The Wrong Question

How modern medicine places the question in the patient’s hand, then sells her the answer

If a woman with mitral valve prolapse asks how to fix it, there is an answer. A surgeon can sew the valve shut. She will be dead within the hour. The procedure has done exactly what was requested.

This was Thomas Cowan’s response to a woman who approached him at Polyface Farm in June 2026, after a talk at the inaugural New Biology Experience.¹ She was in her sixties. By her own account, she had no shortness of breath, no cough, no pain, no signs of heart failure. She ate well, moved daily, slept through the night. But she had been told she had mitral valve prolapse, and she wanted to know what to do about it.

His suggestion confused her. How would she do after the surgery, she asked. He told her he didn’t know of anyone who had done it, but probably dead in half an hour to an hour.

She said: why would I want to do that?

He said: you wouldn’t. But the question had an answer, and the answer kills you. So the question was wrong.

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What the wrong question is

The question takes a stable form. How do I fix this finding? It presupposes that the finding is the disease. It presupposes that the body has made a mistake. It presupposes that there is something to be fixed.

In most cases, each presupposition is false.

The finding is a description of what the body is doing. A mitral valve that prolapses is a valve whose leaflets bow back into the upper chamber of the heart during the heart’s contraction. That is what is being observed on the echocardiogram. The observation is not the disease. The observation is the observation. The disease framing is added by the clinician who reports it.

The body has not made a mistake. The valve is doing what valves do: opening and closing in response to pressure gradients built up over decades of living. If the woman has no symptoms, the valve is not failing her. It is functioning within the range her terrain provides.

There is rarely something to be fixed. The mainstream literature on asymptomatic mitral valve prolapse acknowledges this on its own terms. Avierinos and colleagues, publishing in Circulation in 2002, followed 833 residents of Olmsted County, Minnesota with asymptomatic mitral valve prolapse for a mean of 5.4 years.² Those without severe regurgitation or ventricular dysfunction had survival comparable to the general population. The valve, by itself, did not predict events.

The woman at Polyface Farm met none of the high-risk criteria. Her valve was doing what it was doing, in a body that was, by her own report, well. The fix existed. The disease did not.

The question, manufactured

She did not arrive at Polyface Farm wondering about her mitral valve. A few years earlier, in a clinic somewhere, a doctor put a stethoscope to her chest. Perhaps he heard a click. Perhaps she mentioned a flutter, a moment of light-headedness, something brief and odd she could not quite name. He ordered an echocardiogram. The echocardiogram showed leaflets bowing during the heart’s contraction. A report was generated. The report named a condition.

From that moment on, she had it.

She did not bring the question to the clinic. The question was placed in her hand by the clinic, by the test, by the report, by the naming. By the time she asked Cowan how to fix it, the question felt like hers. It felt like a problem she had noticed and wanted resolved. But the noticing had been done by the machinery. She had felt fine. The machinery had insisted she wasn’t.

This is the part of the encounter that gets erased.

The pattern is not unique to her. The same structure repeats across the screening apparatus.

A number becomes a disease

Consider a woman in her late fifties at her annual physical. No symptoms. No fractures. She walks her dog, lifts her groceries, gardens, sleeps. Her doctor orders a DEXA scan because she is a postmenopausal woman of a certain age and this is what is done.

The scan returns a T-score of -2.7. The threshold for osteoporosis is -2.5. She is now osteoporotic.

She did not have osteoporosis the day before the scan. She had whatever bones she had, doing whatever they had been doing. After the scan, she has a diagnosis. After the diagnosis, she has a question: how do I fix this?

The threshold itself is worth pausing on. In 1994 a World Health Organization working group convened to define osteoporosis for epidemiological purposes.³ The group set the diagnostic line at 2.5 standard deviations below the mean bone density of a young adult reference population. The line was a statistical convenience, not a biological event. The committee drew it. Below the line, you had a disease. Above it, you did not. The number did not change. The label appeared.

The fix is bisphosphonates. Alendronate, risedronate, ibandronate, zoledronate. These are drugs that bind to bone mineral and suppress the cellular remodeling that bone tissue depends on. The drugs increase bone density. The score improves. The fix performs as designed.

What the fix does to the bones is harder to see. Bisphosphonates suppress osteoclast activity, the cellular work of removing old, damaged bone matrix. That removal stops. New bone gets laid on top of bone that should have been cleared. Density rises. Structural integrity does not necessarily follow.

After roughly five years of use, atypical femoral fractures appear. The femur snaps transversely, often during normal walking, often without trauma worthy of the name. These are not the fragility fractures osteoporosis treatment is meant to prevent. They are a different kind of break, characteristic enough that the American Society for Bone and Mineral Research convened a task force in 2010 and revisited it in 2014 to formalize the case definition and acknowledge the association with long-term bisphosphonate use.⁴ Osteonecrosis of the jaw appears in patients on the same drugs, particularly the intravenous formulations. The bone in the jaw fails to heal after dental extraction, sometimes remaining exposed for months or years. The American Association of Oral and Maxillofacial Surgeons issued a position paper in 2014 documenting the syndrome.⁵

The number improved. The bones broke. The jaw exposed. The disease that was diagnosed by the threshold was treated by the drug that hit the threshold, and the woman who took the drug for the disease that was a threshold is now worse off than the day before her scan.

The pattern is identical to the mitral valve. A finding, a label, a fix. The fix performs as designed. The patient deteriorates.

A narrowing becomes a disease

The pattern repeats again. A man in his late fifties presents with mild discomfort during the third mile of his usual walk. His doctor orders a stress test. The stress test is read as positive. An angiogram is ordered. The angiogram shows a 70% narrowing of the left anterior descending coronary artery.

He did not have coronary artery disease that morning. He had a man’s body, doing what his body had been doing for decades. By the end of the day, he has a label and a question. The label is significant coronary stenosis. The question is how to fix it.

The fix is a stent: a wire mesh tube delivered by catheter and expanded inside the narrowed artery. The narrowing is opened. The lumen is restored. The fix performs as designed.

What the fix does for the patient is the question that has been answered, repeatedly, by the cardiology establishment’s own trials. The COURAGE trial, published in the New England Journal of Medicine in 2007, randomized 2,287 patients with stable coronary disease either to stenting plus medical therapy or to medical therapy alone.⁶ After a median follow-up of 4.6 years, there was no difference in death or non-fatal heart attack between the groups. The stents did not save lives. They did not prevent heart attacks. They opened narrowings, exactly as designed, while making no measurable difference to what the patients actually feared.

ORBITA, published in The Lancet in 2017, took the next step.⁷ Patients with stable angina were randomized either to stenting or to a sham procedure, the catheter inserted and withdrawn without placing a stent. After six weeks, the increase in exercise time in the stented group was not significantly greater than in the sham group. The stent, tested against the placebo of the procedure itself, did not improve symptoms.

ISCHEMIA, published in 2020, repeated the finding at scale. Over 5,000 patients with moderate or severe restricted blood flow on stress testing were randomized to an invasive or conservative strategy.⁸ No reduction in cardiovascular events. No mortality benefit.

The narrowing was opened. Nothing improved.

This is not a failure of the procedure. The procedure did what it was asked to do. It opened a narrowing. The narrowing was not the disease.

The industrial logic

The three patients (the woman with the valve, the woman with the score, the man with the narrowing) share a structure. None of them brought the question. The question was manufactured. The manufacturing has parts, and the parts are visible if you look at them.

The first part is the screen. The echocardiogram, the DEXA scan, the angiogram. These are not diagnostic tests in the original sense, performed because a clinical picture suggests a specific condition that must be confirmed or ruled out. They are surveillance tools. They look for findings in populations that don’t yet have symptoms. The yield of any screen rises with its sensitivity. The more sensitive the test, the more findings it produces. Findings are the output.

The second part is the label. A T-score of -2.7 is a number. The number does not become a disease until a committee draws a line. A 70% narrowing is an angiographic estimate. The estimate does not become an indication for intervention until a guideline says it does. Leaflets bowing into the upper chamber of the heart are a pattern of motion. The pattern does not become mitral valve prolapse until a reporting convention says it does. The labels are administrative. They are decisions about what to call things. They are reversible, and they are revised periodically as the indications expand.

The third part is the fix. The drug, the stent, the surgery. The fix exists before the patient walks in. The pharmaceutical company developed the bisphosphonate and needed a population to receive it. The interventional cardiology industry trained operators in stenting and needed lesions to stent. The fix shapes the screen. The screen produces the findings. The findings produce the labels. The labels produce the questions. The questions produce the fixes.

The patient enters the system at the end of the chain. The question feels like hers because she is the one asking it. She does not realize the question has been engineered backward from the fix.

The financial dimension is documented. Merck’s Fosamax (alendronate) generated approximately $3 billion in annual sales before its U.S. patent expired in 2008,⁹ anchoring a bisphosphonate class now sold by Merck, Roche, Novartis, and numerous generic manufacturers. Percutaneous coronary intervention generates tens of thousands of dollars per case in the US system and is performed hundreds of thousands of times a year, supplied by stent manufacturers including Abbott, Boston Scientific, and Medtronic. Abbott’s MitraClip, the dominant transcatheter mitral valve repair device, is the cornerstone product in a structural heart segment that generated $2.2 billion in 2024 sales¹⁰ and continues to expand into new indications. The screening apparatus that produces the findings is, in many large health systems, owned by the same entities that perform the fixes.

This is not a conspiracy. It is a market structure that requires the question to be asked and has built the apparatus that places the question in the patient’s hand. The doctor who orders the screen is not, in most cases, knowingly recruiting her. He is doing what his training, his guidelines, his quality metrics, his clinic protocols, and his liability concerns all tell him to do. When the question arrives, he is doing what he was trained to do with it: naming the finding, offering the fix.

The patient who asks how to fix her mitral valve prolapse is doing precisely what the machinery requires of her. So is the doctor who answers.

What to ask instead

She asked Cowan: how do I fix this?

He asked her: how are you doing?

She told him: fine. No shortness of breath. No cough. No pain. Living a good life. Doing the things she’d been told to do. Eating well, moving, sleeping, gardening, present.

He told her: don’t do anything.

The valve was doing what it was doing. It had been doing it for years. It would probably keep doing it. The valve was not the disease. The valve was a feature of the body she had, which was the body she had lived in well.

The right question, Cowan argued, is approximately the same for everyone in every clinical encounter. It is something like: how do I have a better life? How do I sleep more deeply? Move more easily? Find food that nourishes? Feel present in the days I have left? What in my terrain (toxic exposure, nutritional depletion, electromagnetic burden, emotional weight) can I attend to so that the body I have can do what bodies do?

The right question opens. The wrong question closes at the fix. Once the fix is performed, the patient is left with whatever it has done to her, which is sometimes nothing visible, sometimes a new injury she didn’t carry before, and on rare occasions her death. The right question does not terminate. It opens into the rest of the life she has not yet lived.

She did not need a surgery, because she did not have a disease. She had a finding that had been given a label, and a label that had been given to her as a question. The question came from a system that profits from her asking it. The body, meanwhile, had been functioning well for sixty years without anyone’s permission.

She walked away from the conversation and back into her life. As far as her valve was concerned, she had nothing to do. She had a life to keep living.

The valve, presumably, kept doing what it was doing.

How to Explain It to a 6-Year-Old

A doctor took a picture of a lady’s heart. He drew a circle around one part of the picture. He said, “This part of the picture is the problem. We can fix the picture.”

The lady felt fine. But now there was a circle on the picture, and she wanted to know how to make the circle go away.

The doctor said: we can cut the part inside the circle, or we can put a little thing inside it, or we can change how it looks. Then the circle will look different on the next picture.

She asked: will I feel better afterwards?

The doctor didn’t really answer that. He answered a different question. He answered: we can change the picture.

But the picture was not the lady. The picture was just a picture of one part of her. The lady was the lady. She was already fine.

The right question wasn’t: how do we change the picture?

The right question was: how do I keep being fine?

If a doctor ever shows you a picture and draws a circle on it, remember: the circle is on the picture. It is not on you.

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References

1. Cowan T. Wednesday webinar, 17 June 2026, “New Biology Experience recap.” The mitral valve prolapse exchange occurs in the first half of the recording, following the introductory remarks on the Polyface Farm conference.

2. Avierinos JF, Gersh BJ, Melton LJ 3rd, et al. Natural history of asymptomatic mitral valve prolapse in the community. Circulation. 2002;106(11):1355-1361.

3. World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a WHO study group. WHO Technical Report Series 843. Geneva: WHO, 1994.

4. Shane E, Burr D, Abrahamsen B, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2014;29(1):1-23.

5. Ruggiero SL, Dodson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw: 2014 update. J Oral Maxillofac Surg. 2014;72(10):1938-1956.

6. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516.

7. Al-Lamee R, Thompson D, Dehbi H-M, et al; ORBITA Investigators. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomized controlled trial. Lancet. 2018;391(10115):31-40.

8. Maron DJ, Hochman JS, Reynolds HR, et al; ISCHEMIA Research Group. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med. 2020;382(15):1395-1407.

9. Merck & Co. Form 10-K, 2007. Fosamax (alendronate sodium) reached approximately $3 billion in worldwide annual sales prior to U.S. patent expiration in February 2008. Corroborated by industry reporting in Drug Store News and subsequent generic-entry market analyses.

10. Abbott Laboratories. Fourth-quarter and full-year 2024 results, January 2025. Structural Heart segment full-year 2024 sales of approximately $2.2 billion, with MitraClip as the cornerstone product (segment also includes TriClip, Navitor, and Amplatzer Amulet).

New Biology Clinic

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