Healthcare reform ethical questions

Hard choices and healthcare reform are here.  Donald Berwick, M.D., has been installed as the administrator for the Centers for Medicare and Medicaid services as a “recess appointment” by President Obama.

Dr. Berwick is an academician, a pediatrician who has spent the bulk of his professional existence as the CEO of the Institute for Healthcare Improvement of Cambridge, MA.  He is an outspoken advocate for the single-payer system, admires Britain’s National Health Service, and advances that all health care be linked to “quality metrics.”  In effect, that care is permissible only if and when it conforms to consensus guidelines written by experts.  A “pay-for-performance” program derived from these “best practices” will, in the view of Dr. Berwick, “bend down the cost curve.”

Deviation from the guidelines will be viewed as an insurance fraud, perpetrated by medical professionals and criminalizing their behavior.  In Massachusetts, the purported healthcare model of Obamacare, there are carrots but also sticks: physicians who fail to comply with quality guidelines established by state insurance administrators are publicly discredited and their patients are required to pay three times as much out of pocket to see them.

Be ready for this narrative.  This will be the politically correct language and manner to describe 21st century American Healthcare.  And it will impact you, your family, your friends and your neighbors.  But what about your children?

According to lead articles in the New England Journal of Medicine and JAMA end-of-life expenditures are under scrutiny as a potential means to help reduce “waste” in healthcare.  This will be amongst the first issues addressed by Berwick.

Medically futile care is defined by the absence of clinical benefit despite multiple interventions. At present, the all too familiar end-of-life sequence of the life-supported elderly Alzheimer patient in multisystems failure dominates healthcare bioethical discussions.   But it’s not just the elderly who will arrive at these crossroads or for whom health care resources are likely needed.

Let’s focus on pediatric issues for a moment, for a minor cannot participate in medical decision making (except in rare circumstances).  Children (under age 18) are not consent partners.  Children “assent” to treatment.

What is the value of a child’s life?  How is this determined?  By whom?

Up until the 20th century, most societies accepted childhood death as the way of the world.  The custom of referring to a baby as “it,” a term never applied to adults even when gender is ambiguous, betrays this attitude.  Limitations on the legal rights and status of children grew in part from these circumstances and realities.  The notion of concentrating medical resources on society’s productive members, namely, adults, also stems from this tradition.

In ancient Rome, human life in the biological sense was considered to begin with the first breath.  Yet, it was not until the person reached young adulthood that he became a person in the moral sense, with the full protection of the moral rule against homicide.

In ancient Greece, an entire literature of recognition of a defective child was created that allowed for the destruction of the newborn for the betterment of society.  Aristotle in his Politics and Plato in his Republic advanced that the best interests of society were served by infanticide when a variety of conditions were met.  These included rape, incest, adultery, parental age, defective births, etc.

Today we seem hopelessly locked in debate over motherhood versus womanhood, with little if any insight or flexibility from any of the strident political voices involved.  What should be, if any, the role of government?  Humanism and cultural consensus are ill served by these debates, and positioning and posturing.  But it does extend to our definition of the value of human life at its onset for this society.

The twentieth century brought improvement to the lot of our children.  Child labor laws begin in 1916.  Education began to be considered to be every child’s right.  Medical and surgical care for children was shockingly primitive as late as 1941, when Harvard Medical School established the first chair in child’s surgery.  Up to that point in time, and even for a period thereinafter, children were in general regarded as too weak for most surgical interventions.  The fact, again, that children could not speak for themselves left this surgical dogma unchallenged.

And children are still not a recognized voice in the healthcare debate other than via “interest groups.”

The remarkable advances in pediatrics from immunizations to advanced life support in 24 week old fetuses to intra‑uterine fetal cardiac procedures to separation of conjoined (formerly “Siamese”) twins to organ transplantation have carried hefty price tags.

Who has demanded this technology?  Why have we willingly paid the prices for this care?  Is there any value to advanced rehab in a post‑trauma quadriplegic child or advanced life support in an HIV positive infant?  What about the autistic child, or the multiply genetically defective (“impaired”) newborn?

Are limited or sparse assets or available resources to become the only basis for therapeutic decisions?

Arthur Kohrman states that “Preserving the lives of children attached for long periods of time to technological devices extends not only the lives of human beings but also the definition of being human …”  Technologically dependent people are difficult to construct ethical systems for.  Is the child‑machine combination a being in its own right, or just a stage in a medical metamorphosis?  Would the children of the Iron Lung Age survive in the twenty-first century?

The definition of medical futility as a concrete concept deserves to be utilized carefully and not automatically.

At issue is not whether or not futility is definable, but rather is it good and sensible public policy to admit a legalized and narrow standard?  Criminalizing healthcare delivery, developing punitive consequences for failure to adhere to a fictionalized consensus guideline will be arbitrary, fraught with inequity, and bureaucratize the medical profession beyond any reasonable threshold.

This is not healthcare reform.  It places the system’s needs beyond the individual’s.

“If you don’t know where you’re going,” Casey Stengel liked to say, “you will probably wind up someplace else.”

Jeffrey Hall Dobken is an assistant clinical professor of pediatric immunology and allergy, and certified bioethicist at Weill Cornell School of Medicine in New York City.

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  • Max

    Well said, Dr. Dobken. You will soon get the Obama apologists in here standing up for Dr. Berwick and how his statements have been ‘taken out of context’. I can think of several frequent posters here who will defend him. Until he categorically denies his prior statements and flatly rejects rationing, I will believe his past statements. No lackey or shill will substitute for his own words.

  • Major Medical

    As a 30-year veteran of the health care business, I agree that we need reform. But eliminating waste, cutting expenses and expanding the utilization of HSAs sounds a lot better than a complete overhaul and possible ruin of the system.

  • Donald Green MD

    Any back up for what you have said. As far as I know Dr. Berwick understands that the British system has flaws but values that no patient goes bankrupt, gets sicker, or dies because they do not have insurance. If our system needs a more American fix then become part of the solution.

    • Jeffrey Hall Dobken, M.D.

      Read today’s NEJM (08-20-2010) re NSCLC and timing/use of palliative therapy as an extension of “concerns regarding the use of healthcare services at the end of life”. “Google” EOL (“end of life”) and refine the search just to JAMA or NEJM… and wonder why this explosion of interest in this debate. Res Ipse Loquitor.

      • Alice

        The new PM in the UK is cutting everything (kudos to him), but the sick often do get “sicker” in the UK. I lived there and most of my relatives live there. I believe it’s sub-standard care. I know there are waiting lists for biopsies and scans, and that in itself can make a person “sicker”. And they stopped care for fourth stage breast cancer among other things a year ago (I know national health won’t cover things like anti-nausea drugs for chemo patients. Our cousin had to get that through his private insurance. Many of our relatives pay extra for private insurance which provides far better care than the government national health).

        In the pubs they talk about people going for routine procedures that never came home in the same vein we would discuss going to the movies. Maybe it’s just the Brits and their wicked sense of humor, but it’s very disconcerting. You start to appreciate the US health care, even with all it’s flaws.

        • Healthcare Observer

          ‘And they stopped care for fourth stage breast cancer among other things a year ago’

          This is simply untrue. Please don’t add to the untruths floating round the net.

          • Alice Robertson

            I don’t think you have did your research. I will get it when I get home. I have lived in the UK and the waiting lists are ridiculous.

            Let me say if you had a child with cancer (as I do) you wouldn’t want your child treated there. The rich Brits come here for treatment.

          • Alice

            This is simply untrue. Please don’t add to the untruths floating round the net. [end quote]

            Are you really saying they pay for prescriptions for all? That’s not true. Our cousin in the UK is currently fighting cancer and he couldn’t get the anti-nausea meds after his chemo through national healthcare. He had to get it through his private insurer, but the treatment was through the NHS. The more expensive prescriptions have to be paid for unless you are low-income, retired, or whatever their standards are. And it can be extremely expensive, and even those with free prescriptions can’t get them all (there is a list of prescriptions that are prohibited). Quite frankly, his treatment is really scary. He had to wait so long for the test I believe the cancer spread. He only has limited time left.

      • Healthcare Observer

        Your article is just contributing to absurd hyperbole it seems – not only is there no ‘legalized and narrow standard’ in countries in Europe such as the UK, but are you also suggesting we abandon research, such as that on NSCLC, into palliative care?

        • Alice Robertson

          What I am saying is that the motto for the NHS and the reality are quite different. There are articles from the The Guardian in the UK with quotes from the NHS and terrible treatment of cancer patients, with bad outcomes. Why duplicate a system like that? It just burns right through me when people suggest it’s a better system than it really is. I have several close relatives I believe would be alive if they had immigrated to the US (even with it’s flaws it’s so much better). We can learn from their mistakes, but not if we live in denial over them.

  • F. Castle

    NEWSFLASH — health care deform has officially been declared a disaster by Democrats –

    “Key White House allies are dramatically shifting their attempts to defend health care legislation, abandoning claims that it will reduce costs and the deficit and instead stressing a promise to “improve it.”

    As for the UK NHS — what solutions have they ever created? VERY FEW — they are parasites on the USA.

    • Healthcare Observer

      UK solutions? Well, CAT scan, ultrasound, stem cell research, world’s first IVF baby off the top of my head, plus thousands of less spectacular but now routine procedures – the NHS is one of the few organisations that carries out large trials to improve surgery.

      • Alice Robertson

        I really think you have not did your research well and are believing the Michael Moore undocumentary type of falsehoods. I have direct quotes from the NHS reports. This is just a partial observation of the UK healthcare system I posted last night in another thread where some very unstudied stuff is being posted.

        If you follow this link the whole story is there. A firsthand account from a journalist and the NHS quotes. Really scary stuff. I absolutely do not want this duplicated here.

        Hitchens has some quotes about the system and their leftist limousine set and the dirty sheets (I personally experienced this. I was pregnant and told to hop up on the exam table. I was horrified to see linen sheets with blood on them. I have no idea how long they were there, but they were so bad I didn’t want to put my hands on them, and I experienced this twice). The comment section is just as scary as the actual system. Firsthand experiences from travelers who are just as terrified as my husband and I (he is a Brit):

        Then consider, my friends, Exhibit A. The foul sub-third-world conditions I’ve just described came not from my overactive imagination but from a newly-published official report into the parlous state of affairs at two state-run hospitals in the central English district of Mid Staffordshire.

        According to the report by the Healthcare Commission, standards of care were so “appalling” that between 2005 and 2008 as many as 1,200 patients may have died unnecessarily.

        You should see the photo shrine the victim’s families have erected on one of the walls inside the hospital — like a mini-9/11 memorial; it’s a heartbreaking sight. There are pictures of the loved ones while they were still smiling and healthy, their dates written underneath. And there are printed sheets detailing some of the myriad ways they suffered and died:

        “Medication not monitored for side effects.”

        “Staff shouting, squealing and laughing throughout the night disturbing patients”

        “Patients not helped to the toilet, told to use a bed pan — staff too busy.”

        “Patients not fed or given fluids — food trays just left on the table out of reach.”
        It has been described by the National Health Service’s medical director as a “gross and terrible breach of trust” of patients, though why he should be so shocked is anybody’s guess. It’s not as though this sort of thing hasn’t happened in Britain’s magnificent “free” healthcare system many, many times before

        This, remember, is the “service” so poor that 55 per cent of senior doctors take out private medical insurance so they don’t have to use it; the one where one in 300 hospital deaths is the result of a patient contracting an infection completely unrelated to the one they came in to have treated; where the cancer survival rates are the worst in the civilized world; where more patients die in hospital in a year — 40,000 — than were killed in the 2006 Iraqi civil war.

        • Alina

          Alice –

          You keep posting the same material over and over for different articles. Is there any proof to all these claims of yours? You know, real sources free of bias.

          In the meantime, here you go an article about cancer patients skipping care here in the US:

          Also, Kaiser Family Foundation reported that amongst people buying individual insurance (14 million), 26 pct reported having annual deductibles of $5,000 or more, and 6 pct had deductibles of $10,000 or more.
          “61 pct reported very or somewhat difficult to afford care.”
          They also had a 20 pct premium increase.

          KFF also reports on the premium increase from 1999 to 2009, which is 131 pct, while wages increased only 38 pct and the inflation 28 pct.

          On top of all these add the underinsured from employer-sponsored plans, and the uninsured – see what a “wonderful” system we have?

          It’s easy to talk when it doesn’t happen to you isn’t it?

          • Healthcare Observer

            Well said. This person is taking a few outlying stories and generalising to a whole country. In fact, for example, US and UK cancer mortality stats are almost the same, and the US has by some way the worst stats for medical errors, hospital infections and deaths related to treatment, and of course it has millions of people who have been unable to access standard care that people in Europe have as of right.

          • Alice

            Could Healthcare Observer cite some reports she has “observed” (please no Michael Moore bologna), because the reports I have seen share the US has better cancer care and results, and my personal experience backs that up (I believe with prostate cancer alone the mortality rate is something like 600 percent higher in the UK than here?).

            It’s amazing to me what some people will believe on the surface sometimes, and even the NHS has been caught “doctoring” statistics. I just wonder sometimes with all these anonymous posters lambasting people who are open and honest what is gained by that? How in the world will we ever get to the truth when people with agendas adopt pseudonyms and completely reject the truth? What kind of research skill is that?

            And it’s even more disturbing to have a child with cancer and all the dying swan acts over the uninsured and not one utterance about a young girl who was misdiagnosed and has suffered because a doctor couldn’t be bothered to read her lab report. It’s revealing……isn’t it? And then to put words in their mouth that they don’t care for the uninsured while your proposed methods only add to human suffering. And that’s why these conversations are vital…..and why all the emotional outbursts without real facts, and personally going for the jugular or cyber stalking means nothing gets accomplished. Maybe Washington resembles it’s constituents much better than we give them credit for……to our shame.

    • Alice

      As for the UK NHS — what solutions have they ever created? VERY FEW — they are parasites on the USA. [end quote]

      I read Canada is too. If what I read is true they leech off our research dollars, and therefore, save tons-and-tons of money. And that’s another country where people cross the border to get quicker or better care.

  • Alice

    Humanism and cultural consensus are ill served by these debates, and positioning and posturing [end quote]

    Humanism may be “ill served” but it would seem it’s the cause of the devaluing of human life? Research shows those under 30 years of age are, supposedly, the most narcisstic generation yet. Humanism…at the root.. may very well be the cause of some of the problems you outlined so well.

    • HJ

      Reading Newsweek again? How do you get from humanism to narcissism? Do you have a study for that?

      • Alice

        Reading Newsweek again? How do you get from humanism to narcissism? Do you have a study for that? [end quote]

        Why? You don’t like Newsweek? I have a love/hate relationship with it (sorta like doctors). I have a lot of downtime lately as I wait at the private school (imagine that HJ…I have paid taxes all these years and saved the taxpayers all sorts of money) my girls play sports at. So I read or come online and antagonize people like you :) But the good news is I am sorta likin’ it……ha!

        Okay, I’ll get serious………yes, there was a big study, but I think it was TIME magazine who published it about um….maybe several months ago? I am not sure how their archives work. Maybe a search for the word “narcissism” would bring it up, or for some people just a look in the mirror!

    • Jeffrey Hall Dobken

      Alice: Thank you for your observations and interest in these issues. In another article, entitled “About Marathons and Healthcare” (also previously available via or just “google”), derives the following quote: “It is hardly strange to observe these traits in a culture that has not yet learned how to replace its antique religious imperatives with something beyond hedonism and consumerism despite its attempts to do so.”

      It may be of interest to you.

      • Alice Robertson

        It’s definitely of interest and I wanted to thank you for the tip.

        • Alice

          I did read the article and would answer you privately, but I am not sure how (no link attached to your name). My mind dances with all sorts of periphals that the article brings up, but the point is well-taken…..running the good race….philosophical replacement of ideologies…….personal responsibility…….grace……etc., etc. Nice job!

  • Alice

    Okay HJ I found one quickly…….., but only placed the first part here. A lot of google hits if you want to study narcissism which I imagine the humanists won’t do because they are too busy taking care of moi!

    New Study Finds ‘Most Narcissistic Generation’ on Campuses, Watching YouTube

    Poor Narcissus: He could only gaze into a pool. Today’s college students can watch themselves endlessly on Flickr, MySpace, and YouTube on their 27-inch, flat-screen LCD monitors.

    But does that make them narcissists?

    Jean M. Twenge, an associate professor of psychology at San Diego State University, says gadgets and online social-networking sites have stoked the self-loving tendencies of modern students, known as “Millennials.” On Tuesday, Ms. Twenge unveiled her findings from

    • HJ

      Alice says, “Humanism…at the root.. ”

      If you read my question again, I am not asking about narcissism but the relationship between narcissism and humanism. The Humanist Manifesto was written in 1933…So you arbitrarily connected the two to make a talking point or you have hard evidence that humanism causes narcissism?

      I’ll help you out:

      P. J. Watson, Ralph W. Hood, Jr., and Ronald J. Morris

      University of Tennessee at Chattanooga 37402

      Review of Religious Research, Vol. 25, No. 3 ( March 1984 ).

      This study empirically examined some issues within the debate between religious and humanistic theorists concerning the role of self in life. Predictions by religious theorists that humanistic values are associated with narcissism and by humanists that religious values are incompatible with self-actualization were examined in two correlational studies. No relationship
      was observed between narcissism and humanistic values as measured with the Time Competence (TC) or Inner Support (IS) subscales of the Personal Orien-
      tation Inventory.

  • Alice

    Alice says, “Humanism…at the root.. ”

    HJ says: If you read my question again, I am not asking about narcissism but the relationship between narcissism and humanism. The Humanist Manifesto was written in 1933…So you arbitrarily connected the two to make a talking point or you have hard evidence that humanism causes narcissism?
    [end quote]

    Alice: But I did answer your question about the relationship. The dictionary shares that they are both at the heart of self love. Are they both not sharing the same root of vanity and putting yourself first? When you love yourself it’s both humanism and narcissism.

    narcissim:inordinate fascination with oneself; excessive self-love; vanity
    humanism: 1. any system or mode of thought or action in which human interests, values, and dignity predominate.

  • Independent

    “no patient goes bankrupt, gets sicker, or dies because they do not have insurance”

    That is not true and in fact is blatantly false. I can site three specific example that I am aware of in the last few years.

  • Alice

    That is not true and in fact is blatantly false. I can site three specific example that I am aware of in the last few years. [end quote]

    Truly that is, indeed, very sad. Do you mind if I ask what outlets they tried to pursued? I use this type of information to help others, and believe we learn from the experiences of others (it’s helpful to know what pitfalls await others). Several of my friends are self-employed and use different routes (from no insurance, to government help, to buying the best policy out there, to the Hill-Burton [which was very helpful to them]).

  • Alice

    HJ says: The Humanist Manifesto was written in 1933…So you arbitrarily connected the two to make a talking point or you have hard evidence that humanism causes narcissism? [end quote]

    So, you are quoting from the first Humanist Manifesto? That’s really quite interesting in light of what the conservatives keep warning about Marxism. Hmmm……so maybe……I now know what the “H” in your online name stands for?