Outing the Rorschach Inkblots (2)

A few weeks ago I wrote about the controversy surrounding the publication in Wikipedia of the ten Rorschach inkblots accompanied by the most common responses. (See the original post here.) Now two psychologists have filed complaints with the Saskatchewan Medical Society against Dr. James Heilman, the emergency room physician who posted the images.

Here's the gist of the complaints (see here for more details):

One of them, Andrea Kowaz of the College of Psychologists of British Columbia, complained that by including the inkblots on Wikipedia, Dr. Heilman was violating the test’s secrecy and that if he were a psychologist his behavior would be “viewed as serious misconduct.”

The other letter, from Laurene J. Wilson, a psychologist at Royal University Hospital in Saskatoon, echoed the concern about the test’s security but added that Dr. Heilman “shows disrespect to his professional colleagues in psychology and disparages them in the eyes of the public.”

Dr. Wilson said she had read interviews with Dr. Heilman in which he “refers to psychologists as undertaking practices akin to a magic show with smoke and mirrors.”

I side with Dr. Heilman.

Dr. Kowar accuses Dr. Heilman of "violating the test's secrecy." But the test is just a series of inkblots and an interpretive system. Secrecy is a commitment psychologists make about the test and an aspiration they hold for it. The commitment is a piece of professional self-regulation and isn't binding on others. And a visit to Amazon will show that the secrecy cat is long since out of the bag. All the major texts on Rorschach interpretation are readily available. The idea that the images and the theories about how to interpret responses are secret is a naive fantasy, and the claim that a professional society's code of ethics applies to people outside of the profession is muddled thinking.

Dr. Wilson raises a more vexing question - what do professionals owe to each other in terms of public respect or disrespect? Putting aside the fact that psychology and medicine are different professions, professional etiquette has long demanded that physicians speak of each other respectfully in public. At best this expectation avoids undermining patient respect for doctors who deserve to be respected. At worst it protects colleagues from justified criticism and prevents action to protect patients from harm.

I don't agree that competent psychologists are conducting "practices akin to a magic show with smoke and mirrors" any more than I see emergency room doctors as butchers, even though some psychologists are presumably smoke and mirror charlatans and some ER doctors are probably dangerous butchers. If Dr. Heilman spoke this way and I were part of the Saskatchewan Medical Society I would point out that public trust is crucial for the health professions. He should be free to make reasoned and evidence-based critiques of medical (including psychological) practices, but name calling is demeaning to him as well as to those the names are aimed at. Respectful debate can improve practice and will enhance public trust that the health professions are doing their best to get things right. Name calling does nothing for quality and makes professionals look like children squabbling in a sandbox.

This, however, does not rise to the level of being an ethical violation. I'll be surprised if the Saskatchewan Medical Society concludes otherwise. The Society usually responds within 60 days, so stay tuned!

American Values and Health Reform (3): Medical Progress

This is the third in a series of posts based on “Connecting American Values with Health Reform,” a publication of eleven short essays from The Hastings Center. The aim of the project was to consider what we want health reform to accomplish and to suggest what values our institutions and practices should be built upon, based on the belief that more clarity about underlying values would allow legislators and the public to handle reform more effectively. (See here and here for the two previous posts)

I hope legislators and media folks read Dan Callhan's essay on "Medical Progress: Unintended Consequences." The content will be familiar to those who have followed Callahan's work, but the short piece is provocative, clear, and easy to follow. It provides an ideal basis for a book club type discussion.

Callahan takes off from the observation that "a powerful faith in science as a basic human value, matched by an equally strong belief in medical progress, has been a central feature of American culture from the start." He acknowledges that we are "healthier and more prosperous because of it," but notes that the intensity of our faith in medical progress has put it off limits for ethical inquiry.

With that background Callahan lays out a series of concerns about the policy implications of our unquestioned faith in the value of medical progress:

1. New technologies or intensified use of older ones account for 50% of our annual health care cost increases. "Our technological benefit is turning into our economic bane." Callahan argues that we should do more assessment of cost-benefit ratios and make choices about what we want to pay for.
2. Much of the improvement we have achieved in health and longevity comes from improvements in socioeconomic factors - perhaps 60%. Callahan argues that "one could make a good case that improvements in education and job creation could be a better use of limited funds than better medical care."
3. Given his view that "throwing technology at illness in the name of progress is an increasingly expensive and economically destructive way to go," Callahan urges us "to aim for a better balance between cure-oriented and care-oriented medicine."
4. With regard to prevention, Callahan takes a very tough stand: "the only way to assure a good outcome for prevention programs is to make clear to the public that high cost technologies will be severely limited when the final illness comes. The carrot is that prevention will give us a longer life with a higher quality. The stick will be the message that you should take care of yourself and not expect medicine to save you when your time runs out."
5. As an extension of his comments about prevention, Callahan engages directly with longevity and mortality: "Americans already live, on average, a long life of seventy-seven years. There is no need to go out of our way to chase life extension, or the denial of death, as the sine qua non of medical progress. We need progress in removing the health disparities that keep millions from reaching seventy-seven..." Coming from a younger person this perspective would elicit a torrent of ageism accusations. Coming, however, from someone who, if online information is to be believed, will be 80 next July, Callahan's view may receive the thoughtful and respectful attention it deserves.

Callahan's tone is moderate, but his conclusions are radical:

Serious progress would mean turning back the clock: learning to take care of ourselves, to tolerate some degree of discomfort, to accept the reality of aging and death, and to see our personal doctor as someone as likely to talk with us as to have us scanned. That cluster of backward-looking ideas is what I think of as common sense, affordable progress.

I think most people who have given serious thought to the health system, including conservatives and people of faith, will agree with much of what Callahan says. But in the frenzy of anti-government sentiment that Republicans are fomenting, Callahan's views may elicit an "Aha - they really are planning for euthanasia" reaction from the Rush Limbaugh crowd. The level of political hysteria and public paranoia is so high that even a great communicator like the President would have a lot of difficulty working with Callahan's wise perspective.

American Values and Health Reform (2): Liberty

As I noted in a post last week, The Hastings Center has published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to consider what we want health reform to accomplish and what values our institutions and practices should be built upon, based on the belief that more clarity about underlying values would allow legislators and the public to handle reform more effectively. This post is the second of three I plan to do based on The Hastings Center project.

Bruce Jennings, senior consultant at The Hastings Center, wrote about "liberty." In the context of the orchestrated hooliganism that is disrupting town meetings and the stunningly confused public fear that government involvement means euthanasia, Jennings's comments are remarkably prescient:

Values so ubiquitous [like liberty] are often taken for granted and not sufficiently scrutinized. They therefore have great political power yet are vulnerable to cynical misuse and manipulation...The health reform conversation has to be reframed at the grass roots level so that a new way of seeing what liberty is and what it requires will grow out of that conversation. (emphasis added)

The reframing of liberty that Jennings wants to encourage is to see liberty as freedom to, not simply freedom from:

Health care is not simply about preserving you from the 'outside' interference of others or of disease; it is also about obtaining the active assistance of others so as to enhance the types of activities you can pursue and the kinds of relationships you can have. Thus, health care is as much about positive liberty as it is about negative liberty.

The fundamental American skepticism about claims made by government and other authorities has largely been a force for the good. But as Jennings suggested, our attachment to liberty from external control is vulnerable to "cynical misuse and manipulation." That's what we're seeing now, as in this statement by Newt Gingrich about the allegation by Sarah Palin and others that the House health reform bill promotes euthanasia:

I think people are very concerned, when you start talking about cost controls, that...you're asking us to trust the government. Now, I'm not talking about the Obama administration. I'm talking about the government...We know people who have said routinely, well, you're going to have to make decisions. You're going to have to decide. Communal standards historically is a very dangerous concept...You're asking us to trust turning power over to the government, when there clearly are people in America who believe in -- in establishing euthanasia, including selective standards.

The President has tried to mobilize a sense of crisis about health reform, but thus far the true danger that runaway health costs will euthanize American prosperity does not measure up to the false claim that health reform threatens the lives of our citizens. A subset of the population that appears to hold a monolithic commitment to negative liberty - freedom from -is prepared to believe the Republican lie that an administration led by a "foreigner" is covertly preparing to kill its citizens.

Words like "insane" and "paranoid" are being used too casually. While there probably are a few clinically paranoid people among the hooligan protesters, my guess is that most are folks who would (a) get a "D" in a college ethics class because (b) they are unable or unwilling to see complexity among values but who (c) unlike lazy students are (d) prepared to be mobilized into a fascist gang disrupting public meetings.

Jennings's essential argument is powerful:

One tenet of [health reform] should be that equity in access to health care, reduction in group disparities in health status, and greater attention to the social determinants of the health of populations and individuals are all policy goals through which liberty will be enhanced, not diminished...we must see that health reform involves equitable access to the social preconditions of health, as well as to health care...that when anyone lacks such access the liberty of all is compromised.

His vision, however, won't silence the hooligan disrupters, especially as their fears are stoked by cynical politicians of the Gingrich/Palin ilk. But his analysis, and others, may help legislators and members of the public understand the otherwise perplexing frenzy we are currently seeing and turn against it.

Mandating Health Benefits in Massachusetts

The Boston Globe recently reported that 70 bills requiring insurers to cover specific health services are pending in the Massachusetts legislature. Many of the proposed services are clearly desirable - such as hearing aids for children and treatments for cleft palate.

At the same time that 70 proposals to require new services are pending, the Massachusetts health care reform program is staggering under its burden of cost, and is considering cutbacks on coverage and services. What's going on?

The answer is - business as usual!

We currently make choice the top value for our health system - individual patient choice of physicians and hospitals, individual physician choice of treatments, and individual legislator choice of what to lobby for. Fear of losing choices is the biggest roadblock for national health care reform.

Virtually all of my clinical practice life has been in systems that (a) had overall budgets which (b) were allocated by a combination of expert leadership and patient involvement, with (c) processes that allowed appeal - by physicians or patients - when limits were encountered. But in the last 20 years we've had a big pendulum swing against this kind of managed approach.

I hope we in Massachusetts can come to our senses about the downsides of our choice mania. Runaway cost is the most obvious negative. But governing a health system by the sum of a billion individual choices is like trying to build a house without an plan for the foundation and how the parts will fit together. We haven't yet come to a public understanding of how much quality of care suffers from our lack of coordination.

Legislators who are lobbying for new benefits are focused on a particular choice, but without a sense of how that choice, which might be good in itself, impacts on the system it would play out in. What we're seeing in Massachusetts provides an argument for expert health boards that would be insulated from the kind of immediate public pressure that legislatures are subject to.

My work in ethics involves reflecting about what appears to be the best course of action and the right way to do things. What we're seeing now in the health reform process is the transition from ethics to politics. Our system of (a) relatively unfettered choice combined with (b) third party financing of those choices results in (c) superb market opportunities for the providers of services and, as the public is beginning to recognize (d) runaway costs which (e) undermine wages and national competitiveness. Enormous lobbying funds are fanning fear of "loss of choice to government bureaucrats."

If I were the czar of the health system I would decree dissemination of "accountable health organizations" modelled on Kaiser Permanente, Mayo Clinic, Geisinger, Harvard Vanguard, and other excellent managed clinical programs, in which patients and clinicians collaborate to make collective choices within budgets.

But organizations of this kind limit individual choice. The only alternative to collective self governance is individual risk for the cost of the choices we make. In Massachusetts our legislature is playing both sides of the coin at once - holding health care reform to a budget, but fracturing that budget by proposing 70 new choices. But unlike the federal government, the states can't run deficits, and can't as readily avoid the implcations of their choices. We need to learn to say "no" to ourselves. That's not likely to happen on the national level anytime soon. If we can't learn how to accept and manage limits at the state level we might as well toss in the health care towel.

American Values and Health Reform (1): Responsibility

This spring the Hastings Center published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to go beyond the dizzying area of sound bites and legislation in progress to consider what we want health reform to accomplish and what values our institutions and practices should be built upon. In my view the publication (which I contributed to) can be useful to the health reform process. This post is the first of three I’ll do based on the Hastings Center project.

My assignment was to discuss how the value of “responsibility” relates to the health reform debate. As I sat down to write the piece my mind drifted to a movie I hadn’t seen for at least twenty years – “Shane.” I got a copy from the local library and brought it to my office, hoping colleagues and students wouldn’t discover me watching a cowboy film.

My association to “Shane” was on target. In the film little Joey Starrett is torn between two icons of responsibility – his father, Joe, the homesteader, and Shane, the mysterious cowboy gunslinger.

Joe and Shane embody the two poles of responsibility in U.S. moral discourse. Joe exemplifies responsibility as social solidarity – building a caring community that takes responsibility for the welfare of its members. For homesteaders like Joe, the emblem of responsibility is barn-raising, in which the community bands together to help individuals meet a basic need. Shane exemplifies responsibility as individual action. For cowboys like Shane, the emblem of responsibility is the six-gun and the knowledge of when and how to use it.

Our love affair with the myth of the heroic cowboy enhances the attractiveness of market-based health reform proposals. In place of the cowboy these proposals envision a heroically empowered “consumer,” motivated by “skin in the game” and armed with knowledge, who strides into the marketplace to make choices of high-quality, low-cost health care, in accord with their own values. The empowered consumer stands tall and takes orders from no one. This constellation of values is being used to whip up the frenzy of disruptions we’re currently seeing in town hall meetings around the country. The would-be Shanes shouting at their representatives and even threatening death represent the value of individual responsibility run amok.

Proposals that emphasize universal coverage – like the single payer plan and variants of the Massachusetts program – are enhanced by the myth of an Edenic, barn-raising frontier. The single payer plan envisions a society that pools its resources to minister to the health needs of each member of the community. The Massachusetts plan plays down the communitarian ethos of the single payer approach by (1) requiring each individual to buy insurance rather than requiring contribution via taxes and (2) gives the individual a range of insurance choices. (see here, here and here for discussions of the Massachusetts program.)

One reason the Massachusetts plan has attracted so much attention nationally is the way it addresses the deeply rooted American standoff between the proponents of individual responsibility (Shane) and societal responsibility (Joe Starett). The architects of the plan like to point out that it requires everyone to take responsibility. Individuals are required to purchase health insurance, but are free to choose among a large number of private ("nongovernmental") plans. Employers are required to contribute. The state is required to pay for those too poor to buy their own insurance. And if the state's recent recommendation goes through, providers will be required to form "accountable organizations" and work within budgets.

In his inauguration speech, President Obama invoked responsibility as a major theme - "What is required of us now is a new era of responsibility - a recognition, on the part of every American, that we have duties to ourselves, our nation and the world." It sounds as if the President wants to side with both Shane and Joe Starrett. Whatever emerges from the national health reform process will almost certainly have to find ways of integrating the virtues of Shane and Joe!

Attacking Insurers - Good Politics/Bad Ethics

As you read this post, keep in mind that I direct the ethics program at a nonprofit health insurance company - Harvard Pilgrim Health Care.

The administration is feeling the heat from conservative fear mongering about health reform. The well orchestrated disruptions of Congressional town hall meetings are getting a lot of publicity. To get out of a no win defensive posture, the administration appears to have opted for an anti-insurer strategy.

This may turn out to be a good political move, since public trust of health insurers is low. And of course there's lots to criticize in our health insurance system. In the battle of sound bites, (1) turning public fears away from "ObmamaCare" onto the insurance industry and (2) pinning a "pro-insurance" label onto conservative critics, may be effective politics.

Unfortunately, the tactic also continues the process of disinformation, which has resulted in an extraordinarily low level of public understanding of the health system. Modern health systems need active management. This is true for the Canadian single payer system, the British National Health Service, and our own hodge podge of public and private payers. The driving forces for our out of control health expenditures are the way we provide care as clinicians and the expectations/demands we have as patients.

Health insurers are in the middle of our profligate provider system and our clueless consumer system. In the 1980s and 1990s U.S. public policy asked insurers to alter clinical practice and educate the insured population. There was tremendous pushback against insurer led managed care and insurers have largely backed off from that effort.

Even if a public program is part of what emerges from the reform process, it will have to decide what will and will not be covered, how to apply comparative effectiveness findings, and when marginally beneficial care is too expensive to include. And if accountable medical organizations are asked to take over insurance functions by being given a budgets to care for populations, they will have to carry out these same activities.

As I said in a recent post, my candidate for the demon the administration needs is conservative rhetoric itself. If the conservative attackers mean what they say, the logical extension of their sound bites is that Medicare should be abolished, since it is a government run, single payer program.

The administration isn't proposing a single payer insurance plan. So whatever comes out of the health reform process we will still have an insurance system. Demonizing the programs we'll be turning to for thoughtful guidance to providers and the public may make short term political sense, but it isn't a coherent long term strategy!

Outing the Rorschach Inkblots

There's been a free-for-all at Wikipedia over the publication of Herman Rorschach's famous inkblots.

When the article initially reproduced one of the ten images controversy began to bubble, with psychologists describing the action as an irresponsible threat to the integrity of the test itself. At this point Dr. James Heilman, an emergency room physician at Moose Jaw Union Hospital in Saskatchewan posted all ten, along with the most common interpretations printed underneath each.

I spent several hours today reading the fascinating and often vitriolic exchange on the Wikipedia talk page. It's a tectonic encounter between two cultures - the let-it-all-hang-out openness of the web banging against a concept of professionalism as a self-regulating societal resource. So far they're largely talking at each other, but the argument they're having could provide the basis for an excellent ethics class.

Sometimes the Wiki folks get hot under the collar ("only fascists withhold data") but the basic thrust and strongest argument echoes John Milton's Aeropagitica:

I cannot praise a fugitive and cloistered virtue, unexercised and unbreathed, that never sallies out and sees her adversary, but slinks out of the race where that immortal garland is to be run for, not without dust and heat.

The Wiki perspective is that people have the right to know about as important a cultural phenomenon as the Rorschach test and to think about it for themselves.

The psychologists in the discussion are on strongest ground when they argue that (a) publishing the Rorschach images accompanied by (b) the commonest responses could (c) undermine the validity and usefulness of a test that (d) contributes to psychiatric treatment, court proceedings, and other socially important activities.

The discussion contains a lot of back and forth about the validity of the test itself. Some of the Wiki folks argue, in effect, "the test is worthless, so what's the problem with publishing the images and interpretations?" The psychologists respond by citing research studies they see as showing the value of the Rorschach test. But this pi - - - ng contest isn't the important part of the debate.

I'm not an expert on psychological testing, but in my practice I had enough occasion to see the results of testing of my patients to believe that in skillful hands the Rorschach has a real contribution to make. And I understand the psychologists' concern that the Wikipedia article can lead to gaming of the test by people who want to appear sicker than they are to avoid legal prosecution or healthier than they are to get out of a hospital and, at worst, commit suicide.

But even if the psychologists are right, and the publication of the images along with modal responses weakens the test, we're in a radically different world than when Herman Rorschach published "Psychodiagnostik" in 1921. There's simply no way of keeping knowledge about how the test is interpreted secret from the public. As one of the Wiki folks said - "the horse is not only out of the barn - it is in the freaking next country..." I don't think that's a bad thing - certainly not for society, and even for psychological testing itself.

Hypnosis started as an authoritarian stage technique ("you are in my power...!"), but by the time I first studied it in the early 1970s it had evolved into a highly collaborative "permissive" format, in which therapist and patient designed the approach together. (See here for a discussion of the ethics of hypnosis.) If the publication of the inkblots has any of the impact the psychologists fear I expect that they will develop new ways of giving and interpreting the test, as by talking with the person being tested about what they know about the test and encouraging them to put aside what they've read and heard to use the inkblots for a constructive purpose.

It may be easier to game the test than in the past, but Wikipedia didn't create this risk. If I were coming to court and knew I would be examined by a prosecution psychologist it wouldn't take me long to thumb through the Yellow Pages for psychologists to help me case the tests I'd be confronted with. Psychological testing will have to evolve on the basis of more collaboration and openness than has been true in the past, just as hypnosis had to evolve from an authoritarian to a permissive format.

With the publication of the Rorschach materials, psychologists are experiencing what other health professionals have already encountered - the "empowered" patient, and a skeptical public. Adapting to these changes isn't easy for professionals, but I think doing so is respectful of our patients and ultimately makes us more effective in our mission. But even if I'm wrong about this, as the Wiki participant said, the horse is in the freaking next country, so we don't have much choice!

Republicans Propose Tearing Down Medicare

I'm worried about August. Opponents of health care reform are playing public fears very skillfully. The strongest volleys of sound bites are about evil bureaucrats who will deprive us of choice. The latest thrust is the assertion by Representative Virginia Foxx that the Republican version of the bill "is pro-life because it will not put seniors in a position of being put to death by their government." (see here.)

To my eye the administration is winning the health policy class but losing the political war. The opposition is using the Swift Boat technique - a steady drum of accusations. The response - "that's baloney" - may be accurate, but it's wimpy.

It seems to me that taken literally, the sound bite attacks on reform are an attack on Medicare. A single payer is "un American," "socialized medicine," and "takes away our choices." Medicare is a single payer system for the elderly. Logic tells us that the opponents of health care reform must be plotting to tear down Medicare.

The evil images in the sound bite war are "government bureaucrats" and "insurance company bureaucrats" who will seize on comparative effectiveness research to "come between you and your doctor." There's no better way to insure the demise of Medicare than by prohibiting thoughtful clinical management of the program. Without that the only cost containment measure is continued reduction of fees, which shifts costs to private insurance and perpetuates cost escalation throughout the system.

So my advice for the Democrats is to apply jiu jitsu. Don't just say that the opposition sound bites are false. Take them seriously, and trace out the consequences. This is the technique Socrates used as well. And when we trace out the implications of the opposition rhetoric we find an attack on the most popular component of our current health system.