The June 2019 issue of the journal Astrobiology features an essay on extraterrestrial life that may have some applicability for health matters here on earth. It does so by presenting a contrast between tentative versus defining criteria, by indicating that the function of tentative criteria is not, like that of defining criteria, to provide an estimate (via a decision procedure) of the likelihood that an extraterrestrial phenomenon is the product of life. Instead, it is to identify phenomena that resist classification as living or nonliving as worthy of further investigation for novel life.

The physicist and philosopher of science Thomas Kuhn argued that a recognition that a puzzling empirical phenomenon is anomalous is a driving force behind scientific revolutions. An anomaly is a violation of a paradigm-induced expectation about a domain of natural phenomena. He characterized scientific paradigms broadly as including laws, theories, and other widely accepted scientific beliefs, as well as sanctioned methods and instruments, concerning a domain of phenomena. Paradigms play vital roles in scientific practice, facilitating the construction of hypotheses, design of experiments, and interpretations of results, but they also may hinder the exploration of nature, discouraging certain lines of research and biasing the interpretation of data. Essentially, a paradigm literally may blind researchers to the presence of anomalies. They either are not perceived as puzzling or alternatively, are interpreted as puzzles that eventually will be solved using the resources (concepts, laws, methods, etc.) provided by the paradigm.

Many key initiatives continue to be undertaken in the health sphere with the intention of improving individual and community health status. The Patient Protection and Affordable Care Act of 2010 was the most ambitious and comprehensive effort in that regard in several decades. Some of its provisions represented the best forms of conventional wisdom, but other portions of the law’s components lacked evidence and may have entailed nothing more substantial than a leap of faith that they would produce desired outcomes. A notable example may be the Hospital Readmissions Reduction Program (HRRP), which was designed to reduce costs and prevent deaths by imposing financial penalties on hospitals if their rate of readmissions within 30 days exceeds an arbitrary threshold.

Based on assessments that have appeared recently in prominent journals (e.g., June 13, 2019 issue of New England Journal of Medicine), the HRRP has assumed the coloration of a debatable proposition rather than a proven fact. Key considerations, such as that a HRRP defines only inpatient hospitalizations, not observation stays or emergency department (ED) visits, as readmissions, and social factors involving poverty cloud the picture quite significantly. The Affordable Care Act was a good faith effort to increase access, lower costs, and improve quality. An implicit assumption involving some aspects of the law was that defining criteria rather than tentative criteria existed, which has the potential to blind advocates of some interventions to the actual worth of what is being proposed. Moving forward in health care, rather than define all proposed actions as valid programs, it would be advisable to consider some of them as experiments awaiting proof of effectiveness.

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TENTATIVE VS. DEFINING CRITERIA

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