my point, I need to get at the sensitive matters at the heart of this issue: medical issues and minority status. This involves a lot of sensitive topics, and consequently gathering data on it means collecting potentially sensitive information. 

This leaves me in an interesting position. The fact that I am doing this for a class at an accredited academic institution gives me credibility, if more-so with the lay public than among those who know enough about modern science to realize that I have no real earned credentials. But the point remains, if I posted online that I was conducting a survey for my institution, which falls within a stretched interpretation of the truth, I could probably get many people to disclose otherwise confidential information to me. 

Since I have never taken an oath, and have essentially no oversight in the execution n if this survey, other than the bare minimum privacy safeguards required by the FCC in my use of the internet, which I can satisfy through a simple checkbox in the United States. If I were so inclined, I could take this information entrusted to me, and either sell it, or use it for personal gain. I couldn’t deliberately target individual subjects, more because that would be criminal harassment than because of any breach of trust. But I might be able to get away with posting it online and letting the internet wreak what havoc it will. This would be grossly unethical and bordering on illegal, but I could probably get away with it. 

I would never do that, of course. Besides being wrong on so many different counts, including betraying the trust of my friends, my community, and my university, it would undermine trust in the academic and scientific communities, at a time where they have come under political attack by those who have a vested interest in discrediting truth. And as a person waiting on a breakthrough cure that will allow me to once again be a fully functional human being, I have a vested interest in supporting these institutions. But I could do it, without breaking any laws, or oaths.

Would an oath stop me? If, at the beginning of my sociology class, I had stood alongside my fellow students, with my hand on the Bible I received in scripture class, in which I have sought comfort and wisdom in dark hours, and swore an oath like the Hippocratic one or its modern equivalents to adhere to ethical best practices and keep to my responsibilities as a student and scientist, albeit of sociology rather than one of the more sciency sciences, would that stop me if I had already decided to sell out my friends?

I actually can’t say with confidence. I’m inclined to say it would, but this is coming from the version of me that wouldn’t do that anyway. The version of me that would cross that line is probably closer to my early-teenage self, whom my modern self has come to regard with a mixture of shame and contempt, who essentially believed that promises were made to be broken. I can’t say for sure what this version of myself would have done. He shared a lot of my respect for science and protocol, and there’s a chance he might’ve been really into the whole oath vibe. So it could’ve worked. On the other hand, it he thought he would’ve gained more than he had to lose, I can imagine how he would’ve justified it to himself. 

Of course, the question of the Hippocratic oath isn’t really about the individual that takes it, so much as it is the society around it. It’s not even so much about how the society enforces oaths and punished oath-breakers. With the exception of perjury, we’ve kind of moved away from Greco-Roman style sacred blood oaths. Adultery and divorce, for instance, are both oath-breaking, but apart from the occasional tut-tut, as a society we’ve more or less just agreed to let it slide. Perhaps as a consequence of longer and more diverse lives, we don’t really care about oaths.

Perjury is another interesting case, though. Because contrary to the occasionally held belief, the crime of perjury isn’t actually affected by whether the lie in question is about some other crime. If you’re on the stand for another charge of which you’re innocent, and your alibi is being at Steak Shack, but you say you were at Veggie Villa, that’s exactly as much perjury as if you had been at the scene of the crime and lied about that. This is because witness testimony is treated legally as fact. The crime of perjury isn’t about trying to get out of being punished. It’s about the integrity of the system. That’s why there’s an oath, and why that oath is taken seriously.

The revival of the Hippocratic Oath as an essential part of the culture of medicine came after World War II, at least partially in response to the conclusion of the Nuremberg Trials and revelations about the holocaust. Particularly horrifying was how Nazi doctors had been involved in the process, both in the acute terms of unethical human experimentation, and in providing medical expertise to ensure that the apparatus of extermination was as efficient as possible. The Red Cross was particularly alarmed- here were people who had dedicated their lives to an understanding of the human condition, and had either sacrificed all sense of morality in the interest of satiating base curiosity, or had actively taken the tools of human progress to inflict destruction in service of an evil end. 

Doctors were, and are, protected under the Geneva Convention. Despite Hollywood and video games, shooting a medic wearing medical symbol, even if they are coming off a landing craft towards your country, is a war crime. As a society, we give them enormous power, with the expectation that they will use that power and their knowledge and skills to help us. This isn’t just some set of privileges we give doctors because they’re smart, though; that trust is essential to their job. Doctors can’t perform surgery if they aren’t trusted with knives, and we can’t eradicate polio if no one is willing to be inoculated.

The first of the modern wave of revisions of the Hippocratic Oath to make it relevant and appropriate for today started with the Red Cross after World War II. The goal was twofold. First: establish trust in medical professionals by setting down a simple, overriding set of basic ethical principles that can be distilled down to a simple oath, so that it can be understood by everyone. Second: make this oath not only universal within the field, but culturally ubiquitous, so as to make it effectively self-enforcing. 

It’s hard to say whether this gambit has worked. I’m not sure how you’d design a study to test it. But my gut feeling is that most people trust their own doctors, certainly more than, say, pharmacologists, meteorologists, or economists, at least partially because of the idea of the Hippocratic Oath. The general public understands that doctors are bound by an oath of ethical principles, and this creates trust. It also means that stories about individual incidents of malpractice or ethics breaches tend to be attributed to sole bad actors, rather than large scale conspiracies. After all, there was an oath, and they broke it; clearly it’s on that person, not the people that came up with the oath.

Other fields, of course, have their own ethical standards. And since, in most places, funding for experiments are contingent on approval from an ethics board, they’re reasonably well enforced. A rogue astrophysicist, for instance, would find themselves hard pressed to find the cash on their own to unleash their dark matter particle accelerator, or whatever, if they aren’t getting their funding to pay for electricity. This is arguably a more fail-safe model than the medical field, where with the exception of big, experimental projects, ethical reviews mostly happen after something goes wrong. 

But if you ask people around the world to rate the trustworthiness of both physicians and astrophysicists, I’d wager a decent sum that more people will say they trust the medical doctor more. It’s not because the ethical review infrastructure keeps doctors better in check, it’s not because doctors are any better educated in their field, and it’s certainly not anything about the field itself that makes medicine more consistent or less error prone. It’s because medical doctors have an oath. And whether or not we treat oaths as a big deal these days, they make a clear and understandable line in the sand. 

I don’t know whether other sciences need their own oath. In terms of reducing ethical ethical breaches, I doubt it will have a serious impact. But it might help with the public trust and relatability probables that the scientific community seems to be suffering. If there was an oath that made it apparent how the language of scientists, unlike pundits, is seldom speculative, but always couched in facts; how scientists almost never defend their work even when they believe in it, preferring to let the data speak for itself; and how the best scientists already hold themselves to an inhumanly rigid standard of ethics and impartiality in their work, I think it could go a ways towards improving appreciation of science, and our discourse as a whole.