One of the more erratic aspects of the current contagion is the approach to decision making with regard to controlling the spread of the virus, treating those infected with it and minimizing the associated adverse consequences. These decisions are hampered, as has been mentioned in previous posts, by a frenetic approach to managing data regarding the epidemic, as well as to the large amount of uncertainty and knowledge deficits that afflict even the most esteemed of those experts whose opinions affect those decisions. These factors are exacerbated by variances in the motives of decision-makers, as economic, political, scientific, humanitarian, and practical considerations compete for consideration in decisions-making processes.
Because of the lack of detailed knowledge of the SARS cov-2 virus, decision-makers defer to experts who, subject to the same disabilities, must rely on surrogates and educated guesses. As a result, we practice social distancing policies derived from conjecture and old habits. The six-foot rule, which is a staple of social distancing dogma derives from nearly 90 year old investigations into the spread of certain viruses by coughing and sneezing. Our six-foot rule is a decision based on legacy habits because we don't have anything better, Similarly, the 14 day quarantine rule is based on observations of members of the coronavirus family that are most definitely not SARS cov-2. The estimates of death and extent of infection are based on theoretical computer models that are so dependent on unsupported assumption, that the estimates themselves may as well be assumptions. Rather than assuming the inputs into models of questionable reliability, we could as easily assume the outputs.
It is not unreasonable for for experts to rely on conjecture, analogies, surrogate experiences and educated guesses in the absence of more reliable and rigorous data and more detailed understanding of the processes. It is unreasonable to pretend that these models, predictions, guesses and theories are accurate simply because they are the best we have. It is unreasonable to pretend, in other words, that guesses and conjecture are accurate simply because an expert with inadequate information and understanding adopts them.
Some hospitals have adopted guidelines for the use of hydroxycholoroquine and azithromycin in COVID-19 patients. These often require the patient to exhibit a declining course and to be at high risk of needing intubation and mechanical ventilation. Other physicians question the reasonableness of this, arguing that earlier intervention with these interventions might prevent the deterioration that occasions consideration of second and third line interventions. The decision making here is again reasonable, but certainly not unassailable. The assumptions are that hydroxycholoroqine and azithromycin are unproven interventions, which is undoubtedly true, and therefore both the benefits and risks are uncertain. If however, the patient is at greater risk of death, in the absence of proven interventions, the risk benefit ratio shifts in the direction of intervention. This reasoning does not make either providing the therapy or withholding it correct. It merely illustrates that the model of decision-making, in this example risk-benefit analysis in the face of uncertainty results in a class of decision that might be different under different decision-making criteria. A similar principle is seen in the reluctance of certain medical advisors to resist prescribing these medicines because there is no conclusive proof of their efficacy. This position is wholly defensible within a particular context, i.e. protecting the science and evidence-based foundations of modern medicine. It is less defensible in the context of treating patients infected with a novel pathogen for which no proven therapies exist.
Other decisions demonstrate the same criteria based sensitivity that may make them seem irrational. One example is the prohibition on purchase of "non-essential" items from stores that also sell essential ones. One can contemplate that allowing purchase of non-essential items might lure people from their shelters when they otherwise would remain at home. This, however is a third-order consideration. It is extremely unlikely that the ban on purchasing child safety seats would save a single life that would otherwise be lost to COVID-19. It is not an example of reasonable decision-making but rather an irrational, panicked excess by people who do not seem particularly well suited to such decisions.
A similar principle is observed in the odd orders by certain governors to prohibit practitioners from prescribing choloroquine or hydroxycholoroquine to patients diagnosed with COVID-19. Again there is a certain cursory rationale that may be invoked regarding hoarding or capricious use. However, none of these considerations even remotely abrogates that principle that therapeutic decision should be made between a physician and the patient in the best interest of the patient. Certainly, it might be reasonable for a state medical board to warn that prescribing practices other than to treat active infections would be considered unprofessional conduct, and leave it to the medical profession to regulate, well the practice of medicine. For politicians to insert themselves into the physician-patient relationship is one set of decisions that is unlikely to age well.
Decisions regarding medical and public health interventions are confounded by incomplete, shoddy and manipulated data. They are affected by sometimes conflicting priorities, such as maintaining the evidence based fundamentals of medical care, and the urgencies of a particular case. They are hampered by considerations of political expediency, economic interest and the burdens placed on everyday life, with no tangible evidence of benefit. They are obscured by uncertainty regarding goals: are we trying to flatten the curve, minimize infections, achieve herd immunity, or something else? They are impaired by reluctance to answer hard but inescapable questions: how many deaths or hospitalizations are "worth it" to start getting back to normal? Serious people know that the reasonable answer is some number other than zero, but are reluctant to say so because other considerations are the basis for that reluctance.
One thing that this experience with the Wuhan coronavirus has demonstrated is that, quite frequently, the people who are in a position to make important decisions are not in those positions because of a demonstrated ability to make good decisions.
No comments:
Post a Comment