Do Less, Heal More: The Case for Medical Conservatism (with John Mandrola)

And you mention in the article, um, in your essay, there's some ethical questions here, w- right? To, to do this to someone who maybe n- quote, "needs surgery," the, the goal of the study is to find out if indeed the surgery is effective, but the idea of, of doing this to someone and then really doing nothing is, is borderline unethical.

It feels a little funny, but it's for the good of humankind presumably to find out whether this thing works or not.

So that's the tension, isn't it? Because, uh, we just talked about 700,000 of these procedures h- are done annually, and then the, what are the ethics of doing 700,000 procedures that, uh, really doesn't have any better effect than, than sham surgery or operating on 145 patients? And, you know, we have many examples in cardiology where patients were getting far more invasive surgeries, uh, in, on their heart, uh, that were once studied under placebo were shown to be not beneficial.

And so I, I, I'm not an ethicist, but I can understand that there's, there's tension, but, uh, without doing this placebo-controlled study, we don't know whether they're, whether some of these things are effective.

This feels funny to say 'cause I don't agree with it, but I'm gonna say it anyway.

I think a lot of people would say, "Well, the 700,000 procedures that were done," and spoiler, we're gonna find out that the surgery's not particularly effective relative to the placebo 'cause it, or if not, it, it may be worse.

Um, but, but people would say, "Well, but that's different because those were done to help people, and the sham surgery was, was done just to gouge their knee with this fake arthroscope, this, this useless, non-helpful arthroscope." It's just funny how our ethical judgments are clouded by motivation or presumed motivation.

Of course, that ignores the fact that, you know, people do surgery for all kinds of reasons besides helping people.

They, they, they do get paid.

They [laughs]...

I mean, it, it's not a good analogy, but I think emotionally people would assume that the 700,000 surgeries were well-intentioned, whereas this thing is just, uh, uh, trying to find out what the truth is, which is important, okay, sure, but for those 146 people, it's kinda tough.

Well, I, I guess you could...

I, I understand your point, and I think it's, it, it's an important point, but I, I would counter by saying that you could make an argument that the arthroscope is partially diagnostic, right? So the surgeon's looking into the knee joint might find something else, um, and, and the patient's having that, having that diagnostic procedure.

In, in cardiology, we have a very famous study where, uh, this group in London, uh, did, uh, did, um, looked at patients with single vessel coronary disease.

Severe lesions of a coronary, it was causing angina, and one group got a stent, got the, uh, thing fixed, and one group got a pressure wire and then nothing was done.

And in the [laughs] in the end, Russ, they showed that there was no difference in exercise time from fixing these things.

But the way they, the way they got along with that A study called the ORBITA study was that they said, "Okay, you can have the stent procedure after a six-week period.

You won't know whether you had the stent or had the placebo stent.

But if you just wait six weeks, then we can do the stent."

That's awesome.

[laughs]

And, and, uh, patients in Britain have to wait more than six weeks anyways for their procedure.

So they, they were able to learn so much.

But, uh, uh, so, so there, there's that.

There's some...