Health Care Policy

No Death Panels Needed

Dr Bob
Over at Big Government, we get a glimpse of where ObamaCare will take us: Health Care’s Coming Heart Attack – A Pre-Obama Care Death Panel?

I am writing of the Obama Administration’s – regulatory decision – to go ahead with a massive cut in Medicare payments to cardiologists. I emphasize that this is a regulatory decision because it was not made by the Congress legislatively (not that that would be ok) but, instead, it was made by the massive Health and Human Services Department of the US Government. Given the limited resources of the Medicare budget, in order to increase payments to general practitioners (in an effort to attract more such doctors a good idea), bureaucrats needed to gore somebody’s ox and cardiologists were chosen (a horrible idea).

The decision to do so is astonishing.

Keep in mind that the very purpose of health care is to improve the health and therefore the lives of Americans. The cardiologist community has been wildly successful in that endeavor. Although heart disease remains the #1 killer of Americans, the mortality rate for heart attacks has plummeted. For instance, the post-heart attack, 30-day mortality rate decreased from 18.9 percent in 1995 to 16.1 percent in 2006 and the in-hospital mortality rate decreased from 14.6 percent to 10.1 percent.

Further, between 1994 and 2006, the mortality rate among women 55 and under who suffered a heart attack dropped an incredible 52.9%. For men in that same age group the drop was 33.3%. According to the author of the mortality study that determined those latter figures: “It appears that risk factors, which may be controlled through prevention efforts, are very important in driving these mortality reductions.”

Given those figures, it is hard to argue with the success of cardiologists who sit on the forefront of heart care and heart disease prevention – unless, of course, you are a government bureaucrat.

Rather than pouring more dollars into an obviously successful branch of medicine that is saving lives (the ultimate purpose of health care?), the Obama Administration is going ahead with a plan to cut nearly $1.5 billion from Medicare payment to cardiologists. Obama is doing so by such devices as literally eliminating reimbursement for certain services and/or reducing the amount they will pay for others. Case in point, cardiologists have been able to bill for an extended first visit with Medicare patients to get their history and to recommend a course of treatment. As of January 1, 2009 [2010 – ed.] no longer.
What is being referred to here is Medicare’s decision to eliminate consultation service codes as of Jan 1 2010. These codes are almost exclusively used by specialists, and pay substantially better than standard visit codes, reflecting the higher complexity of care typically involved in specialty care. It is not just the cardiologists who are affected by this administrative change in Medicare payment — it is all specialists: oncology (cancer treatment), infectious disease, pulmonary, surgical specialties such as orthopedics, urology, ENT, neurosurgery, cardiac surgery, etc. etc. They are betting on a premise already proven false: that preventive medicine through primary care will reduce costs.

Specialty care is more expensive because specialists care for the sickest and most complex patients. When you are having your acute MI, you need a cardiologist, not a family practice physician. Specialty care is where the vast number of advances in American medicine have taken place — the advances which give us the best results in the world in cancer treatment, heart disease, and surgical advances such as laparoscopy and other minimally invasive procedures.

The inevitable outcome of these changes are that Medicare patients will have reduced access to specialists, as specialists increasingly are unable to afford taking a loss on every Medicare patient they see due to reimbursements which fall below their costs of providing care. They will by necessity reduce the number of Medicare patients specialists see, or force them to stop seeing Medicare patients altogether, resulting in longer waits to see a specialist and regional shortages of care in these areas. One does not need “death panels” to make policy changes which restrict care to the elderly and disabled; quiet bureaucracy works every bit as well, with the added advantage of plausible deniability.

Welcome to the new millennium in health care. Hope you enjoy your government-run universal health care.

Confessions of a Health Care Rationer

Dr Bob


 
Over at First Things, you will find an excellent article on the topic of rationing in health care, written by a clinical oncologist now working for the insurance industry in evaluating claims for medical necessity. Despite what would at first glance raise concerns about being an apologetic for the private insurance industry, this proves to be a well-balanced essay on the difficult choices in allocating scarce health care resources wisely. It is well worth your time to read in its entirety: Confessions of a Health Care Rationer

It’s a mistake to think of health care as a right. It is not a right; it is a good. Freedom of speech, by contrast, is a right, as is freedom of religious belief. They are privileges that inure to individuals as a consequence of the primordial right, free will. That is why we see them as inalienable. The exercise of these rights does not depend on any action of government, but rather on its inaction. Government may not legitimately interfere with their exercise, but nothing mandates that the government provide us with printing press or chapel.

All modern societies ration health care. A wise society considers the options and chooses a method of doing so which best conforms to its values and capabilities. Thus we come to the terrible question we would so very much like to avoid: How shall we ration health care? How shall we explicitly ration it? So noxious a question is this, so offensive in its tacit assumptions and implications, that most politicians and wishful thinkers will deny that we need to address it at all. They will argue that the fundamental problem is one of distribution, not one of unmeetable demand. They will argue, with more enthusiasm than evidence, that an emphasis on preventive care would substantially reduce aggregate demand. Some will say we must reduce the role of government; others will argue that we should augment it. If only we will adopt their plan—they’ll say—waste, fraud, and abuse will be abolished. There will be chicken—or at least chicken soup—in every pot, and a vaccine in every arm. People love honesty, but they hate the truth. To frankly acknowledge and address the ineluctable reality of healthcare rationing is not merely to touch the proverbial third rail of American politics; it is to lie across the tracks in front of the onrushing train.

Check it out.

Killing Mercy

Dr Bob

The ethics of euthanasia, which as an issue generally stays just barely on our radar screens, given the host of contentious social issues taking up our political and cultural bandwidth, nevertheless may ultimately prove to be an enormous dilemma, with profound impact on both our lives as a society and as individuals. While the issue has only occasionally nosed into the political limelight–usually associated with some initiative regarding physician-assisted suicide–the underlying currents which keep this matter very much alive are powerful and unlikely to be resolved easily or painlessly.

There is broad appeal for the idea of euthanasia. It seems to fit perfectly into our Western democratic principles of the autonomy of the individual, rights and freedom, and the desire to control our own destinies. It seems as well an ideal solution to an out-of-control health care system, where technology and advances in life-sustaining capabilities seem to have taken on a life of their own, driving health care costs to extraordinary levels in the final years of our life, and seemingly removing much of the dignity we believe should be the inherent right of the dying. Patient’s families watch helplessly as their loved ones appear to be strung along in their dying days, tubes and wires exiting from every orifice, a relentless train of unknown physicians and ever-changing nurses breezing in and out of their rooms to tweak this medication or that machine. We all wish for something different for ourselves as well as our loved ones, but seem to be incapable of bringing that vision to fruition.

Euthanasia offers what appears to be an ideal solution to many of these difficulties. We love the idea that the individual may choose the time and place of their own demise; we see an easy and painless exit to prolonged suffering; we visualize a measure of mastery returning to a situation where are all seems out of control; we see a solution to pointless expenditures of vast sums of money on patients with little or no hope of recovery. It is for these reasons that initiatives to legalize this process are commonly called “death with dignity” or some similar euphemism reflecting these positive aspects–and when put forward, often find as a result a substantial degree of public approval.

This appeal grows ever stronger as our culture increasingly emphasizes personal autonomy and de-emphasizes social responsibility. We are, after all, the captains of our own ship, are we not? A culture which believes that individual behavior should be virtually without limit as long as “no one is harmed” can see little or no rational reason why such individual autonomy should not be extended to end-of-life decisions.

The reality, unfortunately, is that “no one is harmed” is a uniquely inadequate standard for human behavior, and our autonomy is far less than we would like to believe. It assumes that human behavior occurs in a vacuum. Thus we hear that sexual relations between consenting adults are entirely reasonable if “no one is harmed”–a standard commonly applied to relationships outside of marriage, for example, which often end up having a profound and destructive effect both on the spouse–and particularly on the children. “No one is harmed” serves as mere justification for autonomous behavior while denying or minimizing the inevitable adverse consequences of this behavior. When Joe has an affair with Susie at the office, and ends up in divorce court as a result, there can be little question that many are harmed: Joe’s children, not the least; his wife; perhaps the husband and children of the woman with whom he has had an affair. Yet in the heat of passion, “no one is harmed” is self-evident–believed even if false. And to mention these obvious ramifications of a supposedly “harmless” behavior is to be “judgmental” and therefore must be assiduously avoided.

But the consequences are real, and their ripple effect throughout society is profound: to cite one simple example, children from broken homes are far more prone to become involved in gangs or crime, to be abused sexually or physically; to initiate early sexual activity and become unwed mothers; to under-perform academically, and to have greater difficulty with relationships as teenagers and adults. These effects–particularly when magnified on a society-wide scale–have effects vastly broader than the personal lives of those who have made such autonomous choices.

Similarly, an argument is often used by libertarians (and others) for drug legalization using this same hold-harmless rationale. After all, who could argue with personal drug use in the privacy of your home, since “no one is harmed?” No one is harmed, of course–unless the residual, unrecognized effects of your drug use affects your reflexes while driving the next day, resulting in an accident; or impairs your judgment at work, costing your employer money or resulting in a workplace injury; or when, in the psychotic paranoia of PCP use, you decide your neighbor is trying to kill you, and beat him senseless with a baseball bat; or when the drug itself, in those so physiologically prone, leads to addictive behavior which proves destructive not merely to the individual, but to family, fellow workers, and society as a whole. Burning up every spare dollar of a family’s finances to support a drug habit, and stealing to support it–surely not an unusual scenario–can hardly be qualified as “no one is harmed.” To claim that there is no societal impact from such individual autonomous behavior is profoundly naive, and represents nothing more than wishful thinking.

But what about euthanasia? Surely it is reasonable to end the life of someone who is suffering unbearably, who is beyond the help of medical science, and who has no hope of survival, is it not? This, of course, is the scenario most commonly presented when legalization of euthanasia is promoted. It should be stated without equivocation that such cases do indeed exist, and represent perhaps the most difficult circumstances in which to argue against euthanasia. But it should also be said that such cases are becoming far less common as pain management techniques and physician training in terminal care improve: in my experience, and in the experience of many of my peers who care for the terminally ill, is a rare occurrence indeed that a patient cannot have even severe, intractable pain managed successfully.

But the core arguments used in support of euthanasia in such dire circumstances are easily extended to other terminal situations–or situations not so very terminal at all. Intractable terminal pain merges seamlessly into hopeless prognosis, regardless of time frame; then flows without interruption to chronic diseases such as multiple sclerosis or severe disabilities. Once the principle of death as compassion becomes the guiding rule, the Grim Reaper will undergo metamorphosis into an angel of light, ready to serve one and all who suffer needlessly.

To mitigate the risk of this so-called “slippery slope,” it has been suggested that safeguards against such mission creep be crafted. Such measures may invoke mandatory second opinions, waiting periods, or committee review, prior to approval of an act of euthanasia. That such measures are ultimately doomed to fail is self-evident: in effect, they impose a roadblock between patient autonomy and relief of suffering and its amelioration through euthanasia–and thus run counter to the core principle sustaining it. It is not difficult to foresee that such roadblocks will quickly be made less “burdensome,” if not rendered utterly impotent, by relentless pressures to prevent patients from needlessly suffering, regardless of their underlying disease.

Perhaps more importantly, the process of assessing and approving an act of euthanasia through second opinions or committee review is not some ethically neutral decision, such as vetting budget items or inventory purchases. Those who serve in such advisory or regulatory capacity must by necessity be open to–indeed supportive of–the idea of euthanasia, lest all reviewed cases be denied. As demand for euthanasia increases, such approvals will become rubber-stamped formalities, existing solely to provide defensive cover for unrestricted assisted termination.

But such arguments against euthanasia are in essence process-oriented, and miss the much larger picture of the effects of individual euthanasia on our collective attitudes about life and death, and our societal constitution. There can be little question that the practice of actively terminating ill or dying patients will have a profound effect on the physicians who engage in this practice. The first few patients euthanized may be done in a spirit of compassion and mercy–but repetition deadens the soul and habitualizes the process. This is routinely seen in many areas of health care training and practice: the first cut of a novice surgeon is frightening and intimidating; the thousandth incision occurs with nary a thought. One’s first autopsy is ghoulish; the hundredth merely objective fact-finding. Euthanasia, practiced regularly, becomes simply another tool: this can be readily seen in the statistics from the Netherlands, where even 15 years ago, a startling percentage of reported cases of euthanasia by physicians took place without explicit patient request — reflecting far more a utilitarian attitude toward euthanasia than some diabolical conspiracy to terminate the terminal. The detached clinicians, utterly desensitized to the act of taking a life, now utilize it as they would the initiation of parenteral nutrition or the decision to remove a diseased gallbladder.

Such false assumptions about the objective impartiality of the decision-making process leading to euthanasia can be seen as well when looking at the family dynamics of this process. We are presented with the picture of the sad but compassionate family, quietly and peacefully coming to the conclusion that Dad–with his full assent, of course–should mercifully have his suffering ended with a simple, painless injection. Lost in this idyllic fantasy is the reality of life in families. Anyone who has gone through the death of a parent and the settlement of an estate knows first-hand the fault lines such a life crisis can expose: old grievances brought back to life, old hot buttons pushed, greed and avarice bubbling to the surface like a toxic witch’s brew. Does brother John want Dad’s dignified death so he can cop the insurance cash for his gambling habit? Does sister Sue, who hates her father and hasn’t spoken to him in years, now suddenly want his prompt demise out of genuine concern for his comfort and dignity? Are the children–watching the estate get decimated by the costs of terminal care–really being objective about their desire for Mom’s peaceful assisted death? And does Mom, who knows she’s dying, feel pressured to ask for the needle so she won’t be a burden to her children? Bitter divisions will arise in families who favor euthanasia and those who oppose it–whether because of their relationship, good or bad, with the parent, or their moral and ethical convictions. To make euthanasia the solution to difficult problems of death and dying, as suggested by its proponents, will instead require the death of our spirits: a societal hardness of heart whose effects will reach far and wide throughout areas of life and culture far beyond the dying process. Mercy killing will kill our mercy; death with dignity so delivered will leave us not dignified but degraded.

The driving force behind legalized euthanasia and physician-assisted suicide is patient autonomy: the desire to maintain control over the dying process, by which, is it hoped, we will maintain our personal dignity. But the end result of legalized euthanasia will instead, in many cases, be loss of patient autonomy. When legalized, medical termination of life will by necessity be instituted with a host of safeguards to prevent its abuse. Such safeguards will include restricting the procedure to those in dire straights: intolerable suffering, a few months to live, and the like. Inherent in these safeguards are the seeds of the death of patient autonomy: such determinations must rely on medical judgments–and therefore will ultimately lie in the hands of physicians rather than patients. It will be physicians who will decide what is intractable pain; it is physicians who will judge how long you have to live; it is physicians who will have the last say on whether your life has hope or is no longer worth living. Such decisions may well be contested–but the legal system will defer to the judgment of the health care profession in these matters. Patient autonomy will quickly become physician autocracy. For those who request euthanasia, it will be easy; for those who do not wish it, but fit the criteria, it will also be far too easy.

This has been the legal and practical evolution of euthanasia in the Netherlands. The legal progression from patient autonomy with safeguards to virtual absence of restrictions on euthanasia is detailed in a superb paper from Brooklyn Law School’s Journal of International Law (available here as a PDF), in which this evolution is detailed:

Soon after the Alkmaar case was decided, the Royal Dutch Medical Association (KNMG) published a set of due care guidelines that purported to define the circumstances in which Dutch physicians could ethically perform euthanasia.

The KNMG guidelines stated that, in order for a physician to respond to a euthanasia request with due care,

  • The euthanasia request must be voluntary, persistent, and well-considered.
  • The patient must suffer from intolerable and incurable pain and a discernible, terminal illness.

Thereafter, Dutch courts adopted the KNMG guidelines as the legal prerequisites of due care in a series of cases between 1985 and 2001. Despite the integration of the KNMG’s due care provisions, courts remained confused regarding what clinical circumstances satisfied the requirements of due care. In 1985, a court acquitted an anesthesiologist who provided euthanasia to a woman suffering from multiple sclerosis. The court thereby eliminated the due care requirement that a patient must suffer from a terminal illness. By 1986, courts decided that a patient need not suffer from physical pain; mental anguish would also satisfy the intolerable pain due care requirement.

Similarly, all reported prosecutions of euthanasia prior to 1993 involved patients who suffered from either physical or mental pain. Then, in the 1993 Assen case, a district court acquitted a physician who had performed active voluntary euthanasia on an otherwise healthy, forty-three year old woman. The patient did not suffer from any diagnosable physical or mental condition, but had recently lost both of her sons and had divorced her husband. With the Assen case, Dutch courts seemed to abandon the requirement that a patient suffer from intolerable pain or, for that matter, from any discernible medical condition as a pre-condition for the noodtoestand [necessity] defense.

The requisite ambiguity of all such safeguards will invariably result in their legal dilution to the point of meaninglessness–a process which increasingly facilitates the expansion not only of voluntary, but also involuntary euthanasia. This is inevitable when one transitions from a fixed, inviolable principle (it is always wrong for a physician to kill a patient) to a relative standard (you may end their lives under certain circumstances). The “certain circumstances” are negotiable, and once established, will evolve, slowly but inexorably, toward little or no standards at all. When the goalposts are movable, we should not be surprised when they actually get moved.

Another effect rarely considered by those favoring euthanasia is its effect on the relationship between patients and their physicians. The physician-patient relationship at its core depends upon trust: the confidence which a patient has that their physician always has their best interests at heart. This is a critical component of the medical covenant–which may involve inflicting pain and hardship (such as surgery, chemotherapy, or other painful or risky treatments) on the patient for their ultimate benefit. Underlying this trust is the patient’s confidence that the physician will never deliberately do them harm.

Once physicians are empowered to terminate life, this trust will invariably erode. This erosion will occur, even were involuntary euthanasia never to occur–a highly unlikely scenario, given the Dutch experience. It will erode because the patient will now understand that the physician has been given the power to cause them great harm, to kill them–with the full legal and ethical sanction of the law. And the knowledge of this will engender fear: fear that the physician may abuse this power; fear that he or she may misinterpret your end-of-life wishes; fear that he may end your life for improper motives, yet justify it later as a legal and ethical act. The inevitable occurrence of involuntary euthanasia–which in an environment of legalized voluntary euthanasia will rarely if ever be prosecuted–will only augment this fear, especially among the elderly and the disabled. In the Netherlands, many seniors carry cards specifying that they do not wish to have their lives terminated–a reflection of a widespread concern that such an occurrence is not uncommon, and is feared.

Montana judge: man has right to assisted suicide

Effects on physicians:

Helen

Effects on Physicians

PHYSICIAN-ASSISTED SUICIDE IN OREGON:
A MEDICAL PERSPECTIVE

Texas Tort Reform

Dr Bob

Over at the Belmont Club, Richard Ramirez has a post citing a proposal by a physician for reform of the health care system. The proposal is thoughtful, with some excellent suggestions (which will never get implemented in today’s environment, sadly).

What caught my eye in the comments was a summary of the changes which tort reform has brought about in Texas by a commenter, Leo Linbeck:

I’m pretty familiar with tort reform in Texas, as my dad was the founding Chairman of Texans for Lawsuit Reform. TLR started in the mid-1990s after forty years of steadily increasing tilting of the civil justice playing field in favor of plaintiffs. There were two major inflection points in this fight:

The 1995 session (with George W. Bush was Governor)

Limited punitive damages
Reformed joint and several liability
Restricted venue shopping
Restored the Deceptive Trade Practices Act to its original purpose of protecting consumers in ordinary consumer transactions
Enacted a half dozen other reforms to curtail specific lawsuit abuses

The 2003 session (with George W. Bush was Governor)

Enacted comprehensive reforms governing medical liability litigation, including a $750,000 limit on non-economic damages
Initiated product liability reforms
Made the burden of proving punitive damages similar to criminal law, requiring a unanimous jury verdict
Comprehensively reformed the statutes governing joint and several liability and class action lawsuits
Imposed limits on appeal bonds, enabling defendants to appeal their lawsuits and not be forced into settlements (this is what pushed Texaco into bankruptcy in its famous lawsuit against Pennzoil)
Further limited the filing of lawsuits that should have been brought in other states or countries

The changes to medical liability in 2003 were extraordinary, and had a very substantial impact, including:

1. In August 2004, the Texas Hospital Association reported a 70% reduction in the number of lawsuits filed against the state’s hospitals.
2. Medical liability insurance rates declined. Many doctors saw average rate reductions of over 21%, with some doctors seeing almost 50% decreases. (Recent information provided to The Perryman Group during the course of this study suggests that premiums are declining even further in 2008.)
3. Beginning in 2003, physicians started returning to Texas. The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years. Perryman has determined that at least 1,887 of those physicians are specifically the result of lawsuit reform.
4. In May 2006, the American Medical Association removed Texas from its list of states experiencing a liability crisis, marking the first time it has removed any state from the list. A recent survey by the Texas Medical Association also found a dramatic increase in physicians’ willingness to resume certain procedures they had stopped performing, including obstetrics, neurosurgical, radiation and oncological procedures.

Last year, TLR commissioned a study by The Perryman Group to figure out the impact of these reforms (the above are excerpted from that report). Here are the economic impact findings of that study:

$112.5 billion increase in annual spending
$51.2 billion increase in annual output – goods and services produced in Texas
$2.6 billion increase in annual state tax revenue
$468.9 million in annual benefits from safer products
$15.2 billion in annual net benefits of enhanced innovation
499,000 permanent jobs
430,000 additional Texans have health insurance today as a result of the medical liability reforms

The complete Perryman Group report is here.

As these numbers show, tort reform can have a substantial impact on economic growth and wealth creation, and a huge impact on the healthcare system in particular. Any serious national healthcare reform must include comprehensive tort reform to reduce the practice of defensive medicine and other perverse incentives.

Which is why I do not consider the current proposals from the Obama Administration to be serious (other than being seriously flawed).

Our current re-invention of the health care system, for all its complexity, completely ignores the problem of runaway malpractice lawyers and the costs of defensive medicine. While not surprising, given the huge contributions to the Dems from attorneys, this deficit alone virtually guarantees a disastrous outcome should it be implemented.

The Children Whom Reason Scorns

Dr Bob

Nazi German euthanasia posterIn the years following the Great War, a sense of doom and panic settled over Germany. Long concerned about a declining birth rate, the country faced the loss of 2 million of its fine young men in the war, the crushing burden of an economy devastated by war and the Great Depression, further compounded by the economic body blow of reparations and the loss of the German colonies imposed by the Treaty of Versailles. Many worried that the Nordic race itself was threatened with extinction.

The burgeoning new sciences of psychology, genetics, and medicine provided a glimmer of hope in this darkness. An intense fascination developed with strengthening and improving the nation through Volksgesundheit–public health. Many physicians and scientists promoted “racial hygiene” – better known today as eugenics. The Germans were hardly alone in this interest – 26 states in the U.S. had forced sterilization laws for criminals and the mentally ill during this period; Ohio debated legalized euthanasia in the 20’s; and even Oliver Wendall Holmes, in Buck v. Bell, famously upheld forced sterilization with the quote: “Three generations of imbeciles are enough!” But Germany’s dire circumstances and its robust scientific and university resources proved a most fertile ground for this philosophy.

These novel ideas percolated rapidly through the social and educational systems steeped in Hegelian deterministic philosophy and social Darwinism. Long lines formed to view exhibits on heredity and genetics, and scientific research, conferences, and publication on topics of race and eugenics were legion. The emphasis was often on the great burden which the chronically ill and mentally and physically deformed placed on a struggling society striving to achieve its historical destiny. In a high school biology textbook – pictured above – a muscular German youth bears two such societal misfits on a barbell, with the exhortation, “You Are Sharing the Load!–a hereditarily-ill person costs 50,000 Reichsmarks by the time they reach 60.” Math textbooks tested students on how many new housing units could be built with the money saved by elimination of long-term care needs. Parents often chose euthanasia for their disabled offspring, rather than face the societal scorn and ostracization of raising a mentally or physically impaired child. This widespread public endorsement and pseudo-scientific support for eugenics set the stage for its wholesale adoption — with horrific consequences — when the Nazi party took power.

The Nazis co-opted medicine fully in their pursuit of racial hygiene, even coercing physicians in occupied countries to provide health and racial information on their patients to occupation authorities, and to participate in forced euthanasia. In a remarkably heroic professional stance, the physicians of the Netherlands steadfastly refused to provide this information, forfeiting their medical licenses as a result, and no small number of physicians were deported to concentration camps for their principled stand. As a testimony to their courage and integrity, not a single episode of involuntary euthanasia was performed by Dutch physicians during the Nazi occupation.

Would that it were still so.

The Netherlands was the first country in the world in which euthanasia and assisted suicide was legally performed, having fully legalized the practice in 2006 after several decades of widespread illegal–but universally unpunished–practice. The Dutch have come into the public consciousness periodically over the past 30vyears, initially with the consideration of assisted suicide laws in Oregon, Washington, Michigan and elsewhere in the early 90’s, and again with their formal legalization of physician-assisted suicide and euthanasia in 2001. Once again they are on the ethical radar, with the disclosure last week of the Groningen Protocol for involuntary euthanasia of infants and children.

The Groningen Protocol is not a government regulation or legislation, but rather a set of hospital guidelines for involuntary euthanasia of children up to age 12:

The Groningen Protocol, as the hospital’s guidelines have come to be known, would create a legal framework for permitting doctors to actively end the life of newborns deemed to be in similar pain from incurable disease or extreme deformities.

The guideline says euthanasia is acceptable when the child’s medical team and independent doctors agree the pain cannot be eased and there is no prospect for improvement, and when parents think it’s best.

Examples include extremely premature births, where children suffer brain damage from bleeding and convulsions; and diseases where a child could only survive on life support for the rest of its life, such as severe cases of spina bifida and epidermosis bullosa, a rare blistering illness.

The hospital revealed last month it carried out four such mercy killings in 2003, and reported all cases to government prosecutors. There have been no legal proceedings against the hospital or the doctors.

While some are shocked and outraged at this policy of medical termination of sick or deformed children (the story has been widely ignored by the mainstream media, and has gotten only limited attention on the Internet), it is merely a logical extension of a philosophy of medicine widely practiced and condoned in the Netherlands for many years, much as it was in Germany between world wars. It is a philosophy where the Useful is the Good, whose victims are the children whom Reason scorned.

Euthanasia is the quick fix to man’s ageless struggle with suffering and disease. The Hippocratic Oath — taken in widely varying forms by most physicians at graduation — was originally administered to a minority of physicians in ancient Greece, who swore to prescribe neither euthanasia nor abortion — both common recommendations by healers of the age. The rapid and widespread acceptance of euthanasia in pre-Nazi Germany occurred because it was eminently reasonable and rational. Beaten down by war, economic hardship, and limited resources, logic dictated that those who could not contribute to the betterment of society cease being a drain on its lifeblood. Long before its application to ethnic groups and enemies of the State, it was administered to those who made us most uncomfortable: the mentally ill, the deformed, the retarded, the social misfit. While invariably promoted as a merciful means of terminating suffering, the suffering relieved is far more that of the enabling society than of its victims. “Death with dignity” is the gleaming white shroud on the rotting corpse of societal fear, self-interest and ruthless self-preservation.

It is sobering and puzzling to ponder how the profession of medicine – whose core article of faith is healing and comfort of the sick – could be so effortlessly transformed into a calculating instrument of judgment and death. It is chilling to read the cold scientific language of Nazi medical experiments or Dutch studies on optimal techniques to minimize complications in euthanasia. Yet this devolution of medicine, with some contemplation, is not hard to discern. It is the natural gravity of man detached from higher principles, operating out of the best his reason alone has to offer, with its inevitable disastrous consequences. Contributing to this march toward depravity:

 ♦ The power of detachment and intellectualization: Physicians by training and disposition are intellectualizers. Non-medical people observing surgery are invariably squeamish, personalizing the experience and often repulsed by the apparent trauma to the patient. Physicians overcome this natural response by detaching themselves from the personal, and transforming the experience into a study in technique, stepwise logical processes, and fascination with disease and anatomy. Indeed, it takes some effort to overcome this training to develop empathy and compassion. It is therefore a relatively small step with such training to turn even killing into another process to be mastered.

 ♦ The dilution of personal responsibility: In Germany, the euthanasia of children was performed with an injection of Luminal, a barbiturate also used for seizures and sedation of the agitated. As a result, it was difficult to determine who was personally responsible for the deed: was it the nurse, who gave too much? The doctor, who ordered too large a dose? Was the patient overly sensitive to the drug? Was the child merely sedated, or in a terminal coma? Of course, all the participants knew what was going on, but responsibility was diluted, giving rationalization and justification full reign. The societal endorsement and widespread practice of euthanasia provided additional cover. When all are culpable, no one is culpable.

 ♦ Compartmentalization: an individual involved in the de-Baathification of Iraq said the following:

There is a duality in Baathists. You can find a Baathist who is a killer, but at home he’s completely normal. It’s like they split their day into two twelve-hour blocks. When people say about someone I know to be a Baathist criminal, ‘No, he’s a good neighbor!’, I believe him.

Humans have the remarkable ability to utterly separate disparate parts of their lives, to accommodate cognitive dissonance. Indeed, there is probably no other way to maintain sanity in the face of enormous personal evil.

 ♦ The banality of evil: Great evil springs in countless small steps from lesser evil. Jesus Christ was doubtless not the first innocent man Pilate condemned to death; soft porn came before child porn, snuff films, and rape videos; in the childhood of the serial killer lies cruelty to animals. Small evils harden the heart, making greater evil easier, more routine, less chilling. We marvel at the hideousness of the final act, but the descent to depravity is a gentle slope downwards.

 ♦ The false optimism of expediency: Solve the problem today, deny any future consequences. We are nearsighted creatures in the extreme, seeing only the benefits of our current actions while dismissing the potential for unknown, disastrous ramifications. When Baby Knauer, an infant with blindness, mental retardation and physical deformities, became the first child euthanized in Germany, who could foresee the horrors of Auschwitz and Dachau? We are blind to the horrendous consequences of our wrong decisions, but see infinite visions of hope for their benefits. As a child I watched television shows touting peaceful nuclear energy as the solution to all the world’s problems, little imagining the fears of the Cuban missile crisis, Chernobyl and Three Mile Island, the minutes before midnight of the Cold War, and the current ogre of nuclear terrorism.

Reason of itself is morally neutral; it can kill children or discover cures for their suffering and disease. Reason tempered by humility, faith, and guidance by higher moral principles has enormous potential for good – and without such restraints, enormous potential for evil.

The desire to end human suffering is morally good. Despite popular misconception, the Judeo-Christian tradition does not view suffering as something good, but rather something evil which exists, but which may be transformed and redeemed by God and grace, to ultimately produce a greater good. This is a difficult sell to a materialistic, secular world, which does not accept the transformational power of God or the existence of spiritual consequences, or principles higher than human reason.

Yet the benefits of suffering, subtle though they may be, can be discerned in many instances even by the unskilled eye. What are the chances that Dutch doctors will find a cure for the late stage cancer or early childhood disease, when they now so quickly and “compassionately” dispense of their sufferers with a lethal injection? Who will teach us patience, compassion, unselfish love, endurance, tenderness, and tolerance, if not those who provide us with the opportunity through their suffering, or mental or physical disability? These are character traits not easily learned, though enormously beneficial to society as well as individuals. How will we learn them if we liquidate our teachers?

Higher moral principles position roadblocks to our behavior, warning us that grave danger lies beyond. When in our hubris and unenlightened reason we crash through them, we do so at great peril, for we do not know what evil lies beyond. The Netherlands will not be another Nazi Germany, as frightening as the parallels may be. It will be different, but it will be evil in some unpredictable way, impossible to foresee when rationalism took the first step across that boundary to kill a patient in mercy.

Assisted Suicide: Coming to a State Near You

Dr Bob

I hope to have more to say on the issue of euthanasia and assisted suicide in the near future. In the meantime, I highly recommend this article by Herbert Hendin, M.D. Dr. Hendin’s book, Seduced by Death: Doctors, Patients, and Assisted Suicide, is an excellent resource on the topic, the result of extensive research and multiple interviews taken while studying euthanasia practices in the Netherlands. This article provides a nice summary of his research and experience, which builds a solid case against euthanasia and physician-assisted suicide.

Washington has recently become the second state to pass an assisted suicide initiative, and, legislating from the bench, a Montana judge has ruled that man has right to assisted suicide.

This movement is on a roll, and you will want to be informed about why this is such a ghastly public policy trend.

A few highlights from the article:

Concern over charges of abuse led the Dutch government to undertake studies of the practice in 1990, 1995 and in 2001 in which physicians’ anonymity was protected and they were given immunity for anything they revealed. Violations of the guidelines then became evident. Half of Dutch doctors feel free to suggest euthanasia to their patients, which compromises the voluntariness of the process. Fifty percent of cases were not reported, which made regulation impossible. The most alarming concern has been the documentation of several thousand cases a year in which patients who have not given their consent have their lives ended by physicians. A quarter of physicians stated that they “terminated the lives of patients without an explicit request” from the patient. Another third of the physicians could conceive of doing so.

An illustration of a case presented to me as requiring euthanasia without consent involved a Dutch nun who was dying painfully of cancer. Her physician felt her religion prevented her from agreeing to euthanasia so he felt both justified and compassionate in ending her life without telling her he was doing so. Practicing assisted suicide and euthanasia appears to encourage physicians to think they know best who should live and who should die, an attitude that leads them to make such decisions without consulting patients–a practice that has no legal sanction in the Netherlands or anywhere else.

Assisted-suicide laws are always framed as being “compassionate” — appealing to the universal fear of dying a prolonged and painful death. Yet the unintended consequences of giving physicians the unrestricted power of life and death are often anything but:

Compassion is not always involved. In one documented case, a patient with disseminated breast cancer who had rejected the possibility of euthanasia had her life ended because, in the physician’s words: “It could have taken another week before she died. I just needed this bed.”

He also extensively studied Oregon’s experience with assisted suicide — the legislation which served as the model for Washington’s law — and found plenty of problems here as well:

Oregon physicians have been given authority without being in a position to exercise it responsibly. They are expected to inform patients that alternatives are possible without being required to be knowledgeable enough to present those alternatives in a meaningful way, or to consult with someone who is. They are expected to evaluate patient decision-making capacity and judgment without a requirement for psychiatric expertise or consultation. They are expected to make decisions about voluntariness without having to see those close to the patient who may be exerting a variety of pressures, from subtle to coercive. They are expected to do all of this without necessarily knowing the patient for longer than 15 days. Since physicians cannot be held responsible for wrongful deaths if they have acted in good faith, substandard medical practice is encouraged, physicians are protected from the con-sequences, and patients are left unprotected while believing they have acquired a new right.

The idea of assisted suicide has enormous allure in a culture of self-gratification and increasingly-shallow moral and ethical principles. Don’t be surprised when it comes your way — be prepared.

Revolution of the Soul

Dr Bob

In the past several days, through the lens of my profession, I have been given a rather stark and disturbing vision of our current cultural revolution. It is, it seems, a revolution every bit as pervasive and transformational — and destructive — as China’s Cultural Revolution of the 60s — and indeed may be but a different manifestation of a global transformation which transpired in those very same decades in the West. Ideas have consequences, as they say, and we are watching them bear fruit before our very eyes in a slow-motion train wreck which seems now to be accelerating at a disturbing rate.

Exhibit 1: Phyllis Chesler’s recent piece, “Every hospital patient has a story”, at PajamasMedia. It is a piece to be read to completion, including its lengthy comment section. Therein she details a recent experience during a hospital stay for a hip replacement, with a rather remarkable litany of rudeness, neglect, indifference, and suffering sustained at the hands of her healers, at an upscale New York hospital. Her story is shocking enough, and revelatory; the comments provide even further insight, running the expected gamut of such a piece in the New Media. There are those simply shocked; those sharing similar horror stories; those relaying far better experiences in contrast; those defending doctors and nurses, those attacking them. There is the obligate wackjob who blames the AMA, and the usual finger-pointing: not enough nurses, too much paperwork, inadequate pay scales to draw quality; the evil insurance companies and the government. All mostly true, to greater or lesser degree — but all missing the core dysfunction by a wide mark. At the final period of her post, one comes away with a sense of hopeless, feeling out of control and angry, despairing that such a situation may be even a part of our reality (and not knowing how large a part it may be), yet at a loss to prevent its malignant progression through our remaining hospitals which may have been spared to date, the encroachment of such a toxic stew of callousness, indifference, and coldness. There seems, in the end, little cause for optimism.

Exhibit 2: It is late, nearly 9 P.M., seeing a final consult at the end of a punishing call day, in the ICU. The patient, chronologically young yet physiologically Methuselan, lies in his bed, oxygen mask affixed to his face by heavy straps, bleeding, as he has for months, from a tumor in his kidney. He would not survive surgery, nor even radiological intervention to stem the hemorrhage by strangling its arterial lifeline. He is, furthermore, in the parlance of modern medicine, “non-compliant”: refusing treatments and diagnostic studies; rude and abusive to nurses and physicians alike; demanding to go home though unlikely to survive there for any significant length of time.

The nurse — young, competent, smart, hard-working, the very best of the modern nursing profession — apprises me of his situation, closing with this knockout punch: “You know, we just passed that initiative — you know, the suicide one. He’d be an excellent candidate.”

She wasn’t joking.

Taken a bit off guard, I responded that it is most unwise to give physicians the power to kill you, for we will become very good at it, and impossible to stop once we are.

She continued: “No, I would love to work for a Dr. Kevorkian. Be an Angel of Death, you know?”

“I know”, I muttered under my breath, as she ran off to another bedside, competently and with great efficiency, to adjust some ventilator or fine-tune some dopamine drip. And hopefully do nothing more.

These vignettes in modern medicine are really not about medicine at all. They are in truth about a culture which has lost its compassion. Our calloused and cynical society has become a raging river fed by a thousand foul and fetid streams. We have, by turns, taught our children that ethics are situational and values neutral; taught our women that compassion and service are signs of weakness, that they must become hard and heartless like the men they hate; taught our men that success and the respect of others comes not through character and integrity but through callousness, cynicism, and greed; and taught ourselves that we are a law unto ourselves, the sole and final arbiter of what is right and what is good.

We have, in our post-modern and post-Christian culture, inexorably and irrevocably turned from our roots in Christian morality and worldview, which was the foundation and font of that which we now know — or used to know — as Western Civilization. Yes, we have preserved the tinsel and the trappings, the gilded and glittering exterior of a decaying sarcophagus, where we speak self-righteously of rights while denying their origin in the divine spark within the human spirit, made in the image of God; where we bray about liberty, but are enslaved to its bejeweled impostor, the damsel of decadence and libertinism; where compassion is naught but another government program to address the consequences of our own aberrant and irresponsible behavior, duly justified, rationalized, and denied. Others must pay so that I may play, you know.

This toxic stew of self-centered callousness has percolated into every pore of our society. In health care, the effects are universal and pernicious. Patients demand perfection, trusting the wisdom of a web browser over the experience of a physician — then running to their attorney to redress every poor outcome which their disease or their destructive lifestyles have helped bring about. Physicians, hardened and cynical from countless battles with corrupt insurance companies, lawyers, and Stalinist government regulation, forget that they exist solely to serve the patient with compassion and self-sacrifice, and that financial recompense is secondary to healing and empathy. Nurses have in large measure become administrators, made ever more remote from their patients by mountains of paperwork and impossible nurse-to-patient ratios, their patient-critical tasks delegated to underlings poorly trained and ill-treated. Hospital administrators are MBAs, with no interest or clue about what constitutes good health care, and are indifferent so long as their departments are profitable and their marketing wizards successful as they trumpet “Care with Compassion” in TV ads, radio, and muzac on hold.

The list could go on far longer, but the theme is clear: we have as a culture become utterly self-focused, trusting no one, demanding our rights while neglecting our responsibilities, seeking to be profitable rather than professional. We have abandoned the responsibility to be patient and caring of others, forgiving of human shortcomings and humble about the limits of our abilities — a responsibility not merely of those in health care but of human beings in civil society. We have, through the dubious gift of extraordinary technological advances, industrialized our profession, and replaced a sacred covenant of commitment to the patient’s best — and its corollary of the patient’s trust in the integrity and motives of physicians and nurses — with the cold legality of contract medicine. Small wonder we are treated as fungible commodities in doctors’ offices and hospital beds. Small wonder we will be euthanized when we have exhausted our compassion quotient, dispatched by highly efficient providers delivering “Death with Dignity.”

This utter self-obsession and cynical callousness is by no means limited to health care. We long for “bipartisanship” in government (by which we hope for reasoned men of principle to come together for the good of those they represent), but get instead the blood-lust of modern politics, where power trumps principle, money is king, and votes are bought and sold like chattel. Lawyers sue everything that breathes — and much that doesn’t — raking in billions while their “victimized clients” get pocket change they can believe in. Airlines pack in passengers like cattle, lose your bags, and toss you a bag of peanuts for your trouble. Road rage is rampant, rudeness rules, rip-offs too common to count. The coarseness in culture is extraordinary — in language, art, media, fashion, and behavior. It is revealing how shocked we find ourselves when encounter someone — regardless of the venue — who is actually pleasant, helpful, courteous, and kind; we have come to expect and tolerate far worse as a matter of course.

The revolution which started in the 60s with the “me” generation is bearing its bitter fruit — though its aging proponents will never admit it. And sadly, there’s no going back: the changes which have infiltrated and infected the culture, inoculated through education, media, entertainment, scientific rationalism, and a relentless and highly successful assault on reason and tradition, are permanent, and their consequences will only grow in magnitude.

So it’s time for a counter-revolution.

There is an alternative to our current cultural narcissism with its corrosive, calloused, destructive bent. It is not a new government program, nor a political movement; no demonstrations in the street, no marches on Washington. Its core ideology is over 2000 years old, and the foot soldiers of the revolution are already widely dispersed throughout the culture.

This revolutionary force is called Christianity, and it’s long past time to raise the banner and spring into action.

The true antidote to the nihilism and corruption of the age will be found, as it has always been, in the church. It has since its inception been a revolutionary force, transforming the hopeless and purposeless anarchy of the pagan world of its infancy by bringing light, hope and joy where there was none before.

It can happen again.

The church, of course, has to no small degree been co-opted by the culture it should have transformed. From TV evangelists preaching God-ordained health and wealth to liberal denominations rejecting the core truths of their foundation and worshiping instead the god of government and humanistic socialism; from pederast priests to episcopal sodomy, Christianity in the West has whored itself to a prosperous but decadent culture. Its salt has lost its saltiness, and it has, not surprisingly, been trampled underfoot by men.

It is time to return to our First Love. It is time once again to become light to an dark and stygian world. It is time for a revolution of the soul.

We must, first and foremost, be about grace and truth. We must begin with the truth of our calling: to be holy, transformed by the power of Christ and the work of the Spirit. We are, by nature of our new birth in Christ, His ambassadors: we are to be the face, the hands, the heart, the words, the compassion of Him who saved us.

The task is enormous, yet for each of us, the steps are small, easily achievable yet enormously powerful.

It must begin with a renewed commitment to obedience and submission to Christ, a willingness to fully subject ourselves to His will, rather than trying to bend His will to ours. It means getting serious about church attendance — not merely as a consumer but as an active participant. We need to renew our devotion to prayer, to Scripture reading, study, and memorization, to fellowship with other Christians. These are simple steps which ground us in truth, and give us access to that power which can first of all transform us, then radiate out to all around us.

Then we must act like the counter-culturists we claim to be. Be patient with those who are difficult; be generous in time and money; express gratitude to those around us (when was the last time you wrote a thank you note to your doctor, your contractor, your attorney, to the manager of the store employee who helped you?). Lose the profanity; guard your tongue. Repair broken relationships, as best you can. Be joyful in difficult times, knowing that God is at work in your life despite your difficulties. Be compassionate rather than judgmental to those whose life choices are destructive or misguided. The tattoos and piercings we ridicule are cries of desperation from those hungering for purpose and meaning.

These things will not come easily to many of us who claim to be Christians, as we have become complacent in our self-gratification and comfortable compromises, fearful of being viewed as extremist or weird, rejected and ridiculed.

Get over it.

You may just find that such renewed passion for Christ and love for others might, just might, transform your life.

And you might just find that it will change the world.

Got a better idea? Good, I didn’t think so.

Let’s get started.

The Bounty Hunter

Dr Bob


I’ve been feeling a bit remiss (but only a bit) about my light posting of late — but hey, it’s summertime, and if Vanderleun can take a vacation, well, why not me?

But of course there’s always something which comes up, which demands some comment — such as this little blurb in the Wall Street Journal today:

Medicare Auditors Recover $700 Million in Overpayments

 
Auditors have recovered nearly $700 million in Medicare overpayments to hospitals and other medical providers in a half-dozen states under a controversial program that pays the auditing firms a portion of amounts they identify.

The program has drawn fire from health-care providers, and hospitals in particular, who call it overly aggressive and too confrontational. But the federal Centers for Medicare and Medicaid Services has supported the move and is in the process of expanding it nationally.

In all, the agency’s recovery audit contractor program caught $1.03 billion of improper payments over about three years, primarily in New York, California and Florida, about $992.7 million of which was overpayments by Medicare. The audits also identified about $38 million that providers should have received but didn’t. (Three states were added toward the end of the trial program, but accounted for only a small part of the recoveries, Medicare officials said.)

The program’s expenses amounted to about 20 cents on the dollar, including $187.2 million paid to the audit firms, and medical providers successfully challenged about $60 million of overpayments identified by the auditors. In the end, about $694 million has been returned to the Medicare trust funds, the Medicare agency said. The auditors reviewed a total of $317 billion in claims.

“All in all, we’re very happy with the results,” said Tim Hill, the agency’s chief financial officer and director of its office of financial management. “It returned a lot of money to the trust fund, particularly when you think that we’re talking about three states.”

I’ll bet you’re very happy, Mr. Hill.

Now, at first glance, this would appear to one of Medicare’s already notorious fraud and abuse investigations, carried out by OIG, but no — there’s no accusation of fraud involved here, although the government is more than happy to let this implication stand.

What this involves is demanding refunds based on different interpretations of Medicare’s mind-boggling regulations. So you provide a health care service, and bill Medicare based on your best understanding of its Byzantine regulations, and get paid. Then, at some future date, a third-party auditor, hired by the Feds, reviews the claim and decides — with no input from clinicians or other health care experts — that you were paid in error. Out goes the notice, pay up or else. Of course, this is always a highly objective, impartial review — the fact that the auditor gets a hefty cut of the refund has absolutely no influence on their judgment, none whatsoever.

Of course, you have a right to appeal — on your own dime and time, hiring your lawyers and taking time off from your practice to prove to the bounty hunter that your interpretation of the regulations is the correct one, and his is wrong. If you win, you get to keep the cash you already earned — minus a small stipend for lost time and lawyers fees. So, on that disputed $35 you got for an office call, you might come out, oh, $20,000 short, give or take a few thousand. But hey: You won!! Ain’t it grand?

Of course the low rate of appeals, entirely predictable based on the above freakonomics, is seen as proof that the audits are finding real problems:

Mr. Hill pointed to the low appeal rate — about 14% of overcharges were appealed, and 4.6% of the total were overturned — as evidence that the audits succeeded. “We know that we got the right answer,” he said.

If an 800-pound gorilla wants to make love to you, it’s always best to fake an orgasm. And the luvin’ ain’t over ’till the gorilla says it’s over…

Of course, these auditors also expend large amounts of time and energy looking for cases where you were underpaid:

RACs [Recovery Audit Contracts] are authorized to review payments for the previous 4 years. The software they use is more capable of picking up overpayments than it is underpayments. This discrepancy is borne out by a CMS report showing that 97% of improper payments in fiscal year 2006 were overpayments, and only 3% were underpayments. No money has been reported as having been returned to physicians because of underpayment.

At this point, the program has been primarily focused on hospitals in a few states, but is being rolled out nationwide, and will quickly be auditing physicians and other health care providers.

I have spoken a considerable length about the maze which is our current reimbursement system. It makes perfect sense, in a way, for the Feds to do exactly this: use bounty hunters to exploit the system’s complexity and inscrutability. They will no doubt recover a bundle of money, keeping the band playing on the Titanic for a few more years.

But sooner or later there’ll be a price to be paid — and that price is access. Repeated pay cuts such as the currently stalled 10.4% Medicare fee reduction being bantered around Congress, combined with heavy-handed recovery audits such as these, will drive physicians to the exits in droves. It is already nearly impossible in our area to find a primary care physician who accepts Medicare patients; a few more years of this B.S. and you’ll likely get a pretty clean sweep: best of luck finding anyone who will see you if you have Medicare or any other Federal health insurance.

Happy hunting on your audits, Mr. Hill.