Do Nothing When Nothing Must Be Done

by: Vishal Khandelwal

Disclaimer: This post isn’t against doctors or financial advisors. I respect both these professions but believe that a system bent on action often leads professionals in these fields astray. The consequences are often bad for their counterparties – patients and investors.

It was sometime in 2008. I had an uncle who was a well-known dermatologist in my hometown. One day, on a routine annual checkup, the radiologist found a lump in his stomach. My uncle then got himself checked by his surgeon friend. The diagnosis was stomach cancer.

This surgeon was one of the best in this field and had even successfully tried a treatment on this exact cancer for other patients that tripled the five-year-survival odds – from 5 percent to 15 percent – albeit with a poor quality of life.

My uncle was not interested in this treatment. He knew the prognosis well and his focus now was spending time with family and feeling as good as possible for whatever time he had on hand.

A few months later, he died at home. He got no surgical treatment, no chemotherapy, no radiation.

Everybody dies. It’s not a frequent topic of discussion, but doctors die, too. And most doctors don’t die like the rest of us.

As Ken Murray wrote in his landmark essay How Doctors Die

What’s unusual about them is not how much treatment they get compared to most other people, but how little.

Of course, like most mortal beings, even doctors don’t want to die. They want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most – dying in pain after being perforated with tubes, hooked up to machines, and assaulted with drugs…and dying alone without saying or hearing a few final comforting words from their loved ones.

Doctors who are terminally ill also remember what the Greek physician Hippocrates, called the father of medicine, said about the limits of medicine

If a man demand from an art a power over what does not belong to the art, or from nature a power over what does not belong to nature, his ignorance is more allied to madness than to lack of knowledge. For in cases where we have the mastery afforded by a natural constitution or by an art, there we may be craftsmen, but nowhere else.

Whenever therefore a man suffers from an ill which is too strong for the means at the disposal of medicine, he surely must not even expect that it can be overcome by medicine.

I remember my aunt telling me how her husband, my dermatologist uncle, shared his end of life wish with his family a few years before his death. He wanted to be sure, when the time comes, that no heroic measures will happen – that he will never experience, during his last moments on earth, someone trying to resuscitate him with aggressive and painful treatments or therapies.

In a work attributed to Hippocrates, it is written that the purpose of medicine is “to do away with the sufferings of the sick, to lessen the violence of their diseases,” but also “to refuse to treat those who are overmastered by diseases, realizing that in such cases medicine is powerless.”

My uncle had seemingly read Hippocrates given that he applied his thinking right when he needed it the most.

A Stanford University School of Medicine survey found that nearly 9 in 10 young physicians just finishing up their residencies or fellowships would not want to receive aggressive treatment if they were terminally ill.

These doctors said they would opt for a ‘do not resuscitate’ approach should they find themselves on the receiving end of medical treatment. Maybe they have seen the suffering of their patients at the end of life and want no part of it. Yet they tend to pursue aggressive, in the name of ‘life-prolonging,’ treatment for patients facing the same prognosis.

The reasons are not as easy as they come to your mind instantly – like doctors being corrupt, sold at the hand of pharma companies, etc.

It’s not always about doctors trying to make more money or because they are intentionally insensitive to their patients’ desires. The core of the problem, as I have learned from my doctor friends and relatives, is a medical system that rewards doctors for taking action, not for talking with and guiding their patients.

Like a doctor friend mentioned to me recently that even when medicine’s current default is in “action” and to “do something,” there comes a tipping point in a serious illness – like I quoted Hippocrates above – where the patient needs to be guided towards inaction (which rarely happens because a doctor won’t get paid for inaction).

In such cases, my friend tells me, the high-intensity treatment becomes more of a burden than the disease itself. Talk to any terminally ill cancer patient who has undergone toxic chemotherapy and/or radiation and you’ll know where I’m coming from.

Add to that the advertising from corporate hospitals trying to lead people to believe that they help patients fight the battle against a disease, like cancer, and the treatment will help them emerge winners. But what happens when the body itself is the battlefield? Who wins? And against whom?

Anyways, feeding into the problem of doctors’ aggressive over-treatment are patients’ unrealistic expectations of what the former can accomplish. Most believe they would fare better than the average patient who took the treatment and did not survive. That’s a typical Lake Wobegon effect, that of an illusory superiority complex.

Now you see, it’s easy to find fault with both doctors and patients in such stories, but in many ways, all the parties are simply victims of a larger system that encourages constant action, which includes overly aggressive treatment, even when inaction would be a much better choice.

Parallels lie in the business of investment and financial advice, and also in how most people invest.

I wrote about my friend’s father who passed a few years ago leaving his son investments in mutual fund schemes that totalled 192. All recommended by an institutional financial advisor.

What was worse than the obnoxious number of these schemes was that each of them was bought through a different folio number. Imagine yourself holding 192 schemes in 192 folios. It’s like making 192 bank deposits in 192 different bank accounts! Now imagine your dependents coming to know about this after you pass away. Their life would become even more miserable.

When I came to know of this situation from my friend, I did not lay much blame on my friend’s father for holding such a scary investment portfolio. He was a frail, old, retired man who wanted to invest as much as he could so that his son and his family would be well-off after his death (though he was at some fault too).

Of course, the concept of ‘buyer beware’ exists in the investment industry. But think of the greedy financial advisor who creates such a big mess in an investor’s (and his dependents’) life. Like this financial advisor, who played havoc with my friend’s father’s money…and trust. All for the sake of his commissions!

Now, most other advisors I know of would never wreak such havoc on their clients’ hard-earned savings. But many advisors I have come across would also not take their own financial advice, which they often advise their clients – multiple mutual fund schemes, unwanted insurance policies, and dud stocks.

Like doctors who equate action with achievement, I have seen financial advisors doing the same. Like medicine, the financial industry also rewards people for taking action. Inaction is often seen as a sign of weakness, inadequacy, and ineptitude.

This is why so many fund managers churn portfolios regularly, so many financial advisors recommend new schemes and insurance policies to their clients regularly, and so many analysts recommend so many stocks worth buying (which they won’t buy themselves).

Chances are that the investor would be better off without such frequent actions and advice. But it’s good to hear that though the advice failed, the advisor at least did something, didn’t he?

Primum non nocere is a Latin phrase that means “first, do no harm.” This is one of the key principles of bioethics that all healthcare students are taught in school and is a fundamental principle throughout the world.

Another way to state it is that, “given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good.”

It reminds the healthcare provider to consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

The reality is that many doctors don’t remember/practice this maxim while prescribing unnecessary treatments to their patients (often patients would ask for such treatment), even when they know that inaction would be a better way to go.

This is true also of many financial advisors who would leave their practice but not practice inaction. And I would lay the blame on investors too, most of whom are always in search of that elusive investment idea that would make them richer faster than the average investor (again, the Lake Wobegon Effect).

A sensible advisor and a sensible investor – like my sensible uncle who rejected unnecessary treatment that would have added a few months to his life but at the terrible cost of quality of life – would often weigh the benefits and negatives of every action or intervention before committing himself to it.

After all, a happy way to live life – and often save a life – is to do nothing when nothing must be done.