The Eighth Circle of Hell

Botticelli’s painting, inspired by Dante Alighieri’s Divine Comedy, depicts Virgil ushering Dante through the 8th circle of hell. This penultimate level of sin was reserved for those who had committed fraud. The dictionary defines fraud as the deceit, trickery, or breach of confidence perpetrated for profit or to gain some unfair or dishonest advantage.

The sin of fraud is often nearly invisible to the perpetrator. The following quote, attributed to the Buddha, describes  the difficulty, “Easily seen is the fault of others, but seeing one’s own fault is far more difficult”.1

Modern research backs up this observation with studies that document how easily unethical behavior can be overlooked. This is particularly true when the recognition of such unethical behavior is not in one’s own immediate self-interest.2

Motivated blindness is a term that describes this slippery slope.3 The bias, whether driven by greed or creed, can become systemic, creating massive moral vacuums.4 History is replete with examples, including Hitler’s holocaust and the purges of Stalin.

In his farewell address to the nation, President Eisenhower urged us to be vigilant in order to confront the lurking threat of an ethical vacuum of power. He warned:

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist. We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together.

Eisenhower delicately expressed the necessity of “an alert and knowledgeable citizenry” to “compel the proper” balance of power to sustain the liberty and prosperity of our citizens. His warning may well have played a role in enhancing the vigilance against future threats of the military-industrial complex.

Could there be an analogous concern within the medical-industrial complex? Is it a stretch to perceive a self-serving element within healthcare that is powerful enough to drive the sector’s significant underperformance? From my perspective as a physician, such a position is all too plausible.

To better experience why, imagine yourself in the role of an oncologist in the following two scenarios.

Case #1 – A hypothetical situation

You have been caring for a patient since he was diagnosed with an incurable lung cancer about a year ago. You have treated him with two aggressive chemotherapy regimens, shrinking his tumor by 40%. He has felt pretty good since stopping chemotherapy three months ago.

Recently he saw a compelling TV ad (like this one)5, suggesting a drug would help him increase the days he could spend with his family. The ad strongly infers that anyone who truly cared about him would certainly want him to take this drug.

You asked your patient if he was concerned about the side effects of the drug mentioned at the end of the ad. He said, “No”. You then asked if he could remember any of the side effects and he again said, “No”.

This was your fourth patient in a month who saw the ad and asked about the drug. Your research of the drug turned up rather unconvincing data. For this patient at this time, your opinion was that the benefits were not worth the risks.6 You advised him that you would be glad to talk further about the drug after his next follow-up  x-ray. You also mentioned that you were glad he was feeling so well.

You did not tell him that you were wary about the drug because the drug company had previously paid a large FDA fine for exaggerating its marketing material. You were also concerned that all of the research on the drug to date was sponsored by the drug company and that it was impossible to tell how much of the research had been performed in countries with little research infrastructure.

The patient and his family had already decided they wanted to take the “chance to live longer” before coming to your office. However, they left saying they would think about what to do.

A week later your receptionist tells you that the family called to cancel all future appointments. They had decided to go to another doctor to get the chemotherapy they wanted.

Two months later the family calls asking for a hospice referral because the drug didn’t work and made him feel awful. The doctor who had given the drug suggested the patient return to his previous oncologist since he wanted no further chemotherapy.

How would you feel? Would you do anything different next time?

Case #2 – A real scenario from my experience

I noted a slight bump up in my income because I had been prescribing more of drug “A”. About a year before that, I had learned from a pharmaceutical firm’s representatives at a conference they were running, that drug “A” may well prevent “chemo brain”. “Chemo brain is the fuzziness in thinking that can occur after cancer chemotherapy, in my experience most often with patients being treated for breast cancer. The data shown was preliminary, but “very promising”. I was excited about the possibility of avoiding this quite alarming, yet common side effect, and I started prescribing the recommended higher dose of the drug.

A year after the conference, I learned that there was even stronger data showing that women with breast cancer who take more of Drug A have a higher rate of death.7 Documents from the company’s internal records showed that the company had been aware of this finding for at least two years. There also was a reasonable biochemical explanation for the increased death rate. I immediately reduced my use of Drug A after I became aware of this data.

How do these cases make you feel?

Let me tell you they make me feel. I am angry and hurt – angry because the financial reality of the system has resulted in profits becoming more important than patients – and hurt because my profession has been largely ineffective in combating this erosion of integrity.

Steve Brill’s well documented exposé, America’s Most Admired Lawbreaker (cited twice in previous Conversations), shows that we sometimes even honor, rather than chastise, those in the throes of motivated blindness.8  The pharmaceutical executive who oversaw the quite profitable marketing rollout strategy resulting in the “lawbreaker’s” $2 billion FDA fine was promoted to CEO shortly after the settlement.

The business analysts/reporters covering the lawsuit downplayed the $2 billion fine as just “the cost of doing business”. The money was at least mentioned; the patients that were hurt in the crossfire of greed were ignored.

I want to be clear that I have found righteous anger rather impotent. If Switch did not have a clear and effective solution for self-insured employers, I wouldn’t have written this blog.

Breakthrough To Better,
Carl

1The Dhammapada
2Ethical Systems on Decision Making
3Conflict of interest and the intrusion of bias
4High Volume, Big Dollars, Rising Tension
5Advertisement
6Drug Review Article
7Erythropoietin and Cancer: The Unintended Consequences…
8America’s Most Admired Lawbreaker

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The purpose of Switch Conversations is to invite business leaders in self-insured companies
to join us in dramatically reducing the cost and improving the effectiveness of healthcare.

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ALL POSTS:
Edition 1 – Solving a Well-Entrenched Problem
Edition 2 – A Case of Dr. Jekyll and Mr. Hyde
Edition 3 – Best marketing tagline of all time?
Edition 4 – Post-Truth Killed a President
Edition 5 – What’s an employer to do?
Edition 6 – Profiting From the Opioid Epidemic
Edition 7 – The Keys to Unlocking Better Decisions
Edition 8 – When Difficult Things Need to be Done Well
Edition 9 – Fixing Healthcare
Edition 10 – Beware of a Singing Cow
Edition 11 – Wise Reflections
Edition 12 – Warning: Reader Discretion Advised
Edition 13 – Can AI save healthcare? (Part 1)
Edition 14 – Can AI save healthcare? (Part 2)
Edition 15 – Can AI save healthcare? (Part 3)
Edition 16 – Embracing Reality to Improve Healthcare
Edition 17 – Everything I Needed To Know…
Edition 18 – The Eighth Circle of Hell
Edition 19 – So… What’s Our Solution?
Edition 20 – Protecting Integrity as a Core Strategy
Edition 21 – An Unadorned Legacy
Edition 22 – Time to Grow Up
Edition 23 – Against All Odds
Edition 24 – When Everyone Has Stopped Listening
Edition 25 – Focusing on What’s Important
Edition 26 – Don’t Give Up Your Shot
Edition 27 – Join the Goodhood
Edition 28 – Fixing Healthcare (Recycled)
Edition 29 – Taming the Healthcare Beast
Edition 30 – Leadership
Edition 31 – Better Health Requires Good Sense
Edition 32 – Little Decisions With Big Consequences
Edition 33 – Transformational Courage
Edition 34 – Transformational Courage – Part 2
Guest Post – Happy Thanksgiving! By Jeff Novick, RD
Edition 35 – Transformational Courage – Part 3

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  • […] ALL POSTS: Edition 1 – Solving a Well-Entrenched Problem Edition 2 – A Case of Dr. Jekyll and Mr. Hyde Edition 3 – Best marketing tagline of all time? Edition 4 – Post-Truth Killed a President Edition 5 – What’s an employer to do? Edition 6 – Profiting From the Opioid Epidemic Edition 7 – The Keys to Unlocking Better Decisions Edition 8 – When Difficult Things Need to be Done Well Edition 9 – Avoid Throwing Good Money After Bad Edition 10 – Beware of a Singing Cow Edition 11 – Wise Reflections Edition 12 – Warning: Reader Discretion Advised Edition 13 – Can AI save healthcare? (Part 1) Edition 14 – Can AI save healthcare? (Part 2) Edition 15 – Can AI save healthcare? (Part 3) Edition 16 – Embracing Reality to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell […]

  • […] ALL POSTS: Edition 1 – Solving a Well-Entrenched Problem Edition 2 – A Case of Dr. Jekyll and Mr. Hyde Edition 3 – Best marketing tagline of all time? Edition 4 – Post-Truth Killed a President Edition 5 – What’s an employer to do? Edition 6 – Profiting From the Opioid Epidemic Edition 7 – The Keys to Unlocking Better Decisions Edition 8 – When Difficult Things Need to be Done Well Edition 9 – Avoid Throwing Good Money After Bad Edition 10 – Beware of a Singing Cow Edition 11 – Wise Reflections Edition 12 – Warning: Reader Discretion Advised Edition 13 – Can AI save healthcare? (Part 1) Edition 14 – Can AI save healthcare? (Part 2) Edition 15 – Can AI save healthcare? (Part 3) Edition 16 – Embracing Reality to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell […]

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  • […] ALL POSTS: Edition 1 – Solving a Well-Entrenched Problem Edition 2 – A Case of Dr. Jekyll and Mr. Hyde Edition 3 – Best marketing tagline of all time? Edition 4 – Post-Truth Killed a President Edition 5 – What’s an employer to do? Edition 6 – Profiting From the Opioid Epidemic Edition 7 – The Keys to Unlocking Better Decisions Edition 8 – When Difficult Things Need to be Done Well Edition 9 – Avoid Throwing Good Money After Bad Edition 10 – Beware of a Singing Cow Edition 11 – Wise Reflections Edition 12 – Warning: Reader Discretion Advised Edition 13 – Can AI save healthcare? (Part 1) Edition 14 – Can AI save healthcare? (Part 2) Edition 15 – Can AI save healthcare? (Part 3) Edition 16 – Embracing Reality to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell […]

  • […] ALL POSTS: Edition 1 – Solving a Well-Entrenched Problem Edition 2 – A Case of Dr. Jekyll and Mr. Hyde Edition 3 – Best marketing tagline of all time? Edition 4 – Post-Truth Killed a President Edition 5 – What’s an employer to do? Edition 6 – Profiting From the Opioid Epidemic Edition 7 – The Keys to Unlocking Better Decisions Edition 8 – When Difficult Things Need to be Done Well Edition 9 – Avoid Throwing Good Money After Bad Edition 10 – Beware of a Singing Cow Edition 11 – Wise Reflections Edition 12 – Warning: Reader Discretion Advised Edition 13 – Can AI save healthcare? (Part 1) Edition 14 – Can AI save healthcare? (Part 2) Edition 15 – Can AI save healthcare? (Part 3) Edition 16 – Embracing Reality to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell […]

  • […] ALL POSTS: Edition 1 – Solving a Well-Entrenched Problem Edition 2 – A Case of Dr. Jekyll and Mr. Hyde Edition 3 – Best marketing tagline of all time? Edition 4 – Post-Truth Killed a President Edition 5 – What’s an employer to do? Edition 6 – Profiting From the Opioid Epidemic Edition 7 – The Keys to Unlocking Better Decisions Edition 8 – When Difficult Things Need to be Done Well Edition 9 – Avoid Throwing Good Money After Bad Edition 10 – Beware of a Singing Cow Edition 11 – Wise Reflections Edition 12 – Warning: Reader Discretion Advised Edition 13 – Can AI save healthcare? (Part 1) Edition 14 – Can AI save healthcare? (Part 2) Edition 15 – Can AI save healthcare? (Part 3) Edition 16 – Embracing Reality to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell […]

  • […] ALL POSTS: Edition 1 – Solving a Well-Entrenched Problem Edition 2 – A Case of Dr. Jekyll and Mr. Hyde Edition 3 – Best marketing tagline of all time? Edition 4 – Post-Truth Killed a President Edition 5 – What’s an employer to do? Edition 6 – Profiting From the Opioid Epidemic Edition 7 – The Keys to Unlocking Better Decisions Edition 8 – When Difficult Things Need to be Done Well Edition 9 – Avoid Throwing Good Money After Bad Edition 10 – Beware of a Singing Cow Edition 11 – Wise Reflections Edition 12 – Warning: Reader Discretion Advised Edition 13 – Can AI save healthcare? (Part 1) Edition 14 – Can AI save healthcare? (Part 2) Edition 15 – Can AI save healthcare? (Part 3) Edition 16 – Embracing Reality to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell […]

  • […] to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell Edition 19 – So… What’s Our […]

  • […] to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell Edition 19 – So… What’s Our […]

  • […] to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell Edition 19 – So… What’s Our […]

  • […] to Improve Healthcare Edition 17 – Everything I Needed To Know… Edition 18 – The Eighth Circle of Hell Edition 19 – So… What’s Our […]