08 July 2009

Critical Response: FKD Nahm, "Neurology, Technology, and the Diagnostic Imperative," Persp. Biol. Med. (2001) 44: 99-107

In his essay exploring the rise of technology in neurological medicine and the philosophical attitudes that underlie the use of that technology by physicians, Frederick Nahm offers several proposals for consideration. He suggests firstly that no one would argue with the claim that diagnostic technologies like CT and MRI offer an important supplement to the physical exam. Nahm judges that this claim might imply that patients are the chief beneficiaries of these diagnostic technologies, but he proposes the more nuanced perspective that these technologies also offer direct and indirect benefits to neurologists. If Kahn is correct in his view, then broader economic considerations enter into the picture. Does management, for example, have an obligation to prevent the needless use of these technologies when diagnosis is all but certain? Kahn never takes a stand on this question. He prefers instead to state simply that his paper demonstrates that physicians and managers evaluate the usefulness of diagnostic technology in terms of both direct benefit to the patient and direct and indirect benefits for neurologists.

What ought we to make of this argument? Like so many arguments that seek to answer bioethical questions through historical analysis, Nahm's argument places limits so substantial on the structure of his paper that many of the most interesting questions are ignored. He supposes, for instance, that it is obvious that all neurologists have a strong diagnostic imperative. That is, that their single largest motivation is to provide the sick patient with a diagnosis.

While there is no reason to disqualify this view as the ideal, Nahm presents little evidence that indicates that this goal extends in practice to all patients, scenarios and contexts. In any case, we know that it does not, because there are several gates through which patients must pass before they reach the neurologist. In American medicine, for instance, they must pass the basic economic thresholds that demonstrate their ability to pay for their medical care. Secondly, the patient must pass beyond the level of primary care provider to the neurologist, and it is thus likely that many physicians other than neurologists will have conducted these diagnostic tests on the patient before their referral to the neurologist. Without effort, we could identify other gates as well.

The curious feature of Nahm’s argument is that while its logic ostensibly pertains to neurological patients and practitioners, its intentions are to resolve economic questions for management. From a managerial perspective, the important question is how to generate revenue. To this goal, the direct benefits of scanning in hospitals are threefold: They generate fast revenue simply in-and-of themselves. They move patients quickly to those medical divisions of labour best suited to provide diagnosis, prognosis and care, and thereby move them more quickly out of the hospital. They mitigate charges of inaction or incompetence, and thus save capital otherwise paid in consequence of litigation. In other words, the question is not what does technology do or not do for patients, but what does it do for management? As so often happens in bioethical arguments, the author fails to recognize the sources of his question and thereby reduces ethical questions to economic imperatives. The ethical can only be the economic when profit motives are not in the picture.

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