Theodore Dalrymple on Negligence and Unaccountability in Medicine

“The medical establishment has become the major threat to health.” — Ivan Illich

Does an overweight patient deserve more resources from the government on account of his condition?

Should Washington D.C. treat mental disorders and addiction as “diseases,” like Parkinson’s, and subsidize treatment accordingly?

As healthcare spending approaches nearly 1/5 of the US economy, we might stop to ask whether the medical profession as a whole is able to think clearly about social and political questions like these.

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Theodore Dalrymple is a retired British psychiatrist and fellow at the Manhattan Institute, who has taken upon himself the unenviable task of reading through every weekly issue of the 2018 New England Journal of Medicine. His new book, False Positive: A Year of Error, Omission, and Political Correctness in the New England Journal of Medicine, discovers a persistent bias from the editors of one of the world’s most respected medical journals.

In it, the lay-person is treated to Dalrymple’s wryly humorous writing and impeccable handle on complex sociological issues and statistical analysis, which often confound the esteemed contributors to the Journal. His most remarkable discovery is perhaps the information the authors and researchers fail to mention in their prestigious studies and reviews of the relevant literature.

For example, in assessing the efficacy of a Cholera vaccine in Haiti, the authors diligently note the year the disease arrived, but fail to mention that it was a UN peacekeeping envoy from Nepal that introduced the deadly virus to the island in 2010. This oversight reveals the taboo among elites against criticizing helper organizations like the UN, despite mounting evidence of their incompetence.

Or, take the treatment of addiction — an increasingly important issue in the medical field given the opioid epidemic of the last few decades. The addict is often presented as a patient whose illness relieves him from the blame and cost of treatment. The Journal’s editorial voice never waivers from this politically-correct stance, even though a reasonably smart high schooler can understand that addicts still retain their agency (and culpability) while in the grips of the substance. To suggest otherwise is to dehumanize and infantilize people, especially the lower class.

Organization chart of the American healthcare system

His innumerable books underline a consistent theme — that the upper classes (including doctors) are all too willing to give the lower classes a free pass for harmful behaviors, and aren’t doing them any favors by doing so.

Theodore joined me for the full hour to discuss the reasons for ever-increasing bureaucratization and socialization of medicine, and how these trends are encouraging unhealthy behaviors at increasing cost to the taxpayer.

Dalrymple — colloquially known as the “skeptical doctor” — is like a responsible adult administering a bitter pill of rationality to the less mature members of his profession, who think they can “make the world a better place” through merely wishing it were so.

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Transcript:

Theodore Dalrymple on Negligence and Unaccountability in Medicine

Bob Zadek: Welcome to The Bob Zadek Show. Thank you so much for listening this Sunday.

One of the conceits of the progressive politicians and followers in the United States, if not around the world, is the blind, unyielding faith in the power of experts. They believe there are a cohort of experts in the country and in the world who know better than us how to organize our lives.

That is why progressives always seek to increase the power of government — not because they are hungry for the power per se, but of course they are — but because it is good for all of us, because we are not competent to run our lives.. Therefore, it is good policy to cede power over our lives to those who are more competent than we are.

This is a theme we have discussed on my show often over the many years that I have been broadcasting. One of the sub-cohorts of experts is the medical profession. We may not be aware of how much power over parts of our lives not directly related to medicine that we have ceded to doctors and the medical profession at large simply because we presume, or they would have us believe, that they know better than we do.

This morning’s show we are going to do an interesting examination with our guests. One of the leading medical publications is the New England Journal of Medicine. It is read by many, if not most doctors. What appears in the New England Journal of Medicine is often taken as Gospel by doctors.

It is given great weight because doctors do not have time to do research themselves. As is the case in any other profession, we need help in practicing our craft as well as we would like, so we resort to publications such as the New England Journal of Medicine.

There are two questions. Is the medical profession’s blind faith in the New England Journal of Medicine well-founded or is it harmful to the medical profession? Far more importantly, is it harmful to the rest of us? Why do we care? Because the policies, sociological and political, which find their way into the New England Journal of Medicine become Gospel among the doctors, and these policies are often wrong when the New England Journal of Medicine takes positions that are non-medical in their content or in their effect.

Theodore Dalrymple, this morning’s guest, is joining us from his home in France. He has written a fascinating book called False Positive. Theodore has taken the trouble and the time to examine 12 months of publication of the New England Journal of Medicine just to see what is going on between the cover and the end page of that journal every month for a year.

What he has found is shocking and astonishing as you will see, and it goes well beyond mere medicine. It creeps into social policies, criminal justice reform, and the like. It represents another episode of the self-appointed experts taking control of aspects of our life.

To share with us his research and his study of 12 months of the New England Journal of Medicine and the shocking effect it has upon all Americans, if not all citizens of the world, I’m happy to welcome Theodore Dalrymple to the show.

Theodore Dalrymple: Thank you.

Omissions and Bad Science

Bob Zadek: You are a retired physician. You have written two dozen books The most recent one is False Positive. What was it that prompted you to conceive of this book? Was there some event that caused you to perk up and get curious about journalism in the New England Journal of Medicine? What caused you concern to write an unusual and extraordinarily important book such as this?

Theodore Dalrymple: If I might start with a slight correction, it is published every week. Not every month. I have a French nephew who was a medical student and he had an examination which he failed in “how to read the medical literature.” It is a very good examination to find out whether people can read something critically, because we don’t read things very critically. He is also my assistant.

I thought I would think of a few rules for him. And then I thought that I would look in the New England Journal and see how much of the New England Journal is actually fairly good.

I must say I was surprised at how often I found very simple errors. In addition, the medical journal has a lot of social commentary. One felt, or I felt, after reading this for many weeks or months, that I was reading some kind of orthodoxy which was actually never challenged in the pages of the Journal.

Bob Zadek: You start with a journal that is a technical journal written for a technical audience, for practicing physicians and the like. This journal has achieved a well-deserved stature, and once it achieved this status it gets to a level to where it is presumed to be speaking the truth, or orthodoxy, it then expands and takes advantage of this position in order to lecture us and scold us and opine on matters well beyond their area of expertise. However, it remains cloaked in this aura of authority because of its name. So, they get to be believed somewhat blindly.

What are some of the examples of how far from the practice of medicine the New England Journal of Medicine wanders, and how off are they when they leave their comfort zone of pure medicine?

Theodore Dalrymple: That can be large things and small things. And sometimes the small things are more revelatory than the big things. So the very first item in the book relates to an article which actually is quite good about Haitian cholera and the hope of a new cholera vaccine. The article says that cholera was unknown in Haiti until 2010. Now, it seems to me that any one of the most minimal curiosity would say, well, if there was no cholera in Haiti until 2010, it might be worth a mention about how it got there. After all, it is a 19th-century disease and Haiti has lots of diseases of its own.

The reason that it wasn’t mentioned, and this is my surmise, was because it was brought by Nepali peacekeeping troops. They came from Nepal where there was a cholera epidemic, and when they arrived in Haiti their sewage was put directly into the water supply of a large part of the country.

As a result of that, between 10,000 and 80,000 people died and about possibly 10% of the entire population suffered from cholera. So it is an interesting question.

And then of course there is the question as to why the origin of this epidemic was not mentioned. And the answer to that seems to be that the journal itself together with the CDC and The Lancet, which is another very important journal, along with the World Health Organization, conspired for quite a long time to prevent it being known that the peacekeeping troops brought cholera to Haiti.

Of course, they didn’t do it deliberately. No one accused them of that. But it was something that they wished to hush up. I’m afraid the New England Journal didn’t cover itself in glory in this episode. So I concluded that actually they didn’t really want anyone to dwell too much on where it came from and why the journal and those other organizations hadn’t mentioned these facts.

Another very important thing to realize is how many of the papers are epidemiological in origin. That is to say they examine the distribution of diseases through populations. They are highly mathematical. Not one in a thousand doctors understand the mathematics. They draw very large conclusions from very doubtful information. So for example, epidemiologists looked at the all-cause death rate from the pollution of the air, found a correlation, and then concluded that the permissible levels of pollution in the whole of the United States should be altered, without any realization of just how difficult and expensive this would be, and without realizing that the logic of this is not to allow any pollution at all, because nobody would say that any pollution is good. Nobody likes pollution. They didn’t see the difficulties. They didn’t see the logical fallacy. It is a very elementary thing that correlation is not causation.

Bob Zadek: What was the thesis of the article? It seems to me that the whole area of air pollution is so much beyond the competence of doctors to either do something about or to understand it. It all relates to physical science and chemistry and simply other disciplines that doctors bring little more to the table than anybody else. So, did it surprise you that even the topic itself would be appearing in the New England Journal of Medicine?

Theodore Dalrymple: Not entirely, because take the question of a cigarette smoking, for example, and lung cancer. The Nazis first discovered this relationship. The epidemiologists early in the early 1950s correlated the death rate from cancer of the lung and cigarette smoking. So, they discovered something which was actually important and there was a plausible explanation as to why smoking would cause cancer. They were doctors who did it.

The problem is that the correlation between smoking and lung cancer and the causation of it was pretty clear. I mean, it was a strong correlation. But the same logic has increasingly been applied to factors in the alleged causation of disease which are weaker and harder to prove. What was originally a reasonable method of proceeding has now extended so that every week we get badgered about what we should eat or what we shouldn’t eat based on studies like this with very weak correlations and without real explanation as to why the correlation would exist. So it’s really an extension of a method which originally is useful and can still be useful, but which is obviously capable of great misuse and over-interpretation.

Many of these correlations, of course, turn out not to be reproducible. I remember in 1972, for example, there was an alleged correlation between green potatoes and spina bifida — when pregnant mothers ate green potatoes. And even now, people can’t agree as to whether this is a real causative correlation or not. Most people think that it isn’t but there are some who still maintain that it is. Now, the point about that is that if you can’t even decide on a relatively simple thing like that, it’s very difficult to give a hundreds and hundreds of recommendations. I think we are still badgered by recommendations as to what we should do on the basis of weak correlation.

Crime and Sociological Determinism

Bob Zadek: I should mention that the book is interesting in that the topics themselves were not topics that you selected because you felt they were important topics. You were driven by the topics which were presented by the articles in the journal as you read them. So the book is an interesting mix of almost independent essays based upon the articles you happen to have read. You spent some time writing persuasively about criminal law and criminal behavior. That is a topic that one would be surprised to see in the New England Journal of Medicine. What interest is it to a general practitioner in the Midwest to see an article on the behavioral sciences and criminal justice? Yet you dedicated a fair amount of time in the book to criminal law.

There’s a phrase I’d like you to help our friends out there understand. I paraphrase when I say you observed in more than one article that “criminals are treated as ill and the ill are treated as criminals.” That resonated with me because that phrase has been the topic of many shows that I have done on the area of drug legalization and on the area of wholesale incarceration for long periods of time of criminals. All of those are to me nonmedical issues that had to be resolved by society. Tell us what you have learned about the journal and its comments on this link between criminal behavior and illness or illness and criminal behavior.

Theodore Dalrymple: You see, if you take an epidemiological view of things and you look at illnesses through the lens of risk factors… so for example, let’s take diet: If you have the wrong diet then you get a disease. Because you can change your diet if you don’t change your diet and then you get the disease, you are in some sense responsible for getting the disease.

However, when someone acts criminally, he is said to be suffering from a disease and needs treatment. There is a therapeutic attitude towards criminality which I disagree with. And actually, you haven’t mentioned that I was a doctor for a long time in a prison. A lot of criminals in my view, have adopted this attitude of regarding themselves as ill.

They think of themselves not as agents but as being in the grips of something. So, for example, they might say that they are addicted to stealing cars just because they do it over and over again and find it exciting. They use a medical term, “addiction.” For what they do. They regard themselves as really the vectors of forces rather than people who have agency. It’s a subtle thing because they know in their hearts and between themselves that this is nonsense, but they get rewards for presenting themselves as if this were true. And if you repeat a lie over and over again, it becomes true. So, I was particularly interested in the question of addiction. In the prison in which I worked, heroin addiction was the most prevalent one.

It is presented everywhere by doctors as a medical illness, pure and simple. Now, there are medical aspects to it. Clearly there are very important medical consequences to taking heroin. But, I argued that it is not a medical condition in itself. There are physiological aspects to it. There is no doubt about that. Addiction is a genuine physiological phenomenon. But addiction to heroin is clearly not just an illness in the way that, say, rheumatoid arthritis or Parkinson’s disease is an illness. It’s not something that is not something that happens to you. It is something that you do. If you don’t mind me going on a little longer, I’ll give you some reasons for thinking this. In Britain anyway, the average length of time that people take heroin intermittently by injection before they become physically addicted to it is 18 months.

In other words, this is not something that just falls on them from out of the sky. In order to inject it, they have to know where to get it. Then they have to know how to prepare it and how to inject it. Injecting yourself is not something that most people want to do. Heroin has unpleasant side effects which you have to learn to disregard. Before any of this starts, people know now that heroin addiction has become so widespread that everyone knows what the consequences are.

So far from it being something that happens to you, I argue that it’s something that some people want. It can’t be just presented as something that happens to you and is straightforwardly a misfortune. And yet that is the attitude of the National Institute on Drug Abuse and this has been adopted more or less as an orthodoxy in the New England Journal, but not in the New England Journal alone. It is in other journals and in general in the leaders of the medical profession, though perhaps not among the foot soldiers in the medical profession.

Scientific Orthodoxy versus Personal Responsibility

Bob Zadek: Now there is a somewhat sinister but human reason why the approach of the medical profession to something like drug addiction might be different than the approach of society at large. We call this motivation public choice or sometimes greed.

How much of criminal behavior is the result of bad actions, simply criminal behavior itself, because somebody is greedy and wants somebody else’s property or wants to harm somebody? How much of that is pure criminality that has to be punished? After all, libertarians believe that the essential purpose of government is to protect us. It spills over because you can get into the areas of causation.

Somebody perhaps is more likely to become a criminal based upon environmental issues and based upon areas of early-stage parenting. So when you start to try to figure out where personal responsibility ought to stop and where it becomes an illness, that is where my head kind of starts to explode. After all, the likelihood that I, with my middle-class upbringing might succumb to criminal behavior is probably much less than somebody in a different environment. So how does one sort out intellectually when illness in the broad sense has something to contribute to criminal behavior?

Do we care or do people just have to play the hand they’re dealt? I have great difficulty annunciating a principal that I am totally happy with.

Theodore Dalrymple: I think the annunciation of the principle that everyone has to deal with the hand they are dealt is important because if you try to equalize that, you are arguing for a society that would make North Korea seem like a haven of freedom.

You can’t equalize the hand that people are dealt. It is still necessary to demand of people that they keep within certain limits. I dealt with this problem every day for years and yes, in the prison in which I worked, a man came to me, a burglar.

In England you have to be pretty incompetent or a very frequent burglar to be caught by the police. And he said to me, “Doctor, does burglary have anything to do with my childhood?”

I said, “Absolutely nothing whatsoever.” He was surprised by my response because he has been taught to believe that his behavior is simply a kind of physical response to circumstances. And I said, “It is quite simple. You want things, you are lazy, and you are not very clever.” Instead of being very annoyed, he started laughing as they always did when you went through this conversation. In a way they were quite relieved because they didn’t have to pretend anymore.

Now it is certainly true, however, that people like that often have horrible childhoods. You can talk about these childhoods but without implying that you are making an excuse for them. You must not give the impression that you are finding the buried psychological treasure that without any effort on your part will stop you from whatever you are doing. There isn’t any technical thing that doctors or psychologists can do to help that person.

Bob Zadek: I have two comments on what you just said. I was smiling as you were talking because I flashed back to American pop culture, specifically the song “Officer Krupke” in West Side Story, and I invite everyone to listen to the words of that song and you will hear exactly what Theodore has just said.

We have a caller on hold. Michael, welcome to the show.

Caller: Congratulations on a fascinating show and the guest’s opinion with which I agree 100% I would just like to comment on one thing. When we started dealing with AIDS and HIV in San Francisco, we did not judge the social behavior of the people who were carrying or involved with it. We just went ahead and looked for remedies. The New England Journal of Medicine published many studies on the remedies of HIV and how to mitigate it rather than deal with who gets it.

The same goes for gonorrhea and syphilis. We do not judge that it is more common among sex workers. We tried to find the cure. We have to limit our criticism — to what extent do we want a medical journal to go and tell me exactly how cholera was introduced into Haiti? Let’s just focus on the narrow issue of cure that belongs to medicine. That’s why my criticism of the logic of the guest, when he said that they did not tell us how cholera was introduced into Haiti. Really that is not the topic that we need to focus on. We need to focus on the cure. There is political correctness in the New England and every other journal, but in this case, I think they should focus on the medical part.

Theodore Dalrymple: Well, with regard to AIDS, he is absolutely correct that we should try to find the cure. But it is also important to find out how the disease spreads. It is not just that we cure, but we also want to know how the disease spreads so that people can have the information to alter their behavior accordingly, to reduce the risk of their getting the disease. So I don’t think it is either/or. And if, for example, people had denied that having unprotected sex propagated HIV, I don’t think you would be doing patients much good.

Similarly, with the case of cholera, you do want people to be careful about moving troops. It is a medical problem. You do want people to think about these things.

Also, the New England Journal had not been mainly disinterested, they actively wanted to deny the truth. And if it hadn’t been for a French bacteriologist and epidemiologist, this truth would have been covered up. And I’m not saying that we should dwell on it to the exclusion of everything else, but it does seem to me a matter of medical interest.

Bob Zadek: We have another caller.

Caller 2: I agree with everything you said Theodore, and I’d like to add something about addiction. One of the clearest distinctions between a disease and an addiction is that you normally don’t decide to have a disease, but with an addiction, you make a decision. You decide to shoot up and decide not to stop. But this is not true of disease. So an addiction is more of a cognitive process. Even though I agree with you that the brain is involved.

Theodore Dalrymple: Addiction is willed. It doesn’t mean that you withdraw all sympathy from them, however, because if someone is partly responsible for his own downfall, it doesn’t mean to say that you don’t sympathize with him. After all, we’re all partly responsible for our own downfalls. I doubt that there’s anybody listening who is not responsible in some way for his own unhappiness. However, we do have this tendency now to say that we would sympathize only with people who are not responsible for their conditions.

Caller 2: We need to teach people how to get over addictions by teaching them that they are not powerless.

Theodore Dalrymple: The problem is, of course, that by the time they realize they want to change, they’ve done so much damage to their life that it is extremely difficult.

Obesity: Illness versus Choice

Bob Zadek: Theodore, another crossover area between medicine and personal responsibility that you comment on is obesity. Tell us briefly what the thesis of the New England Journal of Medicine was on obesity and why you felt that they were spilling over into an area of behavior, rather than a medical issue?

Theodore Dalrymple: Well, obesity is obviously a very complex matter. The epidemic of obesity is not just in the United States, but everywhere in the world. It is not quite as bad as in America but it is pretty bad in many places. The fact is that overeating and eating things which lead to obesity is very common. The problem becomes whether you say to people, “You did this to yourselves so we are not going to help you?”

Do you make people pay extra for health insurance? Do you force them or encourage them to eat different things? Do you make it difficult to obtain certain foods which are bad for them? Who has the responsibility for doing these things?

Bob Zadek: What did you find? How did you differ from what you read in the Journal?

Theodore Dalrymple: Their thesis was more or less that obesity is a disease. There’s nothing else and must be treated as a disease. There’s simply nothing else to say or do. You mustn’t even mentioned that it is a condition of overindulgence.

Bob Zadek: Once again, there is somebody who is a victim. We have discussed many times on the show this victimization of bad behavior, so that people who behave badly are more victims rather than actors in what they are doing. Once you label something a disease you relieve them of any responsibility. It has nothing to do with them. The cause is existential and therefore they simply have to be treated. This means that the cost of their own actions is absorbed by society.

In making that observation Theodore, you remind us of a very important point.

Once society is led to believe that bad behavior is the result of an illness, what happens is that the bad behavior and the cost of fixing that problem, is now absorbed by all of us.The responsibility becomes a collective responsibility rather than an individual responsibility.

So the effect of achieving the labeling of bad behavior as an “illness” is that the responsibility and the cost is transferred from the individual to the collective. And that is fascinating to me because that’s where a discussion of the New England Journal of Medicine spills right over into libertarian concerns.

Now Theodore, what is your conclusion that Americans at large ought to take away from your book and from this transfer in labeling of bad behavior from behavioral to medical?

Theodore Dalrymple: I think the first thing is self-examination. One has to see how far one does it himself. We do not only absolve others, we absolve ourselves. It’s a human temptation to do that.

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