Heads and tails and a liver

A physician is obligated to consider more than a diseased organ, more even than the whole man — he must view the man in his world.

- Harvey Cushing

Be careful, when you get into practice, to cultivate equally well your hearts and your heads.

- William Osler

In 2020, I designed a small online survey called “Distributive Justice in Healthcare”, inspired by the research by Ubel et al [1]. The idea was born out of the early COVID-19 pandemic — a time when ventilators, ICU beds, and even basic protective equipment became scarce overnight. Suddenly, triage became the norm, and difficult decisions had to be made about who gets access to these resources. I found myself wondering how I would make such decisions if I were in charge, which got me into the medical ethics literature.

Distribution of scarce medical resources is most relevant in the context of organ transplants. The triage calculations that happened during COVID happen quietly in every organ transplant committee. Before anyone is even placed on the transplant list, they go through a detailed assessment not only of their medical condition but also of their behavioral and psychosocial factors. Such assessments raise two major problems: first, which questions to ask, and second, how to quantify the answers in order to rank patients on a list — because ultimately, that's what needs to happen.

This is essentially the ancient philosophical problem of comparing the value of different lives, which modern medicine attempts to quantify through quality-adjusted life years (and it sounds like a joke). But poor formulation doesn't make the question disappear. First, you must decide what quality even means, then, whether every year counts the same, and finally, in which contexts these measurements apply. How do you compare the next five years of a child with leukemia to those of a thirty-year-old mother of two? I'm not trying to make anyone emotionally uncomfortable here. The point is to show how quickly these comparisons become far from straightforward, and how the line between clinical reasoning and moral judgment gets blurred.

What doesn't kill you – is probably a commensal

Nothing in biology makes sense except in the light of evolution.

- Theodosius Dobzhansky

When you work on mathematical modelling, you tend to resist the idea of assigning special attributes to certain parts of your system just for the sake of explaining the data. Special cases should emerge from the basic principles of the system, not because there is something inherently special about that case per se. By that logic, there are no special cases, there are only less and more frequent cases, both existing in the state space of your core mechanisms. If this is not the case, either a dimension is missing (which may feel like an inelegant way to resolve the issue, but sometimes it really is necessary), or there may exist a completely different set of mechanisms that would explain that (n+1)^th observation. Probably the best example is the transition from Newtonian to quantum mechanics: Quantum mechanics doesn't just extend Newtonian mechanics - it replaces its foundational assumptions.