It's been virtually impossible to spend any time conscious in the past few weeks and not be very aware of the arrival of the Ebola virus in Texas. Thanks to the new innovations of social media and the timeless human tradition of panic and gossip, the public has vented rage at the Centers for Disease Control, at the city health department in Dallas, and even the two brave nurses who were simply doing their best to provide medical care to a man with a disease that would end up not only taking his life but threaten theirs as well. In an age in which it has become possible to access the entire human body of knowledge on a device that is smaller than a playing card, diseases like Ebola still run rampant across the planet, and despite the deadly consequences that such a disease can bring, the developed nations still have not put the resources toward finding a cure and eradicating the virus from the planet. There are some who would argue that this lack of success has to do with latent racism in the West; however, one obstacle that certainly plays a role is the fact that medicine has certain limits that it has not yet managed to transcend. There is still a great deal of progress to be made in medical research, both in the areas of prioritizing medical research and helping patients to prioritize matters of care. Freedman's attack on the medical society for careless research on treatments that have no positive outcome and Gawande's text displays the struggle physicians face on a daily basis on what to do when faced with a difficult decision based on the type of treatment the patient wants or the physician thinks is best for the patient. Freedman writes about the obstacles that come from unethical research practices, while Gawande writes about the obstacles that come from the conflict between individual interests and collective priorities in health care. As long as those types of debates continue to rage on a micro level, it will continue to be difficult for medicine as a profession to take a more long-term view of progress unfettered by individual desires and the profit motive. The articles overlap in their coverage of conflicts of interest that take place in medicine; they also both take into account elements of the medical industry that can influence patient care, for better and for worse.
David Freedman's article “Lies, Damned Lies, and Medical Science” appears to have a consistent take on the issues at work in medical research from the very headline. The use of a bold, almost tumescent font shows the take that at least the editor, if not the author, has on this topic. Freedman takes the approach of profiling a maverick in medical research, Dr. John Ioannidis, who has made a career out of exposing what he considers the poor scientific practices of his peers in medical research. The tone of the opening paragraphs of the article shows that Freedman considers Ioannidis to be nothing less than a hero in the world of medicine. The article begins with the story of Athina Tatsioni, a brand new doctor who enters the profession by assisting with a research study to prove that Albanian immigrants in Greek hospitals were receiving false diagnoses of appendicitis, because the Greek surgery residents wanted to log more hours in surgery. Dr. Tatsioni reports having a difficult time publishing the journal; the professor who challenged her to conduct the study in the first place is described using the rhetorical device of hyperbole as assembling a cadre of “exceptionally brash and curious young cliniciansto join him in tackling an unusual and controversial agenda” (Freedman, p. 76). When Freedman meets the members of this study group, he uses the rhetorical device of allusion when he says they “would have been at home at a Silicon Valley startup” and “looked like the casually glamorous cast of a television medical drama” (Freedman, p. 76). The reader already feels like he is looking at an episode of House, M.D., rather than at a group of medical students and new physicians. Dr. Ioannidis himself is “dapper and soft-spokenloosely” presiding over the meeting (Freedman, p. 77). Just this beginning shows the innate approval that Freedman has for the people whose story he is about to relate.
Freedman's vivid diction that sets apart this doctor and his research crew as heroes continues into the analysis as well. He describes the issues in medical research as “plaguing the field” (Freedman, p. 78). What Ioannidis found – what to him looked like a systemic set of research practices in which researchers enter projects knowing what they want to find, and then gratuitously finding it, even when those findings reverse earlier precedent – was alarming, particularly because “the great majority of [theories] collapse under the weight of contradictory data when studied rigorously” (Freedman, p. 80). Just as important to Freedman as Dr. Ioannidis' diligence in research, though, are his “humility and graciousness” (Freedman, p. 82). One almost wishes that Freedman would take the sort of reserve that Dr. Ioannidis does: the doctor suggests that “we could solve much of the wrongness problem” in medical research “if the world simply stopped expecting scientists to be right” (Freedman, p. 86). Rather than gush so swimmingly about Dr. Ioannidis' winning personality, Freedman would have done even better to stand back and let Dr. Ioannidis' outstanding research speak for itself. It is that sort of bias, after all, that Ioannidis has been fighting for years.
Gawande's article “Letting Go” takes a look at the other end of the health care question – that at the patient end. From the end of research, the view often takes place through the lens of dollars and cents. The decision that Jonas Salk made not to patent the polio vaccine seems as alien, in some ways, as the use of leeches to draw bad blood and humors out of patients. However, it was not that long ago that doctors thought leeches to be the very forefront of medical practice – and that medicines were given to the patients who needed them. The recent emphasis on profit in the pharmaceutical industry raises a series of questions whenever someone requests a medical treatment that turns out to be a matter of expenditure and pain as opposed to accepting the possibility that medicine has failed and that it is time to consider hospice as an option rather than pushing the envelope further. The story of Sara, who had three different drug regimens for her cancer fail, is the center of Gawande's article. The basic question of the article is this: “What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic cancer – or for that matter, a similarly advanced case of emphysema or congestive heart failure – what would you want your doctors to do?” (Gawande, web). Gawande points out that “the soaring cost of health care is the greatest threat to the country's long-term solvency, and the terminally ill account for a lot of it. Twenty-five percent of all Medicare spending is for the five percent of patients who are in their final year of lie, and most of that money goes for care in their last couple of months which is of little apparent benefit” (Gawande, web). The calculus turns into a tug-of-war between the interests of the taxpayers and the other people within the health care risk pool, and that of the patient. After all, when patient costs go up, premiums go up for everyone within the pool.
One of the central differences between Gawande's paper and Freedman's paper is the clinical tone that Gawande adopts toward a difficult topic. Gawande does not back away from the tough emotional battles that these sorts of medical decisions entail. He acknowledges them, but from a distance, resorting to a form of emotional understatement as a rhetorical device by reporting that “surveys of patients with terminal illness find that their top priorities includebeing with family, having the touch of others, being mentally aware, and not becoming a burden to others” (Gawande, web). The difference is that Gawande seems to be reading at an academic conference, while Freedman sounds like he is on network television. Gawande's form (The New Yorker) is no less aimed at the public than Freedman's, but Gawande's aim is different. Gawande wants us to consider the question of terminal medical care from a different point of view than the affective, and so he drains the emotions out of the conversation with his clinical tone. Freedman wants the reader to jump right in with the new physicians into the quest for sound medical research, and so his tone almost frolics with delight at the winning Dr. Ioannidis. Gawande points out the paradoxes that are intrinsic to a system whose limitations have to do with money rather than technology, and Freedman points out the paradoxes of a medical research industry that faces the conflicts endemic to the profit motive. Both of those sets of paradoxes show me how far American society is from a rational health care policy. Both writers are effective in their own way, and both point out the distance that still separates American medicine from its potential.
Works Cited
Freedman, David. “Lies, Damned Lies, and Medical Science.” The Atlantic November 2010, 76-84.
Gawande, Atul. “Letting Go.” New Yorker 86(22): 36-49.
