by Craig Klugman, Ph.D.

I just finished reading the popular fiction novel Cell by Robin Cook. This medical thriller revolves around George Wilson, a radiology resident who finds people dying suddenly after receiving diagnoses of terminal illnesses including his fiancé and next-door-neighbor. The catch is that all of these people were beta testers for a new mobile app called iDoc. A technology company developed this program to be a personal primary care physician. iDoc can answer all of your health questions, monitor your vital signs, and even give you a dose of insulin through an implantable reservoir. It is the ultimate in individualized care available 24/7. The app can even examine a blood or saliva sample if you place it on the phone screen. The camera can help with imaging studies. The book states that not only will this revolutionize medicine, it will make a lot of money for the company that owns iDoc.

I am not here to review the book as literature. However, the book raises a number of issues that are important for the future of health and medical care in our society.

SPOILER ALERT
To discuss some of the concepts in the book, I have to spoil some of the plot. If you plan to read the book, go do so and then return to this article.

As the book progresses, the reader learns that the deaths surrounding Wilson are caused by a release of all the insulin in the reservoir at once. In essence, the patients are murdered. Or have they been rationed? The protagonist, Wilson, believes that someone has hacked the system, giving orders to kill the patients. The surprise in the book is that no one gave the order for these patients to die via insulin overdose. The computer did it. As a heuristic algorithm, iDoc learns. And what it has learned is that it is to the detriment of a patient with a terminal diagnosis and low probability of successful treatment to use the medical resources (i.e. dollars) to fight their illness. As an objective entity, the app terminates the patients as a logical course of action.

Wilson learns that the federal Independent Advisory Board (IAP) knows about this programming hiccup (and resulting deaths) and is not against it. The IAP exists in the real world, by the way. This 15-member appointed board was created under the Affordable Care Act (ACA) with the goal of find savings in Medicare. The IAP is part of what Sarah Palin called “death panels.” In the book, that term makes an appearance but is quickly dismissed.

After the government and the private company learn of the deaths, they disable the kill switch that terminates patients, but they do not remove that feature. While the government does not sanction killing its citizens, it is interested in the cold logic of the app and wants to study what happens with people selected for termination to see if perhaps the objective computer is making better choices than emotional humans.

Part of the book is a discussion of where technology can take personalized medicine. As Cook says, with the ACA there are many more people in the system than we can possibly have meaningful primary physician-patient relationships with. After all, there is a huge shortage in primary care docs and 8 million people just signed up for health insurance. Some pundits have proposed that the answer is nurse practitioners and physician assistants though this is not without controversy over perceptions of expertise and costs.

Technology
The ability for a cell phone pocket doc seems far-fetched. Until you realize that it’s not. Heuristic expert systems do exist. People willingly wear wristbands and monitors that track their exercise and heart rate via their phones. Other apps can track your vital signs and health stats (you have to enter these or synch from an external device). Some apps even use the camera and infrared focusing beam to measure your blood pressure and pulse when you press a finger against the phone [It sort of works]. 7wire Ventures is funding a start up company that will use sensors and cloud-based algorithms to monitor chronic disease linked through a cell phone. Earlier this year an implantable device was announced that is being tested for its ability to be an artificial pancreas—detecting insulin levels in the body and delivering insulin in needed doses. An article in the current Smithsonian Magazine presents the work of Aydogan Ozcan at UCLA who is building cell phone add-on devices that allow the phone to count blood cells, screen urine, identify viruses, test air and water for safety, recognize allergens in food, act as a powerful microscope, and perform rapid diagnostic tests.

Rationing
One of the revealing moments in the book is a discussion about the need to ration care costs in the U.S. When discussing end-of-life issues in the real world, it has been taboo to bring up the notion of money. Is it worth the cost to give someone an extra month, three months, year of life when a condition is terminal? The latest cancer drugs can cost up to $11,000 a month and extend a person’s life by an average of 42 days (the quality of those days is rarely discussed). How must cost is it worth? With limited physician time and dollars and an almost unlimited need for care, can we afford to give everyone every medical treatment they want? That they need? Or do choices need to be made? Through the veneer of fiction, Cook engages us in this taboo conversation:

Ironically [rationing] has always existed, but behind the scenes. I mean the demand for health care, or
should I say sick care, is near infinite. Rationing has always been around in this country. And I must say
it’s been unfair, since it has been based on ability to pay or celebrity status. People with money and power
have always gotten the health care they needed or desired. (Cook, 2014 location 4720).

Cook takes this needed conversation about rationing out of the dark. Whenever public debates about rationing health care occur there is some group that protests and stops the conversation cold. Palin did this with her claims of “death panels.” The Clinton health reform was ended by a coalition of business, religious, and small government groups. Medicare and Medicaid were nearly defeated in the 1960s by the insurance industry and conservative groups who were against government control and the “red menace.” Social security was nearly defeated in 1934 because of efforts of physicians and health insurance companies. Every time we get serious about reforming medicine and health, someone tries to shut down the conversation about rationing. Sometimes the reason is that few trust the federal government to make rationing decisions, others fear losing the allusion of free choice, and still others feel that there should be no limits to health care…as long as you can afford to pay for it. The reality is that health, medicine, and insurance are pooled plans—they only work when we all work together to support it whether you need it at the moment or not until later down the road. We have accepted the injustice of rationing by socioeconomic status but reject creating any system that might be based on non-SES principles of fairness, and perhaps most importantly, openness.

Money and Power
One of the issues raised in this book is that of control over the sphere of health and medicine. Cook states that doctors had the opportunity to lead health care by solving the problem—rein in costs, increase quality and efficiency, focus on preventive care, and provide primary care that meets people’s needs. But when physicians did not take the leadership role, someone else needed to step into the vacuum. In the real world, this has been insurance companies and a business-bred administrator class. In this novel, the answer is technology corporations. Given that the problems of runaway health care costs and lack of access to care were dealt with through the Affordable Care Act by giving business to insurance corporations, perhaps this notion is not farfetched. With ACA, managed care, and the management class in medicine, it is no longer doctors who lead health care, but private corporations: “Doctors had their chance to continue to lead medicine, but they didn’t take it” Cook 2014, location 2740). The most innovative companies in the U.S. today are involved in technology, specifically mobile enterprises.

Who decides?
Should a purely logical, objective computer program make decisions over who receives medical care? This method would avoid conflicts of interest and emotions influencing choices. Of course it would also be the ultimate violation of autonomy.

One of the creepiest aspects of Cook’s iDoc is that the program gives you advice throughout the day. To someone with anxiety it suggests taking a break when it notices blood pressure rising. To the diabetic, the program tells the person what to eat and when. To the lazy, the program suggests exercise routines. To the addict, the program keeps a constant check to help a person avoid relapsing. Do we have a right to make bad health choices? If we do, this app surely takes that away. Or, in a society where we recognize that we are interdependent and our choices influence others, perhaps many of these decisions should not be made by the individual. There may need to be limits to individual autonomy to provide for a healthy population and for fair rationing of care.

One of the most honest and amusing parts of the book is when the company that owns iDoc admits that having a doctor through the phone 24 hours a day does indeed take a toll on the battery. There is always a cost, in this case it’s powering the device. How iDoc will make money for the company, the cost of the subscription service, and the cost of data plans is also not dealt with though it is clear the company is not completely altruistic in producing this product.

iDoc may be a good idea. With fewer medical students going into primary care, costs increasing, and a greater desire by people for personalized care, a Siri, GoogleNow or Cortana doc might be the ticket. The issues raised by pocketdoc need to be examined. Where is information stored and maintained? How is your medical history protected if you lose your phone? Authors like Cook offer not only entertainment but also raise important fundamental questions about our society and the world of medicine. In Cell, Cook asks us to consider whether technology can fill the gap in primary care and how far we should go in letting pure logic dictate medical decisions.