Arguments Against Comparative Effectiveness Research Deploying Nth Degree Hypotheticals

Medicine is a complicated subject. And new treatments are devised fairly regularly. Also devised fairly regularly are new applications for old treatments, and new ways of doing old treatments. Meanwhile, the general idea is that a doctor will continue practicing for decades after leaving medical nurse and that patients won’t necessarily have advanced degrees that are directly relevant to their ailments. Under the circumstances, you can easily see how everyone’s decision-making might be improved by conducting and disseminating research on the comparative effectiveness of different treatment modalities. Such research could save lives and could also save money. But of course it’s bad for certain for-profit providers of medical services. If I’m in the business of making medical devices or pharmaceutical products, I don’t really want people to know what’s effective, I’d rather just rely on the power of my marketing apparatus.

Among other things, in the absence of real information, high prices and “newness” can act as a signal of quality. Which heart medicine do you want, this old cheap generic one that they give to Medicaid cases or my shiny new and much more expensive one reserved for prosperous patients like you? Well, what I’d really like is some credible research on the question. But the makers of the shiny new more expensive drug don’t like it. Which, as Hilzoy reminds us has brought about some mighty curious arguments from industry’s bought-and-paid-for friends on the right. For example, the Heritage Foundation darkly warns:

The type of information collected by CER could eventually be used inappropriately if a “Federal Health Board” was created to decide which types of treatment would be available to whom and when.

You have to check out the number of steps here:

— First, we implement comparative effectiveness research. — Second, we create a Federal Health Board. — Third, we empower this board not only to decide what the federal government is prepared to pay for, but also what private individuals are allowed to buy on their own. — Fourth, the Federal Health Board starts using this research inappropriately. — There, they conclude, we should eschew step one.

This is on a par with saying we shouldn’t build a steel plant because steel could be used to build AK-47s which could be used to murder innocent people. Sure, this dire sequence of events “could” play out, but the underlying assumption seems to be that the American public is loudly clamoring for inappropriately designed comprehensive health care rationing and the only thing stopping the congress from imposing it is a lack of sound research (nevermind that you could ration inappropriately without research).


Clearly the thing to do is to try to stop this chain of events somewhere further down the line. I do know that something resembling step three is in effect in Canada, but I know of literally nobody in the United States of America who favors this idea. Indeed, my strong sense is that it’s only politically viable in Canada because it’s relatively easy for Canadians to travel to the United States if they want to pay out-of-pocket for medical services. To go to step two would be an extremely difficult political fight. And, frankly, you’d expect it to be a fight in which it was conservatives who were arguing for cuts in federal health spending and liberals arguing for a more generous program. But to try to stop the chain at step one is perverse.