Intervention and Iatrogenics

INTERVENTION AND IATROGENICS

In the case of tonsillectomies, the harm to the children undergoing unnecessary treatment is coupled with the trumpeted gain for some others. The name for such net loss, the (usually hidden or delayed) damage from treatment in excess of the benefits, is iatrogenics, literally, "caused by the healer," iatros being a healer in Greek. Taleb’s discussion in Chapter 21 argues that treatment carries risks of medical harm that should be weighed alongside its expected benefits.

For a classic example of iatrogenics, consider the death of George Washington in December 1799: we have enough evidence that his doctors greatly helped, or at least hastened, his death, thanks to the then standard treatment that included bloodletting (between five and nine pounds of blood).

Taleb makes the sweeping historical claim that, depending on how benefits and harms are counted, medicine before penicillin had a largely negative balance sheet. But it is quite telling that medical iatrogenics seems to have increased over time, along with knowledge, to peak sometime late in the nineteenth century. Thank you, modernity: it was "scientific progress," the birth of the clinic and its substitution for home remedies, that caused death rates to shoot up, mostly from what was then called "hospital fever"—Leibniz had called these hospitals seminaria mortis, seedbeds of death. The evidence of increase in death rates is about as strong as they come, since all the victims were now gathered in one place: people were dying in these institutions who would have survived outside them. The famously mistreated Austro-Hungarian doctor Ignaz Semmelweis had observed that more women died giving birth in hospitals than giving birth on the street. He called the establishment doctors a bunch of criminals—which they were: the doctors who kept killing patients could not accept his facts or act on them since he "had no theory" for his observations. Semmelweis entered a state of depression, helpless to stop what he saw as murders, disgusted at the attitude of the establishment. He ended up in an asylum, where he died, ironically, from the same hospital fever he had been warning against.

Semmelweis's story is sad: a man who was punished, humiliated, and even killed for shouting the truth in order to save others. The worst punishment was his state of helplessness in the face of risks and unfairness. But the story is also a happy one—the truth came out eventually, and his mission ended up paying off, with some delay. And the final lesson is that one should not expect laurels for bringing the truth.

Taleb regards medicine as comparatively good news because he sees efforts to measure and control treatment harm. Writing about the period covered by his book, he claims that medical error kills between three times (which he describes as accepted by doctors) and ten times as many people as car accidents in the United States. He also claims that harm from doctors, excluding hospital infections, causes more deaths than any single cancer. These are his mortality comparisons, not updated estimates. The methodology used by the medical establishment for decision making is still innocent of proper risk-management principles, but medicine is getting better. We have to worry about the incitation to overtreatment on the part of pharmaceutical companies, lobbies, and special interest groups and the production of harm that is not immediately salient and not accounted for as an "error." Pharma plays the game of concealed and distributed iatrogenics, and it has been growing. It is easy to assess iatrogenics when the surgeon amputates the wrong leg or operates on the wrong kidney, or when the patient dies of a drug reaction. He extends his criticism to childhood psychiatric prescribing, arguing that some diagnoses and treatments substitute for changing a child’s environment and that long-term harms may go uncounted. That is his criticism of overtreatment, rather than evidence here that ADHD or depression is an invented condition. Iatrogenics is compounded by the "agency problem" or "principal-agent problem," which emerges when one party (the agent) has personal interests that are divorced from those of the one using his services (the principal). An agency problem can arise when a broker’s commission, a doctor’s payment incentives, or a politician’s career interests conflict with the interests of the people they serve. The conflict creates a risk; it does not establish that every professional gives self-serving advice.