The Pretense of Healthcare

Despite exponential gains in scientific knowledge, some of our most pressing afflictions remain unresolved (and are worsening), begging the question: could our faith in science and technology as panaceas be misplaced? An impartial assessment reveals a troubling dichotomy — while scientific progress surges forward, critical health and welfare problems persist or even deteriorate.

It may be asked, "What does someone in finance and economics know about science and healthcare?" But my foray into this topic was inspired by my favorite economist, F.A. Hayek, who felt compelled to comment on the limitations of science in dealing with human problems in his Nobel Prize acceptance speech, The Pretense of Knowledge:

[T]he confidence in the unlimited power of science is only too often based on a false belief that the scientific method consists of a ready-made technique, or in imitating the form rather than the substance of scientific procedure, as if one needed only to follow some cooking recipes to solve all social problems.

Please make no mistake, I don't claim to be a great polymath like Hayek, but his inquisitive spirit guides my reframing science and healthcare through his business cycle theory lens.

Hayek is best known for his vast contributions to Austrian economics. I don't intend to turn this into an essay on the unfortunate economic policies of our healthcare system (easily done by exploring the many examples of government interference, the undermining of price sensitivity, and the misguided incentives of government farm policy). But I will recall Hayek's business cycle framework as I examine American healthcare more broadly, highlighting the uncritical faith in scientific and technological solutions to improve human welfare.

Acknowledgment of Progress and Limits

Before proceeding, it is important to recognize that science and innovation have undeniably uplifted our lives by improving disease treatments, boosting sanitation, reducing poverty, and expanding access to knowledge. It’s a remarkable story of progress. While certain applications of scientific knowledge may have unintended negative consequences, the scientific method remains invaluable for testing and advancing our understanding of the world.

The crux of the issue lies not in science itself but in how we employ it. Rather than advocating a return to a time before scientific enlightenment, the intent is to shed light on the perils of overestimating its scope.

The Spending/Outcome Gap

Now, let us consider the healthcare apparatus, perhaps the most rigorously "scientific" industry. It’s undeniable that the United States pours vast resources into medical expenditures, accounting for nearly a fifth of its economic output (World Bank). But rates of iatrogenic harm (harm caused by medical treatment or procedures), obesity, chronic illnesses, and pharmaceutical use continue to surge in parallel. Greater spending alone isn't problematic, provided it results in satisfied consumer preferences.

Consider this:

• Childhood obesity has tripled over the past 40 years, with 19.3% of children aged 2–19 now obese, up from 5.5% in the early 1970s. (CDC)

• 60% of American adults have at least one preventable chronic disease, and 40% have two or more. (CDC)

• Despite expansive treatment, hypertension went from affecting around 20% of U.S. adults in the 1960s to about 48% by 2021. (CDC)

• U.S. healthcare spending has risen steadily from around 6.9% of GDP in 1970 to over 18% in 2021. (Peterson-KFF Health System Tracker). 

• Prescription drug spending in the U.S. exceeds $370 billion annually, increasing about 5 percent annually over the past decade. (Statista)

Where is our return on investment in biomedical science? 

Or take the pharmaceutical industry, often hailed for its innovations. How does one explain the inverse correlation between pharma's "cutting-edge" drugs and declining public health? As with past scientific orthodoxies, today's require a cautious review.

For those inclined to appeal to authority, where are those charged with safeguarding the public? Not only do they choose not to investigate the failures, they are the most ardent supporters of the status quo. While the industry-regulator door revolves round and round, and lobbyists rain helicopter money on politicians (to the tune of $233M per year, according to a study by Olivier J. Wouter), communities across the country battle a pharma-generated and government-approved opioid crisis.

The Perils of Technocratic Paternalism

When facing challenges, technocratic paternalism offers scientific interventions — novel therapies, customized analytics, and personalized medications. This mindset assumes that with enough data, modeling, and scientific knowledge, experts can engineer societies to perfection — a conceit of unlimited capability. The premise seems unimpeachable: advanced science creates superior solutions.

But reason betrays this axiom. Perhaps this is just a gigantic example of the streetlight effect in which we turn to the most accessible place for answers. Or there may be something more nefarious ongoing. Either way, these solutions aren't working.

Humans are not metrics, and people shouldn't be treated as subjects to be acted upon but as agents with creativity and free will. When taken too far, reductionism diminishes the human spirit and its capacity for social critique.

We are in the midst of a health outcome bust despite a health spending boom.

America's health outcomes lag behind countries spending a fraction as much. For example, Japan's longevity exceeds America's (by a whopping 10%) while spending 66% less per capita on healthcare (Statista), despite an aging population. Might humility before the limitations of scientific materialism allows for a more inclusive system that blends modern technique with humanistic insight?

From Bust to Boom

Hayek's business cycle theory contends that while well-intentioned, central bank interventions to lower interest rates and boost money supply sow the seeds of a future economic bust. This artificial boom leads to malinvestment and distortion of market signals. 

The rapidly rising yet unproductive healthcare expenditures reflect malinvestment too. In healthcare, the trillions invested have crowded out potentially better approaches while generating diminishing health returns. It is an illusory boom masking accumulating frailties like misaligned profit incentives, regulatory capture, and an overreliance on intervention. Without change, these distortions provoke a self-reinforcing cycle where a lack of progress generates compensatory overspending, fueling further cost inflation and worsening health returns.

While not a perfect analogy to business cycle booms, this bubble of excessive trust in biomedicine now threatens a bust scenario of financial calamity, public dissatisfaction, and social disruption. Avoiding the most acute damage will require rebalancing and integrating scientific reductionism with systems insights and holistic wisdom. The goal should be sustainable progress where innovation and investment are allocated to elevate human flourishing.

But challenging medical or pharmaceutical orthodoxy prompts charges of irrationality and anti-science subversion — bewildering charge considering the essence of science is relentless questioning. This submission to institutional power echoes past scientistic zealotries.

Were Galileo and Pasteur not once condemned for contesting false theories?

A Balanced Approach

Empirical, reductionist modes of inquiry must be situated within a more holistic framework that honors the forms of knowledge embodied in humanistic insights and wisdom traditions. Science alone cannot capture the full richness of the human experience or our place in the ecology of life. Purely technical solutions falter when detached from a larger framework of human flourishing. 

Thus, the task is respectfully integrating evidence-based science with philosophy, spirituality, community, ancient wisdom, and the aspects of existence that are not reducible to atoms and equations. 

For instance, nutritional sciences reveal the biochemical impacts of nutrients and compounds. Yet cultural foodways integrate this with spiritual relationships to food and balanced subsistence lifeways. Medicine identifies risk factors for diabetes, but communities provide connections that prevent social isolation. Genomics reveals disease mechanisms, while mindfulness relieves suffering through presence. 

Of course, holistic paradigms, too, have limitations. Appeals to ancient wisdom without scrutiny can propagate pseudoscience. Further, some conditions clearly require clinical interventions. In developing integrative models, care must be taken not to validate anti-science attitudes. Such a model should thus undergo rigorous scrutiny, measurement of outcomes, and avoidance of ideology or partisanship. The intent is to open space for science's inclusive and ethical application, not advance dogma. 

If science is tempered with epistemic humility about its limitations, resources wasted on costly but marginally impactful technologies could be redirected to strengthen the foundations of health and wellbeing. For example, accepting the inability of high-priced pharmaceuticals alone to address chronic disease creates resources for a food system ripe with nutritious, regeneratively farmed foods. 

In essence, scientific knowledge provides reductionist insight, while humanistic wisdom supplies meaning, ethics, and ideal forms of practice to guide health-affirming choices. Both are essential.

Changing the Paradigm

To implement such change, reforms in government, academia, industry, and journalism must occur. There are too many possibilities to explore here fully, and I don't claim to have a magic bullet, but here are some ideas. 

The government could stop subsidizing unhealthy calories. As author Michael Pollan noted:

“Very simply, we subsidize high-fructose corn syrup in this country, but not carrots. While the surgeon general is raising alarms over the epidemic of obesity, the president is signing farm bills designed to keep the river of cheap corn flowing, guaranteeing that the cheapest calories in the supermarket will continue to be the unhealthiest.” 

Regulatory processes could be realigned to prioritize long-term efficacy and safety over marginal product differentiation. Many drugs approved by the FDA are later pulled from the market due to a lack of efficacy and side effects. Krishnan Chary noted several results of a fast but flawed expected review process. Here's one:

Dabigatran, an oral direct thrombin inhibitor developed by Boehringer Ingelheim, was projected as superior as conventional warfarin and awarded fast-track process. The FDA reviewed and approved the molecules within 6 months on October 19, 2010. FDA justified for producing fast-track status stating dabigatran is safe and hence monitoring can be omitted, unlike warfarin. This justification is nullified by postmarketing surveillance, which revealed increased gastrointestinal bleeding by dabigatran and safety alert announced by May 13, 2014.[5] The same pharmaceutical Boehringer Ingelheim is now marketing Idarucizumab as an antidote for dabigatran-induced bleeding in 2015. Dabigatran and its antidote are neither cost-effective nor safer than warfarin and its antidote, Vitamin K. Developing and marketing a new molecule out of weak hypothesis and then inventing an antidote by the same pharmaceutical company within 4 years support the pitfalls of inadequate review time and process by FDA. 

(Chary KV. Expedited drug review process: Fast, but flawed. J Pharmacol Pharmacother. 2016;7(2):57–61. doi:10.4103/0976–500X.184768)

Patent laws could be restructured to weaken or end pharmaceutical monopolies. A 2016 study in The Journal of the American Medical Association (JAMA) acknowledged:

“The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents.”

Healthcare organizations could invest in non-clinical measures emphasizing the importance of nutrition, movement, resilience, nature contact, and community to complement traditional clinical treatments. 

But the real work occurs at the individual level. Suppose we worked to think more critically with a healthy dose of skepticism, maintain high evidentiary standards, accept personal responsibility for our health and wellness, and defend free speech and open discourse. In that case, we can will the improvements we seek but likely won't get from those who benefit from our current condition.

Opportunity Cost

In closing, this critique has aimed to illuminate the mounting opportunity cost of an unexamined faith in scientific solutions. 

Hayek ends his Pretense of Knowledge speech with a warning:

The recognition of the insuperable limits to his knowledge ought indeed to teach the student of society a lesson of humility which should guard him against becoming an accomplice in men’s fatal striving to control society — a striving which makes him not only a tyrant over his fellows, but which may well make him the destroyer of a civilization which no brain has designed but which has grown from the free efforts of millions of individuals.

With open and interdisciplinary discourse, we may yet harness science in service of the full flowering of human existence. The alternative, unfettered scientism without wisdom, imperils the very future it purports to perfect.