"Cold Souls," "Taboo Trade-offs," and Serious Medicine

The new Paul Giamatti movie, “Cold Souls,” raises interesting points about Serious Medicine. Roger Ebert gave it three stars, and The New York Times called it “flat-out funny.” But from a Serious Medicine point of view, “Cold Souls” deserves to be taken seriously, as it illustrates dilemmas that we have seen, and that we will continue to see, in medical/scientific research.

“Cold Souls” is a comedy, albeit a black comedy, taking inspiration from, most obviously, Nikolai Gogol’s 1842 novel, Dead Souls. But what “Cold Souls” is, most of all, is thought-provoking. It gets us thinking about the Promethean, even Faustian, possibilities of medical technology.

Indeed, as medical science has climbed the grand staircase of advancement over the centuries, every step has been controversial, and some steps have been missteps. Once upon a time, dissection was controversial. So were vaccines. Today, we struggle with tough ethical issues, such as malpractice and organ harvesting, while terrible visions of Dr. Mengele and Dr. Kevorkian continue to haunt us.

But the enormous expanse of medical science has guaranteed that another group, economists, will try to fit it into their own Procrustean Bed of economic analysis. Yup, economists are always trying to boil health and medicine down to mere numbers. And while anything that costs trillions of dollars, worldwide, can and should be subjected to rigorous scrutiny, health-care economists will almost always be regarded skeptically, even hostilely, by their fellow humans. Why? Because, as Jim Woodhill has argued, health care is not an economic good--or at least it’s not an economic good in the sense of that widgets, or pork bellies, are an economic good. And so to apply economics to health care is also to apply “the dismal science” to some of the deepest impulses of human nature.

Indeed, economic analysis of medical science quickly brings to mind the phrase “taboo trade-off.” That phrase, “taboo trade-off” was coined by the University of California’s Philip E. Tetlock in his “Thinking the unthinkable: sacred values and taboo cognitions,” published in Trends in Cognitive Sciences in July 2003.

Tetlock makes the distinction between “taboo trade-offs,” which can’t be thought of as economic, and “routine trade-offs,” which can. As Tetlock explained, there’s a distinction to be made between “taboo trade-offs (which pit sacred values against secular ones) and routine trade-offs (which pit secular values against each other).”

Any attempt to apply economic accounting to health care is usually seen as “hard-nosed,” at best, and “cold-hearted,” at worst--it stumbles over people’s sense of taboo, also known as their deep-seated sense of right and wrong. Such concerns don’t stop economists from doing their thing, of course. In fact, morality-based criticism of economics only encourages some economists, such as the “freakonomics” crowd. Those who love to shock will relish the prospect of shocking further.

But for the overwhelming number of people, in any country in the world, the putative monetary value of a life is a great example of a topic which is, and should be, taboo. So is trafficking in human organs. Such discussions and transactions go on all the time, of course, but people don’t like them, and frequently, the transactions are illegal.

And yet for reasons that introduce us to the full complexity--or, if one prefers, perversity--of human nature, some health-care economists, even those inside the U.S. government, seem to revel in taboo talk.

A case in point is Ezekiel Emanuel, the special White House adviser on health care policy. By his own account, Emanuel has written more than a million words on health-care topics, which led The New York Times to summarize his career as having built “a reputation for pushing limits while exploring uncomfortable life-and-death issues in starkly academic terms.” Translation: Emanuel did a lot of taboo trade-offing.

So is it fair to call Emanuel a “deadly doctor” or even, “Dr. Death”? Well, fair or not, it’s too late. Emanuel has delved into the realm of taboo trade-offs, and it has cost not only him dearly, but also the Obama administration, which has seen support for its health-care plan plummet amidst accusations of “death panels.”

“Cold Souls” makes no reference to 2009 politics, but it, too, thrives in the realm of taboo trade-offs, albeit mostly for laughs. The film presumes that it is possible, scientifically, to extract a soul from an individual, and then, furthermore, to implant that soul in someone else. And yet the film is wrapped up in science, and pseudo-science; the device that does the soul-extracting and soul-implanting looks a lot like an MRI machine.

So, according to the film, out of such dark and weird science has emerged a transnational underground railroad of soul-trafficking. And yet the film always bears in mind the humane point that such “body part” trafficking is taboo--or at least it should be taboo.

So where does “Cold Souls” leave us? The precise notion of soul-trafficking aside, it leaves us with the uncomfortable feeling that edgy medical-trafficking is a) a bad idea, and b) inevitable. If something can be thought up, it will eventually get made. And if something gets made, it will eventually get trafficked, at least by some, in a harmful fashion. So just as there are never any final victories in the anti-crime work of policemen, prosecutors, and prison guards, neither will there be any final victories in efforts to stamp out bad medical ethics, and even evil medical ethics. We can try, we must try, and we will try, but the best that we can look forward to is a long twilight struggle, waged on the ramparts of human decency.

In the endless struggle to help people, the vast majority of doctors and medical scientists are great allies--heroes, in fact. And for the good doctors in the vast army of health-betterment, Hippocrates is the guiding general, the man whose Oath binds medical professionals to the light side. But sadly, not every medical doctor, or scientist, will be a trustworthy and loyal soldier in this great army. And the unrestricted free market, abstracted as it sometimes is by greed and amorality, is an uncertain ally.

“Cold Souls” is funny enough to make us laugh, but creepy enough to make us think.