In the introduction to my submission to the pointless medical certification ‘review’ previous to this one, I noted that no amount of mental gymnastics could overcome the patent conflict of interest of medical bureaucrats organising a review the outcome of which would be to effectively make recommendations as to the value of their own role in the regulatory regime. I observed that the fundamental question is never asked because there is no data on the basis of which the question may be answered: Are the costs of AvMed worth the benefits it causes? And AvMed isn’t about to collect that data.
When I say “costs”, I don’t mean just the fully-burdened costs of AvMed paid by CASA (i.e. us). I include in the costs the careers destroyed, the life’s passions destroyed and the lives lost to suicide as a consequence of AvMed’s decisions. Those are irrelevant externalities to CASA. Then there are the costs of the medical testing to satisfy requirements imposed by CASA, and the stresses and anxieties inflicted on applicants due to CASA-caused delays and uncertainties. Those, too, are irrelevant externalities to CASA.
And then there’s a real safety issue: Pilots who are too scared to even mention some concern to a doctor, lest it get back to AvMed and be used as justification to intrude, demand, restrict or ultimately destroy. (I had a conversation with a pilot acquaintance a while ago about a call he made to AvMed to ask a question about a hypothetical condition. The AvMed person immediately asked for his ARN. “Ya gotta be kidding” was his response. That’s ‘trust’ for you.)
Of course, there must be a line drawn, somewhere, between fit to fly and not fit to fly. But AvMed is not competent to draw that line. It’s actually a political decision, into which decision medical opinion is but one input.
To make the point, it’s pertinent to see what’s happened with Covid 19 arrangements. Before Christmas 2021, our political leaders made a decision to open the borders (well, most borders) and discontinue lockdowns, despite the ongoing objective risks and consequences pointed out – correctly - by medical experts. Neither side of federal politics was arguing for a return to closed borders or lockdowns or increased mask mandates or whatever prior to the most recent federal election or in response to ongoing ‘waves’ of infections. The politicians sensed – correctly – that the great majority of the populace was well and truly over the restrictions and were no longer in any mood to have them continue. The price being paid
by society for Covid 19 restrictions were too high compared with the benefits
to society in return.
Those same medical experts continued and continue to point out –
quite correctly - the extent to which deaths due to Covid 19 would continue, and that the hospital and broader medical system would continue to be stretched and medical procedures would be ‘crowded out’ by Covid 19 cases. And those predictions were correct. But the political leaders have stuck with their decision. In short, they actually did their job: Took responsibility for what is a quintessentially political decision: putting values on lives. They won’t say it out loud, but that’s precisely the effect of the decision.
And thank heavens they stuck with their decision. Because if they had not, and instead just acted strictly in accordance with the opinion of the medical bureaucrats, we know where we’d be now. That’s because medical bureaucrats given the job of minimising Covid 19 deaths do not take into consideration all of the costs that are irrelevant externalities to them in their stovepipe. They’d be locking us down again, with each new wave of infections and variant of the virus.
My favourite analogy – because it is an aviation one – was drawn by a recognised epidemiologist Mike Toole from the Burnet Institute in an article I read a while ago:
I learned that a Boeing 737-800, which is the most common domestic plane used in Australia, carries 184 passengers and crew,” he said. “So, we’re reporting more than a 737 crashing every week.
Yep Professor Toole, that’s correct. More than a 737 load of fatalities in Australia due to Covid 19, every week. And that’s what our political leaders have decided to accept, because that is the mood of the great majority of the populace.
But CASA AvMed continues to be left to its own devices. Unfortunately for us in aviation, the effects of the human foible called cognitive bias mean AvMed gets away with damaging overreactions to the objective risks. Humans naturally over-estimate the probabilities of ghastly events. AvMed effectively decides the standard and decides what is necessary to satisfy AvMed that the standard is met, and Avmed is indifferent to the costs imposed on others as a consequence. The costs are irrelevant externalities.
But in 21st century Australia, I reckon CASA AvMed does more damage than it prevents.
That word “prevention” brings up the issue of causation. AvMed just assumes that there is a causal connection between what it does on the one hand and improved safety outcomes compared with what would happen if AvMed did not do it on the other. (Indeed, the same may validly be said about CASA generally.)
That’s what’s called “causation for Martians”. That’s an analogy, drawn by a smart person, with Martians observing road traffic in cities on Earth and coming to the conclusion that the traffic lights
cause the cars to stop and go. (If you feel that the Martians could be correct, try this experiment: Next time you stop your car at a red light, apply the handbrake, put the gearbox in neutral, fold your arms and take your feet off the pedals. Note what does
not happen when the lights turn green.)
Let’s take a few examples.
First: 6 monthly ECGs imposed by AvMed when the individual certificate holder’s doctor and medical specialists say they are unjustified at that frequency. Those tests cost the individual a lot in time and money. Those tests consume finite and very valuable medical resources.
If there were some evidence to show that AvMed knows better than an individual’s doctor and medical specialists, because a 6 monthly ECG picked up something which would not have been picked up if the ECGs were instead carried out when the individual’s doctor and medical specialists said they were justified, that would be a data point which, if combined with similar data points, would provide objective evidence of a causal connection between the 6 monthly ECGs and a safety outcome. That objective evidence does not exist. Those ECGs merely waste the applicant’s time and money, waste finite and very valuable medical expertise and resources – a particularly egregious waste in our current circumstances - and provide busy work to medical bureaucrats and input to AvMed studies.
Secondly: AvMed is going to die on the stupid hill of colour vision deficiency, again, but not until substantial CASA resources are diverted to defending the stupid hill while the careers and career aspirations of thousands of people are thrown into disarray again.
Thirdly: AvMed recently slipped a question as to the applicant’s ethnicity into the medical certificate questionnaire. AvMed’s justification is that there is some link between particular ethnicities and cardio-vascular risk.
However, there is no data to support the contention that, in the many decades before the question about ethnicity was added, medical certificate holders of particular ethnicities were ‘slipping through the cracks’ and having a higher rate of cardio-vascular related aviation accidents or incidents in Australia. Applicants and their doctors and, if necessary, specialists are perfectly capable of assessing an individual’s cardio-vascular risk and expressing expert opinions as to that risk to CASA, without CASA needing to know the applicant’s ethnicity.
(I’ve made an inquiry to the Human Rights Commission about whether this question and what CASA proposes to do about the answers constitute racial discrimination. The circumstances seem to me to comprise at least “an act involving a distinction … based on … ethnic origin” in terms of s 9 of the Racial Discrimination Act 1975 (RDA) and do not fall within the scope of the exceptions provided in s 8 of the RDA. CASA has power to make regulations inconsistent with the Disability Discrimination and Sex Discrimination legislation, but I’m not aware of an equivalent for the RDA. In any event, it’s not “necessary” for CASA to know an applicant’s ethnicity if CASA is given evidence as to the applicant’s actual cardio-vascular risk by people who know what they’re talking about. I’ve also chased up my complaint to the OAIC about CASA’s use of our medical information without being able to provide a single piece of squashed tree setting out its procedures for de-identification of the information or evidencing audits of the effectiveness of and compliance with those procedures. And that’s even assuming CASA has the function of doing or arranging medical studies, which function I haven’t been able to spot in the CA Act.)
At the moment CASA Avmed seems to me to be suffering grandiose delusions that it is going to lead ICAO convention countries on a crusade to bring
real safety to air navigation, which means AvMed needing to know everything and second guessing everybody. They’ve been encouraged to do so, through having been left to their own devices. The response to nearly every FOI request I submit about AvMed reveals failures of basic governance that should be applied to all public officials.
A while ago I asked an AvMed doctor how many times a pilot with a safety pilot condition imposed on his or her medical certificate by CASA had suffered incapacitation such that the safety pilot had to intervene. After all: That would be an immediately reportable matter and the ATSB and therefore CASA would know about it. And if the condition were justified in fact, there would occasionally be an incapacitation event requiring the intervention of the safety pilot. Dissembling was the (unsurprising) response. Translation: None. I immediately concede that chances are it will happen, eventually, if it hasn’t already happened. But some holders of Class 1 medical certificates die suddenly of undiagnosed conditions, too.
As we know, the experiment has been run and the results are in. If AvMed stopped second-guessing the opinions of qualified medical practitioners and specialists, would there be the equivalent of a 737 load of deaths
caused each week? Each month? Each year? Each decade?
Some might say that preventing, for example, 18 deaths per year (184 divided by 10) is more than enough justification. But that’s just a political opinion, not a medical opinion. Remember: We as a society have chosen a path that leads to around 184 deaths per week due to Covid 19. Many of those deaths would be avoided if we returned to lockdowns.
And the opinion assumes that, absent AvMed’s micro-management, we’d all go crazy and fly when we know we’re not fit. Of course, in the real world, us certificate holders have always effectively self-certified our fitness each and every time we decide whether or not to fly.
And
the only pilots I know who’ve died unexpectedly of undiagnosed medical conditions were the holders of Class 1 medical certificates at the time of their death, again demonstrating that the Avmed certification process guarantees nothing.
And don’t forget: In Australia, ‘self-certified’ pilots already share the skies with jets full of passengers, and have done so for a looonnng time, and ‘self-certified’ pilots already fly in controlled airspace, and have done so for a looooong time.
I’ve little doubt that if AvMed ceased to micro-manage medical fitness, there would probably be some tiny increase in medical-related aviation incidents. But the point is that the costs of those incidents would be small compared to the reduction in the costs of (including the costs of damage done by) AvMed’s micro-management.
AvMed’s own description of what it does provides an insight into the mindset:
When an application for a medical certificate may include particular diagnoses, indicate multiple conditions, or are in any other way considered complex, the application is circulated across a team of doctors in CASA who are trained in aviation medicine.
They study the case to determine possible risks to aviation safety and to determine any required surveillance. This ensures that such matters have the benefit of multiple medical perspectives, and it is CASA’s view that this collegial arrangement improves the quality of aeromedical decision making. This process is referred to as Complex Case Management.
The work-up of these cases can take about a week, and the discussion typically occurs in the next week. In some cases, there may be a need for additional information or for a specialist consultant opinion.
AvMed engages in these no-doubt solemn deliberations in the belief that the weight of aviation safety is upon their shoulders, alone, and they are collectively better qualified than medical professionals and specialists with knowledge of an individual pilot (or other certificate applicant), to express opinions about the aero-medical implications of and ongoing ‘management’ of the individual’s ‘conditions’.
Grandiose delusions. It’s an echo chamber. (There’s another, unsavoury, metaphor that starts with “circle”.)
AvMed will, on the basis of cherry-picked results of studies and a self-serving interpretation of things like the NHMRC ‘Evidence Hierarchy’, decide that AvMed’s collective opinion is based on ‘better’ evidence than is before the medical professionals with knowledge of an individual pilot (or other certificate applicant). AvMed will spin the ‘complexity’ into the worst possible safety risk and impose the most expensive, restrictive and potentially dangerous ‘surveillance’ regime on the applicant, because AvMed knows better. Just ask them. They are constantly looking for evidence to justify their prejudices. That’s what happened, again, with colour vision deficiency.
Any idiot with access to the internet can do what they currently do.
AvMed are encouraged to keep doing what they are doing by being left to their own devices to impose whatever costs they consider necessary and do whatever damage they consider necessary in the name of the safety of air navigation. My submission to the GA inquiry includes examples of deliberate, systemic unlawful behaviours by AvMed. What’s happened? Nothing.
The answer to my FOI request for access to documents identifying the individual who authorised the addition of the question about ethnicity in the medical certificate questionnaire returned no documents and this explanation: “The decision to include the ethnicity question in the medical certificate application was a consensus decision made by the Senior Medical Officers (SMOs) at their annual meeting in February 2023.” CASA should extend the concept to issuing pilot licences and AOCs: Put it to an internal vote.
And then there’s the minor point that it’s not ethnicity that
causes differences in cardio-vascular risks. It’s that people of some ethnicities are members of minority groups who have restricted opportunities to live in healthy neighbourhoods and have access to high-quality education and healthcare. “The fact that minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system.” … “There is no biologic basis for race-based health disparities. Despite this, race predicts health outcomes. However, it is racism, and not race, that is the fundamental driver of these health inequities.” I’m sure members of these ethnic minorities will be chuffed at being labelled by AvMed as being bigger risks to the safety of air navigation than others in Australia.
AvMed is not a disinterested and objective participant in all this. As if they are capable of giving a disinterested and objective answer to the question whether the costs of what they do are justified by the benefits. And they are emotionally attached to their medical opinions and decisions. The fact that AvMed never admits any mistakes – even after the unassailable evidence of the mistake is put before them - speaks volumes – deafening volumes - about the current culture. And no matter how many times they’ve been told not to do it because they’re not qualified, they keep fronting the AAT presuming to give expert opinion evidence about their own opinions.
CASA – and especially AvMed - should not be running these ‘review’ processes in the first place. That’s a manifestation of the paradigm problem: The regulator in effect being left to decide its own role in the regulatory regime, in which decision the regulator is fundamentally conflicted. As the regulatory regime becomes more and more complex, year after year, and the regime continues to be a symbiosis in which the industry depends on (and pays fees for) a multitude of certificates and approvals and permissions and exemptions from the regulator, the regulator has to increase in size to run all those human-draulic processes efficiently, or the machine slows down and can’t keep up. That, and AvMed’s pursuit of the grandiose delusion of world leadership, is why AvMed’s ‘service’ metrics are abysmal. And if you think the billions consumed by this regulatory juggernaut have all contributed positively to safety, you should consider a visit or return to the planet Mars.
Safe flying.