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Individual Incentives Can Be Skewed

When I wrote about comparative effectiveness research, I focused on the merits of including funding in the deficit spending bill as a path to more socialized health care. I haven't changed my opinion on that, but it's worth noting that the idea behind this research is reasonable. Do our interventions produce results?

Following that, here's an interesting analysis of comparative effectiveness research that focuses on the relevant issues (link via Kevin, M.D.). The analysis contains useful examples, and is worth reading. I don't think we'll get what we expect from the newly-funded research unless we expect more decision-making power handed to bureaucrats. Still, the idea behind comparative effectiveness research is reasonable.

But the more useful, immediate discussion is this:

Here’s where things get dicey. A chief medical officer I know was once discussing unnecessary procedures in his healthcare system. In a rare moment of unvarnished truthtelling, one of his procedural specialists told him, “I make my living off unnecessary procedures.” Even if we stick to the correct side of the ethical fault line, doctors and companies inevitably believe in their technologies and products, making it tricky to get them to willingly lay down their arms. ...

You can probably figure out that I'm going to discuss this in the context of infant circumcision. First, let me make this clear, in case anyone's missed me saying it previously: I do not believe there is a conspiracy to circumcise infant males. It is a common, actively-pursued goal, but it does not fit the nefarious intent behind a conspiracy.

That does not mean that individual doctors are immune to the undeniable point that genital surgery is not indicated for most infant males. The ethical claim is impregnable to excuses based in cultural and moral relativism. What incentive does a doctor like Dr. Neil Pollock have to begin deferring to his patients' needs rather than his own?

Dr. Neil Pollock, who performs about 2,500 infant circumcisions annually in Metro Vancouver, travelled to Rwanda in December to teach his circumcision method to local surgeons.
...

Pollock is hopeful that the painless [ed. note: Even if true, the ethical claim must win out.] nature of his technique, which takes less than a minute to perform, will persuade many Rwandan parents to consider circumcision for their infants.

Once again: When public health officials discuss the potential reduction in HIV risk from voluntary, adult male circumcision, they always forget voluntary and adult. Always.

Looking at comparative effectiveness research, Dr. Pollock is based in Vancouver, British Columbia, outside the realm of the deficit spending bill's reach. He's good anecdotal evidence, though, because he shows what it means to be uninterested in placing your patient's needs and rights first. He's built a practice around performing more than 12 infant circumcisions per business day. Will he readily give that up, since he's so clearly invested in continuing the involuntary procedure?

Of course, the conclusion on infant circumcision is already in. Here's what the Canadian Pediatric Society says about routine infant circumcision:

Recommendation: Circumcision of newborns should not be routinely performed.

I see no reason to believe there will be any difference in the US. Most American doctors already ignore the ethical case for protecting the rights of infant males. There are people invested in perpetuating the imposition of unnecessary genital cutting. No government study is going to change that.

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