Saving the World, and Healing the Sick
February 12, 2015 § Leave a comment
When I applied to medical school, I had to write a personal statement: selling how exceptional my achievements were, what wonderful personal qualities I had, and my noble motivations for wanting to be a doctor. The last of these is the most embarrassing in retrospect:
I want to study medicine because of a desire I have to help others, and so the chance of spending a career doing something worthwhile I cannot resist. Of course, Doctors [sic] don’t have a monopoly on altruism, but I believe the attributes I have lend themselves best to medicine, as opposed to all the work I could do instead.
These “I like science and I want to help people” sentiments are common in budding doctors: when I recite this bit of my personal statement in a talk (generally as a self-flagellating opening gambit) I get a mix of laughs and groans of recognition – most wrote something similar. The impression I get from those who have to read this juvenalia is the “I like science and I want to help people” wannabe doctor is regarded akin to a child zooming around on their bike with stabilizers – an endearing work in progress. As they became seasoned in the blood sweat and tears of clinical practice, the vainglorious naivete will transform into a more grizzled, realistic, humane compassion. Less dying nobly, more living humbly; less JD, and more Perry Cox.
I still have a long way to go.
A portrait of the altruist as a young man
My other interest back then was philosophy, so much so that it was a toss-up whether I should try and study medicine or philosophy. Along the way I read ethics, which led to utilitarianism, which led to Singer’s ‘Famine, Affluence, and Morality‘. I remember at the time thinking how austere and demanding it was, but after some wrestling with my conscience I decided it was the right thing to do. So at around the age of sixteen I decided I would devote my life towards making the world better: of course, that would mean giving lots of my money to charity; and of course I had to spend my life doing something important (I settled on curing AIDS as a suitably worthy goal); and so, of course, the rather painful to read personal statement above.
I chose medicine, and kept philosophy around as an affectation during medical school. My altruistic zeal faded under the pressure of work. It took another philosophy book – Living High and Letting Die (ironically bought at a charity shop) – to prod these thoughts back into the front of my mind.
The moral case made by Singer and Unger (and many others) has a simple summary. Very large numbers of people are suffering and dying from so-called ‘diseases of poverty’ – diseases that would be cured, or prevented, or ameliorated if only those afflicted could afford to. If you are rich – which, relative to those suffering from diseases of poverty, virtually everyone reading this will be – you can afford to. So you could give some of your money to help these people: you would still be very well off, and you’d make some of them a lot better. Why not?
Some soft numbers make the consequentialist case harder to resist. Although it is hard to estimate (on which more later) it is conservatively reckoned a few thousand pounds, given well, could save a child’s life. It seems hard to pretend that anyone’s few grand is worth more than a child’s life: if we could choose between depriving Richard the rich person of a few thousand pounds worth of stuff (a couple of nice holidays, say) or depriving Pauline the pauper of her 2 year old child, the choice that should be made is obvious. Nothing morally relevant changes when the few thousand pounds are not Richard’s but our own. Giving lots of our money away is thus a moral bargain, and few of us are taking advantage of it as much as we should.
You needn’t be a thoroughgoing consequentialist to accept this sort of reasoning. Singer et al. strive to show assent to much weaker moral principles (e.g. “If you can secure a really great good for someone else via a much smaller sacrifice on your part, you ought to make this sacrifice”) are enough to drive a much greater concern for charity. Besides, other ways of thinking converge here: perhaps one should give lots because it begins to live up to Jesus’s commandment to love your neighbour as yourself – I understand most world religions are similarly keen on charity; or perhaps one should give lots because what made us rich and made them poor is unjust, and giving goes part way to correcting this inequity – perhaps it should even be viewed as reparations for prior colonial injustices; or perhaps something else.
In any case, I renewed my faith in the ‘giving lots’ principle of charity. It was around this time I first heard of Giving What We Can – a group of people who were pledging to give 10% of their income to help beat global poverty. At the time I ignored them, because I thought (with the easy self-assured righteousness of someone living on their parents’ forbearance and government-subsidized credit) that 10% wasn’t enough, and I was obviously going to give much more than that when I started earning – conveniently a long time away.
It took me a few more years to realize that Giving What We Can was for people planning to give 10% or more (and indeed the guy who set it up was doing just that), and there might be benefits to joining a community of such people, and trying to encourage others to do what I was planning to. So I joined up in 2012 or so, generally made a nuisance of myself both in my local university group and the wider organization, and looked forward to completing medical school and having a salary to start practicing what I had been preaching interminably.
N.B: This section is going to talk about how much I have given to charity. This violates norms about it being bad, or immodest, or self-aggrandizing to talk about ones charitable giving: Let not thy left hand know what thy right hand doeth, etc. My intent in doing so is to encourage more charitable giving, to normalize bolder efforts at charity – and, besides, I don’t take what I am doing to be particularly praiseworthy. If you’re unsatisfied at this defense, accept my apology, and feel free to scroll through.
I’m writing this after around 18 months of being a doctor, and thus 18 months of earning a salary.
Last academic year (Aug ’13 to Jul ’14) I earned £33,214 and gave £10,836, about a third of my (pre-tax) income. I put a spreadsheet of my giving here: I didn’t give anything at first as I wanted to buy various bits and pieces for my medical career, but steadily ramped up my giving as I found I could afford to give quite a lot – in the last few months I was giving just over half my money away. Although I do not have such good figures for the first six months of the current academic year thanks to various administrivia, I intend to stick with giving around half, and will be giving several thousand pounds of my (now slightly larger) salary towards this end.
What am I giving to, exactly? When I joined Giving What We Can, I found out that giving smart was as important as giving lots. My naive assumption was that there wasn’t much to choose between different interventions: Tuberculosis, Malaria, HIV, starvation (and many more) are all awful things, so it made little difference which particular horror one’s money was directed against. The data proved me wrong: different interventions tackling the same disease can vary in efficacy by orders of magnitude, and so there are vast dividends to finding the most effective interventions, and the most effective charities. Happily, both Giving What We Can and another group called Givewell tackle this very hard question, and reassuringly their recommendations align closely. So about half of my money goes into a charitable trust run by Giving What We Can, which in turn distributes it to these extremely high performing charities.[ref]For those interested in how this is distributed via the trust: you can instruct the trust to give to charities it includes in whatever proportions you see fit. I have stipulated the trust distributes my money in proportion to the other charities the trust dispenses funds to – so if half the money given via the trust goes to the Against Malaria Foundation and the other half to Deworm the World, then my donation is split 50:50 between the two (and mutatis mutandis to whatever the actual balance of contributions actually are). The underlying idea is to exploit peer knowledge. Although one can identify what look like very high performing charities, picking between these for the very highest ‘value for money’ is hard, on which sensible people disagree. I don’t back myself to have a better insight than they, but I can apply an ‘equal-weight’ type view and so try and follow the weighted sum of sensible opinion, which should be closer to the mark than my own guessing. The closest financial analogy would be an index fund.[/ref]
The other half is directed to more ‘behind the scenes’ work. Answering the ‘what does the most good?’ question is extremely hard, and rides on top of several other extremely hard questions, yet getting better answers could be extremely valuable. So last year the other half was given to funding research into these questions. I plan to do the same sort of thing this year: half of my giving towards effective charities, and the other half aimed at ‘behind the scenes’ work, in the hope this will lead to even better outcomes (and more donations!) further down the road.[ref]Another possibility, given how helpful I have found this way of thinking about things for myself, is the fund efforts to spread the word more widely. I’m not sure yet.[/ref]
I’m no Superman
N.B. This section is going to talk (among other things) about how wealthy I am. Similar to above, I know doing so is unseemly, but I think the ends justify the means. Again, apologies if I am wrong, and feel free to skip.
When people find out how much I’m giving, they tend to react with either admiration (one Buddhist FY1 I know said it was ‘amazing’, and that it would earn me great merit for my next life – here’s hoping!); consternation (in the words of one medical registrar: “It really upsets me how much you’re giving. Promise me you’ll stop.”); or, perhaps most commonly, cynicism (“You’ll change your tune when you get a mortgage/have kids/you have to deal with your wife’s shoe budget etc.”). I don’t think any of these attitudes are quite right.
I am giving a larger proportion than the average household in the UK (around 0.5% of gross income) [ref] I couldn’t find a direct source of this, so I had to calculate it myself, which is more error prone. The average weekly donation per household (in 2008) was £2.42, giving a yearly donation of £126.27. Average gross individual income was £26,800, which means a somewhat overestimate of proportion would be 126.27/26,800, or 0.47%[/ref] but I’m also earning a lot more: I doubt my accounting is perfect, but a salary of £33,000-ish last year puts me into the top 25% of UK individuals by income, and well above the UK median household income of ~£23,200 – and, unlike many UK households, I don’t have children or adult dependents to look after. [ref]Although, in fairness, the Office of National Statistics try and account for this via equivalisation.[/ref]
This inequity is starker on a global scale: Britons are much richer than most of the world. [ref]People often remark, “Yeah, but this isn’t a fair comparison, because your money would go a lot further in the developing world”. That’s true, but this effect is already accounted for by purchasing parity adjustment. So a graph like this would be even more starkly iniquitous if ‘real’ income was used.[/ref] My post tax income of ~£26,295 puts me into the top 3% of people by wealth, and 24.7 times richer than the average person on the planet (you can run your own numbers here).
It is a bit tricky to work out exactly where I stand ‘post giving’ given Gift Aid etc., but I’m still probably above median in the UK, and comfortably in the top decile globally. Medical salaries increase with seniority, so, even if I continue giving half, my position in the global pecking order will improve still further. So even after my giving, I am still earning more than the average ‘man on the street’ where I live, and many, many times more than the average person alive today.
This partly explains why I don’t feel poorly off or destitute. There are other parts. One is that giving generally makes you happier, and often more happier than buying things for yourself. Another is that I am fortunate in non-monetary respects: my biggest medical problem is dandruff, I have a loving family, a wide and interesting circle of friends, a fulfilling job, an e-reader which I can use to store (and occasionally read) the finest works of western literature, an internet connection I should use for better things than loitering on social media, and so on, and so on, and so on. I am blessed beyond all measure of desert.
So I don’t think that my giving has made me ‘worse off’. If you put a gun to my head and said, “Here’s the money you gave away back. You must spend it solely to further your own happiness”, I probably wouldn’t give it away: I guess a mix of holidays, savings, books, music and trips to the theatre might make me even happier (but who knows? people are bad at affective forecasting). But I’m pretty confident giving has made me happier compared to the case where I never had the money in the first place. So the downside looks like, “By giving, I have made myself even happier from an already very happy baseline, but foregone opportunities to give myself a larger happiness increment still”. This seems a trivial downside at worst, and not worth mentioning across the scales from the upside, which might be several lives saved, or a larger number of lives improved and horrible diseases prevented.
I agree with the cynics that these sorts of ‘sacrifices’ are pretty easy when you are as unjustly privileged as I am. And of course my circumstances might change: maybe my good run is interrupted by some misfortune, or (as I hope is more likely) maybe ‘life gets in the way’ – marriage, kids, and middle England might come knocking. If things change, then they change – although I hope in the latter case I could follow examples of Toby Ord and Bernadette Young, or Julia Wise and Jeff Kaufmann in terms of combining a family with charitable giving. But in the meanwhile, I plan to make the best of my current lot.
A tale of two sickies
The “I like science and I want to help people” sentiment tends to go hand-in-hand with a romanticized image of what medicine is and what doctors do: saving lives every episode of your own private medical melodrama, the patients and their suffering hand-picked as if by the patron saint of the vainglorious to be strewn in front of you as your own Potemkin vale of soul-making[ref]
Doctors were the most self-righteous people on earth, Schwartz thought. Healthy and wealthy themselves, surrounded by the sick and dying — it made them feel invincible, and feeling invincible made them pricks. They thought they understood suffering because they saw it every day. They didn’t understand shit.
Chad Harbach, The Art of Fielding.[/ref], and the self-indulgent moaning of working unpaid overtime and being exhausted but deep down you’re okay with it because you’re making a difference.
In reality, expansion of morbidity and other doctors assiduously picking low-hanging fruit for their patients makes medical practice, to a first approximation, either trying to snatch glimpses of better health for those with chronic, deteriorating conditions medical science cannot cure, or extremely risk-adverse screening to pick up, among those who are essentially well, the unfortunate few who really need help. You generally don’t save lives, especially if you’re junior, because there’s a long hierarchy of supervising doctors who are poised to leap in and save the day in case you don’t.
In 18 months of being a doctor, I can point to one instance where I maybe – maybe – saved someone’s life. She was 92, on a respiratory ward for pneumonia, and had suddenly become breathless on a background of on-again, off-again chest pain. She was compromised, her chest sounded wet, and the X-ray showed fluid on the lungs, and the bloods later demonstrated a heart attack. I was on call, and the medical registrar (generally the guardian angel of the hospital wards, especially when you’re a shit-scared first year) was with an even sicker patient. I sprung into action: oxygen, morphine, GTN, CPAP, relatives, forlorn call to ITU to confirm that ward-based treatment was the ceiling of care – in other words, if this didn’t work, they wouldn’t take her, and she would die.
Happily, it worked, and she got better in the next couple of hours, and went home well a while later. Could I really say I saved her life? At the very least I have to share credit with the nurses and assistants who readied all the kit and administered all the drugs I’d prescribed, not to mention being astute enough to see she was really unwell and demanding the doctor come quickly. Credit diffuses further if we include (and we should) all the people who were needed for her to recover and leave hospital: her usual team of doctors, and the specialists who reviewed her, several teams of nursing staff on two different wards, physiotherapists, occupational therapists, pharmacists, and many more. Besides, maybe all my panicked doctoring was coincidental to her getting better by herself; and even if the doctoring was vital, maybe another doctor could have stepped into the breach in time had I not been able to do it myself.
So the total ‘QALY yield’ for my ‘life saving’ was not that high, especially when we add in that at 92 this lady’s expected lifespan is fairly short even if she returns to good health. Of course, I did other things in the last 18 months: I could brag about (in ascending order of frequency) some atypically astute diagnoses, performing some tricky practical procedures, prescribing analgesia, and marshalling paper work as some other ‘QALY positive’ things to add to the sum total of my good deeds. In sum, thought, it probably isn’t that much – as all the caveats to my ‘saving a life’ apply here.
Besides, the life-saving isn’t the thing I am most proud of in my nascent medical career. It’s this:
My first rotation was on a general medical ward. One of the patients was mid eighties admitted after a fall. He had a long list of co-morbidities, amongst them vascular dementia. Medically, he was making an unremarkable recovery, but he was upset and morose: as he kept saying, he had been with his wife for 60 years, and was lost without her. Each bed (including his) had a phone which could be used with cards bought in the corridor outside, and the ward phone was only five meters from his bed. Both were several steps too far for his severely impaired cognition: he had a digit span of 3 at best, did not remember how to operate a phone, and had a shaky grasp of where he was and why his wife wasn’t there.
It took a couple of days for me to realize I could help him out. I promised I would help him talk to his wife, but I forgot him amongst the other patients. The day after he told me again how how lonely he was, how much he wanted to be with his wife, how they had been married for sixty years… he had forgotten my promise, but it reminded me.
Stung by my failing, I got to work. I checked with the ward clerk that the patient’s phones could receive calls (they could). I noted his number down from his bedside. I found his wife’s number from his medical notes, and phoned her. She was also frail (although faculties intact) and recovering from her own fall at their home, and so could not easily visit, although she hoped to as soon as she was able. I gave her his number, and suggested she call it now. I loitered by his bed for a couple of minutes until the phone rang, and I handed it to him. He thanked me tearfully the day after.
Chequebooks and stethoscopes
Anecdotes make unreliable data[ref]Aside: Although they are data, thus the adage “The plural of anecdote is not data”, is – sensu stricto – false. That said, people generally over-interpret and overweigh ‘anecdata’, and so the implied norm of being cautious using it is wise.[/ref]; in the world of evidence based medicine, the greatest weight is given to systematic reviews, meta-analyses, and randomized controlled trials, whilst ‘expert opinion’ is right at the bottom – I would be still lower.
Although the ‘hard data’ on how much good doctors really do is hard to come by, I have found it even more sobering than the many times experience have formed parables about the limits and oversights of technocratic medicine.
The only published attempt I know was by Bunker, an epidemiologist. His strategy was looking at trial data to look at the impact of the most common medical interventions, and then extrapolating them to the population. Medicine turns out pretty well – it can take credit for a few of the many years added to life expectancy in the developed world since the turn of the last century. Playing with some numbers, you can get a fairly good-sounding estimate of the impact of a doctor like me over their career: ~2500 QALYs.[ref]QALY – Quality-adjusted life year, a subset of health adjusted life years. The idea is to produce a unified metric of health that can be used to compare diseases (and their treatments) to one another. Calculating the ‘life year’ part is relatively simple: look at how how diseases shorten life, and how well a treatment lengthens it, on average. The ‘Quality adjustment’ is harder: one tries to come up with ‘weights’ for given disabilities to see how much worse they are to live with than perfect health (so if blindness was weighed at 0.5, then 2 years of blindness are about as good as one year of healthy life). Techniques for getting weightings vary, and are admittedly far from perfect. They are probably better than other candidates for weighing health, hence their wide adoption by national and global health organizations.[/ref]
Bunker freely admitted these estimates are “more than speculative and less than precise”. They are also systemically optimistic, and the means of deriving from them an individual doctor’s impact even more so. We know trial data overestimates the benefit of treatment when ‘out in the wild’ of clinical practice. It is also obvious that doctors can’t take sole credit for medicine (what about nurses, pharmacists, porters, and, well, everyone else?); that the relationship between doctors and health is confounded (what about better education, wealth, hygiene, and the other social determinants of health?); that doctors should have diminishing marginal turns, and be replaceable – if I was never a doctor, there would not be a ‘Greg shaped hole’ in the national health service.
A better analysis would try and correct for confounders, try and account for diminishing returns, and maybe look at macro measures of health disease and their relationships to doctor numbers. I couldn’t find that, so I tried to do it myself. The bottom line is bad news for medics (but perhaps better news for everyone else!) The ‘QALY impact’ of a medical career is not ~2500 QALYs, but maybe ~150, and as the data and methods improve, the numbers get smaller still (I hope it never goes negative…) Rather than saving lives every episode, one is adding a few years of life every year.
The comparison to charity is humbling. The ‘cost per QALY’ of a leading charity (such as the Against Malaria Foundation) may lie around ~£60/QALY. So the good of my medical career is approximately the same as £9000, given well. Pro rata, it means a year is worth around £240, each working day just over £1. Not only can your chequebook beat my stethoscope, your pocket change can as well. [ref]People often object to consequentializing measures like QALYs as they inevitably don’t capture all that really matters – the benefit of letting my patient talk to his wife again is poorly captured by aggregate measures of health. It invites Dickensian satire: the Thomas Gradgrinds of good deeds, carefully moving beads along their moral abacuses without a humane grasp of what it means:
‘Very well, then. He is a veterinary surgeon, a farrier and horsebreaker. Give me your definition of a horse.’
(Sissy Jupe thrown into the greatest alarm by this demand.)
‘Girl number twenty unable to define a horse!’ said Mr. Gradgrind, for the general behoof of all the little pitchers. ‘Girl number twenty possessed of no facts, in reference to one of the commonest of animals! Some boy’s definition of a horse. Bitzer, yours.’
The square finger, moving here and there, lighted suddenly on Bitzer, perhaps because he chanced to sit in the same ray of sunlight which, darting in at one of the bare windows of the intensely whitewashed room, irradiated Sissy. For, the boys and girls sat on face of the inclined plane in two compact bodies, divided up the centre by a narrow interval; and Sissy, being at the corner of a row on the other side, came in for the beginning of a sunbeam, of which Bitzer, being at the comer of a row on the other side, a few rows in advance, caught the end. But, whereas the girl was dark-eyed and dark-haired, that she seemed to receive a deeper and more lustrous colour from the sun when it shone upon her, the boy was so light-eyed and light-haired that the self-same rays appeared to draw out of him what little colour he ever possessed. His cold eyes would hardly have been eyes, but for the short ends of lashes which, by bringing them into immediate contrast with something paler than themselves, expressed their form. His shortcropped hair might have been a mere continuation of the sandy freckles on his forehead and face. His skin was so unwholesomely deficient in the natural tinge, that he looked as though, if he were cut, he would bleed white.
‘Bitzer,’ said Thomas Gradgrind. ‘Your definition of a horse.’
‘Quadruped. Graminivorous. Forty teeth, namely twenty-four grinders, four eye-teeth, and twelve incisive. Sheds coat in the spring; in marshy countries, sheds hoofs, too. Hoofs hard, but requiring to be shod with iron. Age known by marks in mouth.’ Thus (and much more) Bitzer.
‘Now girl number twenty,’ said Mr. Gradgrind. ‘You know what a horse is.’
QALYs are imperfect, but they do count, and although a QALY measure of the good my medical career does fails to capture all of its value, it will similarly fail to capture the goods of high performing charity. Every death of a child from malaria has its own tragic story – stories which we all too seldom hear. We err badly if we attend to how vivid goods and evils are to our imagination, rather than to their size; first responders to multiple casualty incident are told to ignore those who are screaming at first, but to look carefully for any people who are so desperately injured they cannot even cry for help. And if a common failing of doctors is to become drunk on their apostolic role and self-righteous power, looking at ‘just the bare numbers’, sobering as they are, may part-way provide a cure.[/ref]
On saving the world
The seventeen year old who wanted to be a doctor should be disappointed: medicine has a modest impact on people living long and being healthy, and although an individual doctor may be the mechanism through which this modest impact flows, little of it depended on you.
But doctor’s don’t have a monopoly on altruism, and the seventeen year old me who wanted to save the world would be overjoyed. The difference a doctor makes is significant, even if it is small in QALY terms; charity can make a large difference in QALY terms, and its ‘real’ value is larger still. I have not lost out, and only benefited from thinking carefully and trying my best to make a difference – hopefully (and expectedly) many others have benefited too. I’d encourage anyone to start thinking harder about these matters, to get involved, and to give more – and better.
I hope, after reading this, you do.