Junkfood Science: July 2009

July 30, 2009

Weight of the Nation — “We have a plan”

If anti-obesity news coverage has seemed to get a shot in the arm the past few days, you might want to know why. The Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity has literally given it an injection of media stories, even down to free graphics and banners, with its inaugural obesity conference, Weight of the Nation, held in Washington, D.C. on July 27-29th.

The conference, funded by a grant from Robert Wood Johnson Foundation and partnered with preventive wellness, chronic disease councils, and disease management and public health organizations, was announced a couple of months ago, saying its objectives will be to set policies and environmental strategies to overcome barriers to obesity prevention and control in communities, healthcare, schools and workplaces… set specific policy and environmental initiatives impacting obesity; and highlight the use of law-based efforts to prevent and control obesity (e.g., legislation, regulation and policies). The agenda is all politics, not a single examination of the science.

How many know what the CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) does? It’s the arm of the agency directing the development of the government’s regulations, economic strategies and laws to impose changes in the country’s infrastructure and society — at the community, state and national levels. “For your health,” and more specifically changing the “obesogenic environment,” is being used as the grounds. As its website explains, the CDC has “collaborated with policymakers, partners and stakeholders in these leadership activities” — which have included some frightening programs if anyone stops and thinks about them for a moment, such as “Legal Preparedness for Chronic Disease Prevention” and “Legal Preparedness for Obesity Prevention and Control.”

Its website openly describes its partnerships. To change medical settings, for example, the CDC is “creating partnerships with commercial health plans.” For changing communities, its partnerships include the Healthy Eating Active Living Convergence Partnership, to change transportation and food systems; and the Common Community Measures for Obesity Prevention (Measures Project), which works to change local governments' policies. Few people likely know about these groups, or that those seeming grassroots movements of non-government, nonprofit groups in their communities and states are actually funded by the CDC to put the goals of the government and its partners into action. As the website explains:

Twenty-three states are currently funded through CDC's Nutrition and Physical Activity and Obesity (NPAO) Cooperative Agreement Program which coordinates statewide efforts with multiple partners to address obesity. The program's focus is on policy and environmental change initiatives. These initiatives help support the following behavioral targets: increasing physical activity; the consumption of fruits and vegetables; and breastfeeding initiation, duration, and exclusivity; and decreasing television viewing, the consumption of sugar-sweetened beverages and the consumption of high-calorie/low-nutrient foods. The program seeks to address health disparities and requires a comprehensive state plan.

The Common Community Measures for Obesity Prevention Project is a Robert Wood Johnson Foundation program in collaboration with the Kellogg Foundation, Kaiser Permanente and the CDC Foundation. The Healthy Eating Active Living Convergence Partnership, as its website says, “is a collaboration of funders who have come together with the shared goal of changing policies and environments to better achieve the vision of healthy people living in healthy places.” It’s also a partnership of the Robert Wood Johnson Foundation, Kellogg Foundation, Kaiser Permanente, California Endowment and the CDC. Any industry or stakeholder, even the largest drug company in the world, can set up a foundation to lobby for its interests yet those receiving foundation money aren't seen as having any conflicts of interests to report or as having any industry ties.

According to this week’s Weight of the Nation program, the NPAO expects two outcomes of this conference, besides a media blitz:

First, in collaboration with partners, CDC will synthesize lessons learned from the conference to identify the challenges to obesity prevention and control, identify setting appropriate policy and environmental strategies to overcome these challenges and determine indicators of progress in implementing these strategies, and then disseminate policy and environmental best practices for obesity prevention and control. Then, CDC will utilize this information to produce its “National Road Map for Obesity Prevention and Control”; guidelines for investing in integrated obesity prevention and control initiatives.

Stakeholders are setting national policy. Worse, we’re funding them.


Background — “CDC says” doesn’t mean science says

Before we take it as a given that science has proven obesity to be a deadly crisis requiring a massive reorder of our society, it’s critical to understand the difference between science and marketing. Few consumers realize that most of what we hear coming from the CDC isn’t from the scientists at the CDC’s National Center for Health Statistics (NCHS), but from CDC’s various marketing divisions. It’s important to understand the difference.

As regular readers remember, in 2005, after CDC scientists published the CDC’s own national data and nearly brought down the government’s entire war on obesity, a press conference was hastily called to, as then director Dr. Julie Gerberding said, “translate our science more effectively so that we avoid this kind of communication in the future.” [The CDC’s evidence had shown that, instead of being deadly, obesity (BMI 30 to <35) was associated with a 24% lower risk for premature death than those of ‘normal’ weight, and that even most fat people outlive those of normal weight.]

It was at this conference, the public first learned that the CDC had been massively restructured to create what its director called, “the new CDC.” It created the National Center for Health Marketing and a second center on public health informatics, as well as four new coordinating centers. “At the new CDC, we are engaging the entire agency in the development of our strategies around obesity,” said Dr.Gerberding.

Dr. Edward Sondick, director of the NCHS, said that the bottom line is the NCHS was to be placed within the Coordinating Center for Health Information, along with the National Center for Health Marketing and the National Center for Public Health Informatics. In other words, the NCHS (and its problematic science) was put behind several layers of political firewalls. Thereafter, all communications to the public would come through CDC communications and marketing departments. The CDC directors would have first access to NCHS data before it is released to the public to ensure that the scientific data was released as “actionable” points based on the government’s Healthy People goals.

The org chart just approved looks little different from that first one after the reorganization, with coordinating centers of health information, under which you’ll find the National Centers for Health Statistics, along with the new one for Public Health Informatics, and for Health Marketing; the new National Center for Chronic Diseases Prevention and Health Promotion is under the Coordinating Center for Health Promotion. [Click on any image to see enlarged.]

You may also remember that there was a mass exodus of the top CDC scientists during 2004-2006, who were concerned with the honesty and integrity of science and the information reaching the public. By the end of 2006, in addition to more than a dozen leading scientists, all but two of the directors of CDC’s eight primary scientific centers had left.

When Dr. Gerberding said that every activity of the CDC would be engaged in its strategies around obesity, she meant it. And it continues to be evident today, as in the CDC’s latest budget for fiscal year 2010. Its total $10,101,606,000 budget includes $6,389,000,000 in discretionary spending authority for the CDC and another $1,000,000,000 from the stimulus bill. The changes in this year’s budget reveal its dissolute priorities, such as cuts in Vaccines for Children by $54.1 million, while increasing funding for REACH (Racial and Ethnic Approach to Community Health) by $4 million, and gives $18.54 million more for Health Promotion.

● The budget for obesity programs under the Nutrition, Physical Activity and Obesity department totals $44.4 million; which includes “developing innovative partnerships,” such as with the Healthy Eating Active Living Convergence Partnership and with the Produce for Better Health Foundation (where the CDC co-chairs the National Fruit and Vegetable Alliance). PBH was honored at the Weight of Nation conference, by the way, with an award for its work “advancing policies and environmental strategies to prevent and control obesity.”

● The $62.47 million budget for REACH, which targets minority communities for intervention, is part of its Healthy Communities Program which, it says, is an integral part of CDC’s response to the epidemics of obesity and chronic disease.”

● $7.3 million is for the Behavioral Risk Factor Surveillance System.

● $12.3 million for Genomics is described as “opportunities for public health and preventive medicine, which support the President‘s Healthier U.S. Initiative and the Secretary‘s Personalized Health Care Initiative.”

● $65.99 million is budgeted for diabetes surveillance, prevention and education (such as its Diabetes Primary Prevention Initiative which is “focused on approaches that identify people with pre-diabetes... to adapt lifestyle behaviors aimed at reducing modiable risk factors for type 2 diabetes” – i.e. obesity).

● $341 million is for cancer prevention and control programs, such as WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation, which targets low-income women “to improve diet, physical activity, and other lifestyle behaviors to prevent, delay, and control cardiovascular and other chronic diseases”) and NCCCP (National Comprehensive Cancer Control Program, which “provide a blueprint to encourage healthy lifestyles, promote recommended cancer screening guidelines and tests,…[and] education programs about cancers or their associated risk factors”).

● The $62.78 million budget for School Health is focused on physical activity, nutrition and tobacco use prevention and other priority health risk behaviors, most notably obesity and type 2 diabetes (which it says “has become increasingly prevalent among children and adolescents as rates of overweight and obesity rise”) and funds 22 state agencies “to focus on reducing chronic disease risk factors such as tobacco use, poor nutrition, and physical inactivity” and funds 29 NGOs (non-governmental organizations) to “promote healthy behaviors for the nation’s youth.”

● $22.8 million is for its Healthy Communities program for “community leaders and public health professionals to equip these entities to effectively confront the urgent realities of the growing national crisis in obesity and other chronic diseases in their communities.”

And there's much more, but you get the idea. As the sampling of links above show, the scientific evidence, often from CDC statistics itself, fails to support any of these programs. That’s why it’s never been more important for us to remember those fallacies of logic and to think and look deeper than the headlines.

The speakers at this week’s Weight of the Nation conference came from these extensive partnerships. For example on Monday, Dr. Thomas Frieden, M.D., MPH, alongside the acting Surgeon General, Steven K. Galson, M.D., MPH, and the Senior Vice President of Robert Wood Johnson Foundation, James S. Marks, M.D., MPH, opened the conference. Dr. Frieden’s proposals to tax sugary drinks and salt to prevent obesity and diabetes didn’t have any science behind them when he was New York City’s Health Commissioner and didn’t become any better when he became the new Director of the CDC.

Tuesday, HHS Secretary Kathleen Sebelius spoke about moving the CDC’s preventive wellness policies forward and “transform our healthcare system from a sickness system to a wellness system.” If you thought her speech, which was also issued in a press release, sounded like it was written by RWJF, you would be right. All of the oft-repeated, and unsupported, claims about the deadly crisis of obesity were there, with RWJF even cited as the source. The government’s solutions are based on the pop beliefs about the causes of obesity: bad eating and sedentary lifestyles. Not what obesity researchers have long recognized.

Before she told audiences “about some of the exciting plans the administration has in this area,” she talked about the children. She cited a list of health problems caused by childhood overweight, according to RWJF, even down to the oft-repeated claim that this might be the first generation to have shorter lives than their parents. “The share of children that are overweight has quadrupled in the last 40 years,” she said. “Type 2 diabetes used to be called ‘adult-onset’ diabetes. Now doctors don't use the term because so many kids are getting it.” This is coming from the leader of the nation’s health agency.

But, Secretary Sebelius said “we finally have a plan” to put the nation on a weight loss diet. Thanks to research, she said, “we don’t just have good ideas, we have ideas that are tested and whose success can be measured.” She was right that every proposal she described has been tested — and they’ve all failed to show any effect on reducing obesity over time and improving actual health outcomes. And every independent examination of the evidence has concluded diet and behavioral changes are ineffective.

So, the government proposes to throw more money at them:

President Obama and I are committed to delivering a health care system that provides all Americans with better quality and lower costs. And fighting obesity is at the heart of both of these goals. That's why the President and the First Lady have made investing in prevention and wellness one of their top priorities.

It's why we're going to require health insurance plans to cover preventative services like the kind of counseling and care that can help people lose weight or keep the weight off in the first place. It's why as part of health reform, we'll also be investing in programs like the ones highlighted in the CDC report… President Obama and I don't think this issue can wait. And neither does Congress, which is why they appropriated $1 billion for prevention as part of the American Recovery and Reinvestment Act.

Part of this money will go to immunizations and another part will go to prevent patients from getting infections during surgeries and other medical treatments. But most of the money is going towards a prevention initiative that was developed by the CDC and the Office of Public Health and Science with input from many of the groups that are here today.

We aren't ready to officially announce this initiative, but we expect that a significant amount of the money will go to help states and communities attack obesity and other public health challenges.

This Weight of the Nation summit was carefully staged to correspond to the release of policy papers also funded by RWJF and CDC’s partners. Tuesday afternoon, the Urban Institute hosted a media event called “Ousting Obesity: Strategies from the Tobacco Wars” where it released its policy paper for combating the obesity epidemic. It proposed fat taxes, as Dr. Frieden had, purportedly to reduce consumption of foods they want the public to believe are fattening (based on Britain’s traffic light system that judges the health value of food according to its sugar, fat and salt content). Their policies included other food regulations, such as calorie counts on menus, bans on advertisement and marketing of “fattening food,” and subsidies of fruits and vegetables. The tables and text in the last half of the report revealed what it was really about. They calculated the revenue that state governments could bring in with fat taxes, even after funding fruit and vegetable initiatives to appear to support healthy eating.

The Urban Institute describes its Health Policy Center as devoted to examining the social, economic and government problems affecting health insurance. This report was funded by WellPoint Foundation, the foundation for Wellpoint, a family of health insurance companies that includes the Blue Cross and Blue Cross Blue Shield licensee in 14 states, pharmacy benefit managers and managed care services. WellPoint Foundation has been spending $30 million over three years to lobby for mandatory health insurance to cover the uninsured and $16 million to market health management programs. Last Monday, on July 20th, the Urban Institute hosted its “Step One: Pass Health Reform Legislation. Step Two: Administer Reforms” to correspond with another policy paper it released, funded by RWJF. It covered policy initiatives that really need no further explanation:

● structuring a health insurance exchange [which determines what government-approved plans people will be allowed to purchase]

● administering individual mandates and subsidies

● subsidizing health insurance premiums and cost sharing

● regulating health insurance

● restructuring health insurance markets

● simplifying administration and controlling costs (electronic medical records)


Retrospective

More than two years ago, a Dr. Miguel A. Faria, Jr., M.D., made troubling observations in the journal Surgical Neurology about the misuse of statistics and epidemiology surrounding most of the studies associated with the Healthy People 2010 agenda. There is a worrying trend in academic medicine, he said, that “equates statistics with science, and sophistication in quantitative procedures with research excellence.”

The corollary of this trend is a tendency to look for answers to medical problems from people with expertise in mathematical manipulation and information technology, rather than from people with an understanding of disease and its causes

Much of CDC-funded research and Healthy People 2010 initiatives, he explained, “are generally geared toward promoting social engineering and enlarging the scope and collective role of government in the lives of citizens… than with making genuine scientific advances and improving the health of humanity.”

In some cases, these [CDC] grant proposals (many of which are actually funded) use or misuse statistics, collect data of dubious validity, and even use “legal strategies” to reach social goals and formulate health care policies that the public health researchers believe may achieve “social justice.”… The reader will be surprised to learn that I found probably as many lawyers and social workers as practicing physicians and nurses applying for public health “scientific” research grants!

Public health is no longer about people’s health, but about preventive wellness and efforts to change behaviors for the good of society. It redefines medical ethics to mean a collective act of healthism. A leading organization in the government’s preventive wellness movement and promoter of the Healthy People 2010 goals is Partnership for Prevention, funded by RWJF and GlaxoSmithKline, along with Prescription for Health, a five-year initiative funded by RWJF.

When Dr. Faria wrote this a few years ago, it may have sounded extremist, but it doesn’t sound so much so today:

Frankly, money is being squandered by public health, politicized, pre-conceived research toward collectivist agendas, while the government (and the insurance companies follow suit) keeps cutting reimbursement for the physicians and nurses who are actually ministering care to patients with real, individual medical problems. It's not only a question of squandering money and misallocation of finite health care resources, but also, in the end, a question of population-based ethics versus the reinstitution of the individual-based ethics of Hippocrates.


© 2009 Sandy Szwarc


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July 27, 2009

Prioritized lives

We can never be allowed to hear good news about our health. The government won’t allow it. “Such is the strength of cultural miserabilism today that even the most smile-inducing good news stories can swiftly be turned into doom-laden tales about the terrible future humanity faces,” wrote Brendan O’Neill, editor of Spiked.

Reporting on the latest U.S. Census Bureau report, finding that advances in science, safe food production, healthcare and prosperity have allowed people, worldwide, to live longer, healthier and wealthier lives, Brendan’s article had a much deeper message. It examined our prejudices, our compassion for others and how our society is coming to view the value of human life.

His thought-provoking article, titled “Older people are more than food for worms,” was about aging, but could just as easily have been about fat people, handicapped people and everyone deserving of our kindness. It was a reminder of our shared humanness and the need for ethical behavior.

As he wrote, rather than being seen as good news, the Census Bureau’s report was treated as worrying, if not bad news:

The growth of the older population will have ‘formidable consequences’ and pose ‘widespread challenges’, we were told. There was talk of an ageing ‘tipping point’, ‘burdens’ on social services, and the need to ‘sound the alarm’ about how the presence on Earth of all these old folks might provoke ‘intergenerational conflict’. In one fell swoop, we went from the revelation that mankind has successfully extended life beyond birth-work-death to warnings of burdensome old people sucking up all of our health and social resources and possibly launching a war of attrition against the young. Nothing better captures the downbeat nature of public life today... The new fear of the old springs from today’s tendency to treat social policy challenges, which an ageing population no doubt is, as insurmountable demographic nightmares – and more fundamentally from our inability to give meaning to human life and see it as something more than a bovine, biological thing.

An ageing population is an unadulterated good thing. Throughout history we have sought to extend human life in order that people – and humanity more broadly – might realise their potential…

But when we do enjoy longer life expectancies, suddenly success is treated as a sign of doom and older people as little more than burdens.

They’re no longer thought of as wise people whose experience of life counts for something important but as individuals with ‘outdated and irrelevant’ views: they’re grumpy, a bit racist, hell they don’t even believe in global warming. The treatment of older people as burdensome and irrelevant speaks to Western society’s increasing estrangement from, and its fear and suspicion of, the ageing process…

Our fetishisation of youth is a way of erecting a barrier against the future, keeping everything in an innocent childish state in order to avoid having a grown-up debate about our potentially grown-up futures. Today’s ambivalent or outright hostile attitude towards the ageing process really reveals our inability to give meaning to human existence today.

Rather than seeing older people as an integral part of some social fabric… we see them as a drain on society’s apparently limited resources. Rather than seeing older people as individuals with hopes and aspirations like the rest of us, we see them increasingly as little more than bovine creatures with a long list of burdensome medical needs. Many now ask: ‘Who wants to live to be old when you’ll only be sick and slow and incapacitated?’ – revealing our inability to see the profounder side to life behind any health problems individuals might have to endure.

“Quality of life” as seen through the eyes of a youth-oriented society does not mean the lives of older people are any less meaningful. When older lives are no longer valued by society, at what age do they become “too old” to get medical care and use public healthcare resources that could go to healthier, younger people?


If you’re too old, no care for you

This week, news in Sweden reported a woman had been left to endure incredible pain due to a treatable condition for four years from the age of 79; then had to wait more than a year to see a specialist in the public healthcare system before being told she was too old to get a surgery she needed. She was given pain pills and turned away. ‘I can understand that the county feels it is expensive to 'fix' us elderly, there more and more of us,” she told Östgöta Correspondente, “but in general, I am healthy. We end up paying for healthcare for younger people, but we don’t get anything ourselves.”

That happened in Sweden’s government-managed healthcare, but could never happen here… could it? Readers deserve to know about Dr. Ezekiel Emanuel, M.D., Ph.D., who serves as the director of the Clinical Bioethics Department at the U.S. National Institutes of Health. He's a key creator of Obama’s healthcare reform plan and his bioethics advisor. He’s also the brother of White House Chief of Staff Rahm Emanuel.

Dr. Emanuel has been appointed to two key positions by the Administration: health-policy adviser at the Office of Management and Budget and a lead member of the Federal Council on Comparative Effectiveness Research, deciding how healthcare resources will be rationed. [After reading this, what comparative effectiveness research is really doing and its resulting spending priorities, covered here, may be clearer.]

His ex-wife, Linda Emanuel, by the way, headed the American Medical Association’s Institute for Ethics, launched in 1997, focused on assisted suicide, terminal care, genetics and managed care. One of its initial projects, was to educate doctors on end of life care, funded by Robert Wood Johnson Foundation with $1.5 million to start and which went on to fund it ($5.3 million between 2000-2003, alone). Its real purpose and disconcerting messages may help to explain why the AMA’s promotion of a new medical ethics that displaces the Hippocratic Oath has resulted in widespread rejection among practicing doctors of the AMA, as well as government-managed care. She spoke at an aging conference at RWJF two months ago, on May 21st, on reducing healthcare costs “without causing a panic by introducing explicit rationing of care.”

The Journal of the American Medical Association published a paper funded by Robert Wood Johnson Foundation and Blue Shield of California Foundation on June 18, 2008. Dr. Emanuel and co-author Victor Fuchs, Ph.D. of Stanford University, examined “overutilization” of healthcare and increases in the costs. They attributed four factors to doctors:

First, there is the matter of physician culture. Medical school education and postgraduate training emphasize thoroughness. When evaluating a patient, students, interns, and residents are trained to identify and praised for and graded on enumerating all possible diagnoses and tests that would confirm or exclude them… In medical training, meticulousness, not effectiveness, is rewarded.

This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to “use my power to help the sick to the best of my ability and judgment”

The Hippocratic Oath, the very foundation of medical ethics and the one that the Nazi doctors abandoned, is seen as a problem because it raises healthcare costs. To contain costs, Dr. Emanuel and Fuchs recommended “many more experiments [of] pay for performance, bundled payments, partial capitation, value-based payment or other payment methods that promote prudent use of resources.”

Specifically, how medical care is planned to be allocated (rationed) in the United States was described in the January 31st issue of the journal Lancet in “Principles for allocation of scarce medical interventions” by Dr. Emanuel and colleagues. In making rationing decisions, they recommend an alternative triage system they called “the complete lives system, which prioritizes younger people who have not yet lived a complete life.” Their ‘complete life’ principle also purportedly includes prognosis, lottery and instrumental value principles.

They first rejected caring for the sickest people first, writing:

Preferential allocation of a scarce liver to an acutely ill person unjustly ignores a currently healthier person with progressive liver disease, who might be worse off when he or she later suffers liver failure… [However], when interventions are persistently scarce, saving the progressively ill person later will always involve depriving others.

What is instrumental value? It “prioritizes specific individuals to enable or encourage future usefulness,” they wrote. “Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation.”

Youngest first, they explained, directs resources to those who’ve had “less of something supremely valuable—life-years.” Their proposed ‘complete lives’ principle modifies the youngest-first principle, they wrote, by prioritizing adolescents and young adults over infants. “Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.” They supplied an age graph, showing how healthcare resources will be prioritized:

The ‘complete lives’ system also considers prognosis, since its aim is to achieve complete lives. “A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life… When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable,” they wrote. In conclusion:

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated… the complete lives system justifies preference to younger people… Age can be established quickly and accurately from identity documents.

Remember, in the United States, the government now forces every citizen at retirement age into government managed care, Medicare. The only way to opt out is to relinquish all of the social security benefits you’ve paid into your entire life. The first proposal from the administration to “save healthcare costs” was to cut $313 billion from Medicare, which cares for seniors and disabled people. Didn’t anyone wonder how they really proposed to do that?*

The government, our government, is already working on deciding what lives are more valuable based on their usefulness and burden on the state, how long we will be allowed to live, and which of us will die.

Sixty-eight years ago, the appeals for compassion and ethical principles, and public condemnation of what was happening, sounded somewhat like O’Neill’s article, but with considerable more urgency. What is deeply disturbing is that the words spoken by Clemens von Galen at Münster Cathedral on August 3, 1941 in an effort to stop the Final Solution (ordered that fall) feel so imperative for us today:

[T]he doctrine is being followed, according to which one may destroy so-called “worthless life”… because, in the opinion of some department, on the testimony of some commission, they have become 'worthless life' because according to this testimony they are 'unproductive national comrades.' … of no further value for the nation and the state…

[W]e are dealing with human beings, our fellow human beings, our brothers and sisters. With poor people, sick people, if you like unproductive people. But have they for that reason forfeited the right to life? Have you, have I the right to live only so long as we are productive, so long as we are recognized by others as productive? ... then woe betide us all when we become old and frail!... then woe betide the invalids who have used up, sacrificed and lost their health and strength in the productive process… then woe betide loyal soldiers who return to the homeland seriously disabled, as cripples, as invalids. If it is once accepted that people have the right to kill 'unproductive' fellow humans—and even if initially it only affects the poor defenseless mentally ill—then as a matter of principle murder is permitted for all unproductive people, in other words for the incurably sick, the people who have become invalids through labor and war, for us all when we become old, frail and therefore unproductive.

Then, it is only necessary for some secret edict to order that the method developed for the mentally ill should be extended to other 'unproductive' people, that it should be applied to those suffering from incurable lung disease, to the elderly who are frail or invalids, to the severely disabled soldiers. Then none of our lives will be safe any more. Some commission can put us on the list of the 'unproductive,' who in their opinion have become worthless life. And no police force will protect us and no court will investigate our murder and give the murderer the punishment he deserves.

Who will be able to trust his doctor any more? He may report his patient as 'unproductive' and receive instructions to kill him. It is impossible to imagine the degree of moral depravity, of general mistrust that would then spread even through families if this dreadful doctrine is tolerated, accepted and followed.


© 2009 Szwarc


* That’s also why, in part, it was important to understand economics and the facts of who the uninsured really are in this country. Instead of finding a way to help the 7% of Americans who actually need our help and rather than caring for seniors at the time in their lives when they most need medical care, healthcare reform will have taxpayers pay for managed care for 18 million generally healthy young adults, 9.5 million illegal aliens, and 17 million with incomes over $50,000.


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July 26, 2009

He who controls the medical profession, controls life

As hard as some are trying to make healthcare reform to be about political sides, it is really about human lives. Sadly, because the general public largely doesn’t understand what healthcare reform is really about, the very people who are most likely to be harmed by it — older, fat, disabled, poor and the most vulnerable — are the ones being most led to believe that it’s about taking care of them. Even sadder, experienced medical professionals have seen where we’re being led for well over a decade, but the information hasn’t reached patients and people.

The debate, especially the one in the media, is centered on emotional, intuitively-correct arguments and anecdotes, rather than careful examinations deeper than the headlines to understand the facts, economics, history, medical evidence and, most of all, the ethics of the issue. It’s uncomfortable and hard to think about things that are unpopular to question, including our own beliefs.

As difficult as it is to contemplate, the emotional perspectives on healthcare reform are largely driven by whether one thinks individuals are basically good, caring people who try to do the right thing and will help those in need, or if one thinks everyone is looking out for themselves and what’s in it for them. The ethical questions come in when those looking at what’s in it for themselves try to convince themselves and others that they are acting more ethically.

“Evil acts can be given an aura of moral legitimacy by noble-sounding… expressions,” wrote Walter E. Williams last November when he explained the difference between laudable charitable acts done by caring people to help their neighbors versus forcible use of one person to serve the purposes of another.

The second perspective in this debate comes from whether one thinks individuals are too dumb and irresponsible to decide what’s best for themselves, to choose their own doctors and make their own lifestyle choices, and that doctors are incapable of making sound clinical judgments or do their jobs — or if you believe that you have the right to decide what’s best for someone else; to make others pay for and comply with treatments, diets and lifestyles you believe are best for the common good; to prevent other people from seeing the doctors or seeking the care they want; and to mandate the care doctors must provide. The ethical questions come in when those looking to take away the choices and control the actions of other people, including doctors, try to convince themselves and us that what they want is not only right, but a right.

“There can be no such thing as a ‘right’ to products or services created by the effort of others, and this most definitely includes medical products and services,” explained Yaron Brook, managing director of BH Equity Research, in a recent Forbes article. “Rights, as our founding fathers conceived them, are not claims to economic goods, but freedoms of action…The rights of some cannot require the coercion and sacrifice of others.” This entitlement idea, he said, has been the key driver of the expansion of government medicine in America and led to the growing unaffordability of healthcare. Prior to the government’s entrance into medicine, basic health care was affordable for virtually all Americans, “while those few who could not were able to rely on abundant private charity.” Had this system been allowed to continue, he wrote, “Americans’ rising productivity would have allowed them to buy better and better health care, just as, today, we buy better and more varied food and clothing than people did a century ago.” The history was described in more detail by one reader, who noted the immorality of government mandates that have caused everyone’s medical costs to skyrocket to among the highest in the world and created more problems with healthcare access. “No amount of ‘need’ on the part of one man entitles him to initiate the use of force to take another man’s property.”

Taking our information from mainstream media and social marketing venues can lead us to believe that those voices we most hear also represent what most people think, including most doctors and medical professionals. Over the past fifteen years, increasingly what we hear from media and spokespersons leads us to believe there’s a new medical ethics that is displacing our doctors' Hippocratic Oath to do what’s best for patients and replaced it with a duty to act foremost for the common good and based on costs to society. But are most of the doctors and nurses — the ones caring for you and me — really embracing the new medical ethics?


What do our doctors and medical professionals think?

When we are sick and entrust a doctor with our lives, most of us want to feel we can trust that the care we are receiving is based on our doctor’s years of experience and clinical judgment, that medical ethics and the personal and private relationship we have with our doctor are guiding our doctor to do what he/she believes will be best for us, and that our care is in accordance with our own choices. It’s a terribly frightening thought for most people that, instead, the medical marketplace and its bottom line is calling the shots and that our doctor could be being forced to answer to a growing hoard of government regulators; politicians; lawyers; policy makers; pharmaceutical, healthcare industry and insurance companies; and oversight agencies.

Before we let the media scare us into believing that most doctors are following this new medical ethic and no longer care most what’s best for us. Before we let the media scare us into believing that most doctors are so incompetent and corrupt they need governmental oversight and mandated clinical guidelines in order to provide safe, ‘quality’ care. Before we let the media convince us that only a few uncaring, uninformed people with political motives are opposing healthcare reform… We should listen.

The voices rarely heard in mainstream media are those of the medical professionals who are providing the hands-on care we receive. The general public doesn’t realize that what experienced doctors and nurses have been discussing for years is far different from what we hear from doctors on TV and in academia. It turns out that most doctors do care, very much, for their patients and they have not abandoned the medical ethics that brought them to medicine. Their opposition to third-party managed care is because it violates the most fundamental medical ethics.

“What the public does not know,” wrote Dr. Sean Khozin, M.D., MPH, in a post on Sermo, “is the pervasive hypocrisy of the [healthcare] system and how it has diminished the authority of the only true advocates of patients: physicians.”

Sermo is the world’s largest online medical community with more than 100,000 registered licensed physicians in 68 specialties and in all 50 states who collaborate on difficult cases, share clinical research and work towards better patient outcomes. It has been active since 2006. This past week, it released the results of a survey of a nearly 10,000 doctors representative of the U.S. physician population in regional distribution, urban and rural locations, age and nearly all specialties. These doctors were all verified to have valid, active licenses to practice medicine in the United States, with a median 25 years of practice experience.

It reported that 94% of the physicians do not endorse the healthcare reform bill in the House [which is soon to be melded with the Senate’s similar version] or government managed care. Not one of the healthcare issues cited by practicing doctors as being most important were addressed in the legislation. In fact, practicing physicians believe it reinforces and will worsen what they described as the “insurance industry’s undue authority and oppressive control over healthcare,” the “excessive and misguided government administrative costs” and regulations that require doctors to spend more time on documentation than with their patients, while giving non-medical professionals oversight and decision-making authority over the care they can provide.

Nor do most practicing physicians support the American Medical Association’s recent endorsement of such healthcare reform. For years, opposition to the American Medical Association (which has been steadily moving towards promotion of those new medical ethics) has grown among doctors and the AMA’s membership is now estimated at only 15-20% of doctors. As the CEO of Sermo said of the healthcare reform legislation, it perpetuates the AMA’s core revenue streams and puts its own financial interests ahead of doctors and patients.

What isn’t grasped by laypeople who support healthcare reform, is that most doctors and medical professionals do believe healthcare reform is needed, but what medical professionals know is necessary to deliver the best care to their patients and in the most cost-effective manner bears no resemblance to the current system and to any managed care healthcare reform legislation, in the House or Senate, in this Administration or any previous. “We do not believe, ”said Dr. Todd Williamson, M.D., president of the Georgia Medial Association, “that increasing the federal government’s control over the practice of medicine is the best way to heal our ailing system.”

The concerns of doctors and medical professionals and what they’ve been seeing happening to medicine and healthcare for years has been well-documented in thousands of discussions in medical forums and journals that the public, sadly, never sees. Last year, in an effort to get information to the public, doctors wrote an open letter from America’s Physicians, which has been signed by more than 13,000 doctors so far. It shows that most doctors do hold dear their Hippocratic Oath and the traditions of medical ethics. As it stated:

[O]ur healthcare system has lost focus to the point where patient well-being is placed after politics, profits and special interests. Healthcare costs are on the rise and patients have lost their freedom of choice. These trends are hurting our economy and compromising the doctor-patient relationship. As a result, it has become difficult for physicians to deliver the best possible care... You are paying a lot for healthcare and not receiving enough in return. Your insurance premiums continue to increase while your healthcare options are dwindling. Gatekeepers, insurance networks and restrictive regulations limit your choice of doctors and your access to care. You have been made dependent on complicated and expensive health insurance plans. Employers are forced to take money out of your paycheck to purchase health coverage. If you lose your job, you are left with no safety net and the money you have paid for health coverage vanishes. The time you spend with your physician has become remarkably brief due to regulatory hurdles requiring doctors to spend more time on documentation than with you.

We believe the following factors have made our current healthcare system unsustainable:

The insurance industry's undue authority and oppressive control over healthcare processes

Excessive and misguided government regulation

The practice of defensive medicine in response to a harmful and costly legal environment

We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients' health have absolute control...


The medical ethics of managed care

This isn’t about politics. This is about the ethics of forcing medical professionals to do what third party payers— government Medicare, Medicaid and private insurers — order. With the medical home model that’s been under planning for years, electronic medical records and pay-for-performance measures will give the government, insurance, pharmaceutical and medical industry unprecedented surveillance, control and oversight over patient care, leaving doctors unable to provide the care they feel best and patients unable to have a choice. Most medical professionals recognize that many of the clinical guidelines, regulations and performance measures they will be compelled to follow are, as covered at JFS for years, not based on sound science, have not been shown to improve health outcomes for patients, and will harm large numbers of patients — most especially those who are aging, fat and socioeconomically disadvantaged.

Under nationalized managed care, those with bad numbers (health indices that the evidence shows are not measures of health or risks of chronic disease or premature death, but of age, size, heredity and social-economic status) or special needs will be targeted as costing society too much. We've already seen the "costs" of obesity and chronic disease of aging used to support all manner of public policies, interventions and surveillance. Those not seen as complying with prescribed diets, lifestyles, exercise regimens, screening tests, weight loss, counseling and taking medications will be blamed for failing to take responsibility to stay healthy and, therefore, undeserving of care when they get sick. We've already seen these beliefs in preventive wellness widely circulated, too. This has become serious really fast. We can no longer afford to just worry about trivial things like if someone thinks we look too fat.

We’ve already examined the concerns of medical professionals with managed care, as well as the proposed rationing of care based on comparative effectiveness that target those who are older, fat, disabled and the most vulnerable in need of care. The unthinkable consequences are closer than we might want to even think about. You’d have to live under a rock, too, to not know that Obama’s Science Czar has proposed some of the most unconscionable acts of eugenics, based on radically unsound beliefs, and his appointment sent shock waves through the scientific community that understands the science surrounding population control. But never before in the history of our country, have we been this close to making federal law that formalizes withholding of care to certain groups of people.

“Never before have we been this close to adopting a system that will tell certain citizens to forego treatment for the good of their country,” John Griffing poignantly wrote this morning in American Thinker while explaining Section 1233 of the health reform legislation. “Today’s Medicare recipients could be the first to experience our government’s new solution to America's ‘useless eaters’,” he wrote. “When all is said and done, the ultimate result of the proposed bill is to transfer to government the unprecedented power of determining who lives and who dies.”

Healthcare reform may prove to be the most expensive and deadliest consequence of the public’s scientific illiteracy, prejudices and inability to understand sound science. Healthcare reform may prove to be the most costly and deadly consequence of people failing to learn history and realize what is being reenacted and the unconceivable place it’s taking us. [Yet few people have read the more than a thousand pages of the legislation, let alone read Ominous Parallels, The Nazi Doctors and War Against the Weak.]

Sure, there are some bad doctors out there who are incompetent or follow greed rather than creed, and others who are guilty of looking the other way. But it’s reassuring that medical ethics is not dead and so many doctors have been trying to speak out, even at risk to their careers. Most doctors and nurses made medicine their vocation because they care about people and love helping people, and still do. What ethical oath have government appointees, politicians and corporate executives pledged?


What’s really behind healthcare reform

Most practicing doctors believe medicine can return to caring for patients and address the problems with the healthcare system without losing the things that make it among the best care in the world. But, as cardiologist Dr. Westby G. Fisher, M.D., said, “we can’t do that and continue to fund the gravy train. And that gravy train is the multi-billion dollar health insurance industry with executives who made over $24M annually in 2007, the $800B pharmaceutical industry with executive compensations of over 25 million dollars the same year, the over $24 billion spent in one year in our country on new hospital construction, the nearly half a billion dollars in political campaign contributions from health care special interests a single year (2008), and the 55-80% increase in malpractice insurance premiums that your doctors have paid over the past 5 years.”

What most consumers don’t realize is that healthcare reform chiefly isn’t about helping people, covering the uninsured or addressing health disparities, but about increasing the private-public medical industry and making money for them. Doctors have been watching the evolution of medicine and healthcare depart from caring for patients to caring for its bottom line and expanding the system’s sphere of power and control. “One only has to look at the diagram of the recently-proposed health care system interconnections,” he wrote, “to realize that the health care providers and consumers are on opposite sides, separated by so much regulation and oversight, we wonder who stands to win.”

Do those who are leading seniors, fat people or minorities to support managed care, healthy lifestyles and medicalization — whose script is right out of the pages of Nazi healthism — realize that they are really working to advance the agendas of the pharmaceutical, medical supply and insurance industries and their government agency partners? Do they understand what they are supporting?

While all eyes have been focused on the weight of the latest Surgeon General nominee, for example, few know that she is a Robert Wood Johnson Foundation Trustee, having serviced on its national advisory committee of prescription drugs for health. As she told media on her election to the RWJF Board of Trustees, “I am proud to be a part of accomplishing significant and lasting social change.”

But the most important person in government overseeing healthcare reform, is Nancy-Ann Min DeParle, who President Obama appointed as director of the White House Office of Health Care Reform in March. Also known as the Healthcare Reform Czar, this position is above Cabinet-level and answers only to the President and has been given the authority to make or influence decisions for Cabinet-level agencies. The Healthcare Reform Czar position, as readers may remember, was originally slated to go to Tom Daschle in addition to serving as Secretary of Health and Human Services, until his vast conflicts of interests came out during the Senate confirmation hearings for Secretary of the HHS and put him out of the picture. In his place, Ms DeParle was quietly appointed the Healthcare Reform Czar, which is not subject to Senate confirmation.

It is doubtful that the general public knows much, if anything, about the person behind healthcare reform. Ms DeParle holds a law degree from Harvard Law School, not a medical degree, according to whitehouse.gov — which provides few details on the corporate boards she’s served on, saying only that she “brings a unique industry perspective from her work in the private sector.” Most of her positions have been administering and serving on the boards of major medical companies. Shortly after her Czar appointment, she stepped down from the corporate boards of Cerner, Medco Health Solutions (a pharmacy benefit manager), Boston Scientific (medical devices manufacturer), CareMore Health Plan and Legacy Hospital partners, as well as from CCMP Capital Advisors LLC, a private equity firm whose interests include a Medicare managed care plan. She is also a trustee of the Robert Wood Johnson Foundation, receiving earnings not only in that position, but $7,500 a speech for Johnson & Johnson.

According to an in-depth investigative report by the Investigative Reporting Workshop and msnbc.com, and SES filings, she has earned more than $6.6 million since early 2001 for her work for major medical companies. Details of her income from the medical industry were released on July 2nd, here. “[T]he public wasn’t told that much of that corporate career was built at companies that have frequently had to defend themselves against federal investigations,” the report added. “After leaving government, DeParle accepted director positions at half a dozen companies suspected of violating the very laws and regulations she had enforced for Medicare. Those companies got into further trouble on her watch as a director.” Five of those corporations have paid a total of $566 million since 2003 to settle fraud or product liability cases, often involving tax dollars paid by Medicare.

Her Czar appointment will no doubt have significant impact for the corporations she formerly served, said the report. While promoting electronic records, for instance, no one mentions that she served on the Board of Cerner Corporation, a major manufacturer of electronic medical records software, from May 2001 until the day after her White House appointment, earning at least $680,000 in compensations. Cerner has boasted that it is well-positioned to take advantage of the stimulus bill, which provided $19 billion for electronic medical records.

Yet, many consumers still don’t understand what healthcare reform is mostly about, even though it was clear long ago just by examining the science and evidence. They want to believe that it’s about helping them.

What do experienced medical professionals advocate for healthcare reform? To return medicine to the ethical, caring practice it once was that puts patients and people first, not profits and politics.

Let’s put the patient in control, with the doctor as trusted adviser. Let’s not lose the liberty that is our right as Americans. — Dr. Donald Palmisano, M.D., July 22, 2009, National Press Club in Washington, D.C.



© 2009 Sandy Szwarc


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July 21, 2009

From the cognitive disconnect pages

Our thoughts go out to our friends across the pond today and to parents with sick children there. The King's Fund and the Institute for Fiscal Studies released a new analysis of National Health Services and found healthcare spending in England has more than doubled in real terms just since 1999/2000. “Our analysis shows that the NHS is facing the most significant financial challenge in its history,” said John Appleby, chief economist at the King’s Fund.

Yet, even with these realities, stories on other pages of the papers today demonstrate that government often has nonsensical spending priorities.

The King's Fund and the Institute for Fiscal Studies report on the financial prospects for the NHS from 2011 to 2017, examined the government’s plausible options and the consequences of each, stating that the “prospects for future funding now look bleak.”

The financial crisis is estimated by the Treasury to have dealt a permanent blow to the size of the UK economy, with a significant knock-on impact on the strength of the public finances. Given this, it is hard to see how the next spending review…could unveil further real terms increases in the NHS budget without significant reductions in spending elsewhere, or the introduction of tax-raising measures.

As the Times wrote, the report found that “even under the most optimistic funding scenario, the NHS will struggle to meet people’s healthcare needs without significantly increasing its productivity after 2011.” The productivity of government-provided services, according to the Office for National Statistics, however, has fallen every year between 1997 and 2007 (by an average of 0.4%), while it has grown in the private sector by 2% per year. The King’s Fund and Institute for Fiscal Studies report said that “even if the NHS budget is not cut in real terms, future funding is likely to fall short of the population’s healthcare needs by more than £30 billion [$49.55 billion in U.S. dollars].

While facing cuts in services, the report said, if the NHS freezes it budget, it still needs to bring in about “£10.6 billion — equivalent to an extra £340 per family” in additional revenue (taxes). According to the news, Niall Dickson, the chief executive of the King’s Fund, said: “The scale of what is about to hit the healthcare system is unprecedented. It would be a grave mistake to underestimate the challenge ahead.”


Is the government reading the news?

The Wales Western Mail reported on a report from the charity Sands which said funding pressures and shortage of qualified maternity care providers was contributing to nearly 300 infant deaths a year in Wales. Calling the situation a “national tragedy,” Neal Long, Sands’ chief executive, said that for far too long, the rate of infant deaths and stillbirths have been ignored “and yet there is a growing body of evidence to suggest that many babies’ lives could be saved.” This situation has been well-documented for years, while worsening.

The report echoed earlier work by the charity Bliss [covered here], which last year found that minimum staffing standards are still not being met in Wales and that units regularly have to close to new admissions due to lack of staff. It said that mothers and babies are being transferred between units, in some cases very long distances, which puts and intense strain on families at a critical time.

Health Minister Edwina Hart was reported as responding to concerns about neonatal service by announcing a £4million [$6.61 million] cash injection over two years for neonatal transport service. With the average cost of a transport helicopter alone about $5 million, let alone transport isolettes and trained medical professionals to transport critically ill babies, the money isn’t likely to go very far. The senior nurse manager of neonatal services at Gwent Healthcare NHS Trust said that all Welsh neonatal services are still facing chronic funding problems. The all-Wales review of neonatal services, she said, had found that services were in crisis and needed £12million just to sustain them, and that there was a shortage of 170 neonatal nurses just in Wales. Nothing, however, was ever done.

The RAND Europe study on neonatal services released last year was not mentioned in the news. It found that neonatal intensive care increases the survival rates of newborns, especially those with low birth weight or gestational age. “Effective neonatal care also improves morbidity rates, improving the long-term health prospects and quality of life for premature or low birth weight babies. In doing so the long-term burden on state sponsored health and social care systems is reduced.” As it explained:

Low staffing levels is a pervasive problem in UK neonatal services: all three regions of the UK fall short of the recommended staffing levels laid down by the British Association of Perinatal Medicine (BAPM). Scotland is well-staffed at consultant level, but lacking in neonatal nurses. Northern Ireland has a particular deficit of nurses, and staffing levels in Wales are critical at both the consultant and specialised nursing levels. In particular, there is evidence that the absence of dedicated neonatal transport teams produces staffing problems on neonatal wards. Across the UK as a whole in 2006, 78 pe cent of neonatal units had to turn babies away because of lack of capacity. This figure is eight percent higher than in 2005.There was little evidence of shortages in staffing or cots in the non-UK neonatal networks [United States, Canada, Australia, etc.] considered in this report… the evidence suggested that the infrastructure supporting neonatal services in Wales is less developed than in Scotland or Northern Ireland…

It’s almost inconceivable the frustration and heartache neonatal nurses and parents of critically ill newborns under NHS must feel. For years, they’ve tried to get needed medical care that all evidence shows can greatly improve babies’ survival and future health and well being, as well as to lower long-term medical expenses for the healthcare system. Meanwhile, the government continues to spend countless millions of pounds (dollars) on frivilous programs with no evidence they work in order to address a nonexistent health crisis.

The Edinburgh Evening News reported another government program is spending “apparently £23 billion [$37.99 billion U.S. dollars]” to offer free holidays, called an “outdoor education,” to Scotland’s children to get them moving and build character. It plans “to send every 11-year-old on a five-day adventure break, kayaking, climbing and abseiling among other things… [and] free swimming for all children, at least two hours of PE a week and more outdoor activities, most of which are meant to tackle childhood obesity levels.”

The Scotsman reports that the money NHS Lothian spends each year on weight loss and anti-obesity interventions grows. “In Scotland there has been a massive rise in the number of free medicines being requested to fight obesity – 25 times higher than a decade ago and up six percent alone in 2007.”

Calling it a “record government investment,” the government has also invested £56million [about $92.5 million U.S. dollars] over the next three years to encourage children to eat “healthily,” the news said.

Remember that Scottish Diet Action Plan launched in 1996, aimed to get everyone in Scotland to eat healthier to lose weight and prevent “obesity-associated” diseases? This massive initiative included every popular healthy eating idea that’s probably ever been proposed. Hungry for Success, part of the Action Plan geared to school children was well-funded, with $126.09 million (US dollars) committed to its first three years and more for the next three.

It was a flop. After a decade of intense interventions, it showed no effect on children’s’ consumption of fruits and vegetables. It also failed to have any impact on reducing children’s rates of “overweight and obesity.” The results were not at all surprising to medical professionals because the interventions were based on flawed premises on the causes of children’s diversity in sizes.

Not only does the government’s own data show that none of its massive anti-childhood obesity programs are based on evidence, it also shows the money has been spent on an unsupportable crisis. When the Scottish government developed its massive Hungry for Success program to eradicate childhood obesity, there was no epidemic of childhood obesity.

As we know, by reporting only the percentages of growing children crossing new arbitrary definitions for “overweight or obese,” it’s easy to create the illusion of skyrocketing obesity rates. But that doesn’t reveal the changes in actual heights and weights among children. It only gives half of the story.

As readers remember, researchers at the Department of Public Health, UMDS, St. Thomas’ Campus in London, had tracked the growth of English and Scottish children from 1972 through 1994, recording actual heights and weights measured each year among representative samplings of children, ages 5 - 10, as part of the National Study of Health and Growth study. By every test of health examined, the government found children were healthier. The most notable sign that Scottish children were growing healthier and better nourished was a steady increase in their heights over the decades.

Instead of an epidemic of children popping out like obesity balloons about to burst, their weights (the other part of the BMI equation, and the only one heralded) grew almost exactly matching the growth in heights.

Which would you choose to spend taxpayers’ scarce healthcare money on: medical care for critically-ill babies or free vacations and fruit? The choice might be clear to us, but we’re not from the government.


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July 19, 2009

Today’s changing medical ethics — where it’s taking us

There’s no such thing as a kindler, gentler capitation. — Pamela K. Mulligan, Ph.D., Canadian Family Physician, 2002

Last week, the Massachusetts’ state commission proposed a radical restructuring of how doctors, hospitals and healthcare providers will be paid in an effort to keep the state’s model universal coverage program from bankruptcy. Their proposals give us even more disturbing insights on what is being envisioned for all of us with health care reform.

If you are older (or think you might get older sometime), have a disability or any condition that needs medical care (or think you might ever need medical care), or have a lifestyle that the government doesn’t think is healthful, you will want to know what is being planned. You’ve just been thrown under the bus.

As the Special Commission on the Health Care Payment System said, healthcare spending has been rising by more than 8 percent a year in Massachusetts, faster than anywhere else in the country and at a pace that far exceeds the rise in the cost of living; and by their projections, will double by 2020. The costs of the state’s universal coverage program is threatening to bankrupt businesses and patients, they noted. The commission’s next move to try and keep universal coverage afloat are being closely followed in Washington, according to the news.

What are the commission’s latest recommendations? The state commission has proposed paying providers a flat fee for each patient, forcing healthcare providers to coordinate all of the patient’s care within that budget. This payment system, called capitation, likely sent shock waves through the hearts of experienced medical professionals. That’s because capitation isn’t anything new. We’ve been down this road before, with results so devastating to the practice of medicine and welfare of patients, even while failing in its goal of lowering costs, it was largely abandoned.

Members of the state commission vowed that this time capitation, which they’ve renamed a “global payment” system, will be different.

It’s worse. And not just because capitation will be universally mandated and patients will have no other choices of other types of plans. As they described in the 74-page Recommendations of the Special Commission on the Health Care Payment System, they state they will use financial incentives to force doctors into acting as care coordinators consistent with the medical home model and purportedly costs would be contained through Pay-for-Performance (P4P) measures which will offer financial rewards to providers who comply with specified quality measures. [The P4P measures the commission recommends are those created by the same interests preparing our medical homes. New readers can follow the links for decoded background information and disclosures.]

Their global payment system would involve completely restructuring the healthcare system. Providers (primary-care and specialist doctors, hospitals and home health agencies) would have to form large Accountable Care Organizations, with the ACOs to receive the annual fee-per-patient from the state to divide among them all. This effectively eliminates private, independent doctor practices.

The commission’s scheme also establishes another new authority, an Executive Branch agency, that will decide how much money will be allotted for the care of each type of patient.[See "Comparative effective research-what it means for us" to learn how the healthcare reform movement is deciding how resources and care will be allocated (i.e. rationed), and “Vision for our healthcare” for what the federal government is already doing.] This new government agency will also be charged with robust monitoring and oversight of compliance.

Despite these far-reaching proposals, the commission acknowledged that there is scant evidence that P4P, the medical home model or global payments have positive effects, improve quality of patient care or patient outcomes, or that they reduce healthcare costs. But correlations suggest that they might work, they wrote. “Medical homes are generally in an early stage of development,” according to their supplemental documentation, so “evidence of their effectiveness as currently implemented is limited.” There is also limited evidence for making evidence-based spending decisions, they wrote, with the largest and longest example in the country being the Oregon Health Plan which famously took on the task of prioritizing state expenditures based on comparative effectiveness analysis. [Covered here and here].

Reports to the State

As outlined in the July 1st report, Recommendations for the Massachusetts Health Care Quality and Cost Council’s Three Year Reporting Plan,the state mandates not only integrated electronic medical records, but also wants to increase the number of reportable conditions each year. “Patients must be attributed to physicians who will be held accountable for the quality and cost of care provided to them,” they wrote.

And accountable to the State.

Starting next year, doctors and hospitals must report patients with hip and knee replacement, lower back pain, diabetes, cardiovascular disease, respiratory disease; adherence to screening tests including mammograms and colonoscopies; and prenatal care. In 2011, reported conditions will include depression, hypertension, kidney disease, pediatric conditions, GI disorders, urinary tract infections, female genital disorders and contraception use. In 2012, the state recommends adding home health care, hospice and dental to its reporting requirements; along with conditions such as skin disorders, influenza, glaucoma and cancer treatment. For 2013 and beyond, they want the conditions reported to the state to include connective tissue disorders such as systemic lupus, nutritional disorders, thyroid disease, cataracts, headaches and more; along with adherence to obesity prevention and tobacco cessation interventions.

Healthcare reform advocates believe you want the state to know this information about you, and to monitor you and their doctors’ compliance with interventions it determines best — interventions developed by stakeholders, interventions that are not based on sound scientific evidence. Is that really what you want?


History lessons unlearned

“Those who cannot remember the past, are condemned to repeat it.” — George Santayana (1863 – 1952)

For nonmedical or younger readers who may be unfamiliar with capitation and what this new payment proposal means, here is a glimpse of what doctors were talking about in the medical literature when it was first widely promoted when managed care was failing to reduce costs. It may help you better understand the news spin this past week. It may also help to better understand the concerns that medical professionals have with all of this. It's long but more important to know than ever.

As Dr. Patrick C. Alguire, M.D., Director of Education and Career Development with the American College of Physicians explained, capitation payments are part of the efforts of some managed care plans to control costs. Capitation is a fixed amount of money per patient paid in advance for the delivery of health care services for a certain period of time. Capitation includes a list of specific interventions the provider must provide, with most including specific preventive screenings, diagnostic services and treatments; lab tests; health education and counseling and medications. Healthcare providers risk losing money if they provide care that goes over their budget, or if they make referrals to specialists or for expensive diagnostic tests or treatments; or if they fail to comply with the care mandates; while they can keep more money for themselves if they spend less.

You can guess the end results of this idea. If you are unlucky enough to have been born with any condition that requires ongoing care or is expensive to treat — or have a condition like normal aging, or obesity that the government has mandated must receive screening tests, labwork and interventions — fewer doctors will be able to afford to care for you and risk you costing them money. Nor will they want to bring more government oversight and scrutiny onto their practices. And if you develop a symptom that could be serious, doctors will have a financial incentive to downplay it and not treat it aggressively in order to keep more state money for this year.

Plus, how quickly will you be labeled as a noncompliant patient and be unable to find a doctor, if you don’t want to undergo the screenings, labwork and interventions, including diets, counseling and medications, that the government mandates?

During the 1990s, the medical literature was filled with ethical discussions and loud protests by American medical professionals who were experiencing capitation as part of healthcare reform and managed care. Similar discussions were taking place among Canadian doctors when capitation was proposed in 1997 as part of Ontario’s Health Services Restructuring Commission’s reform recommendations for its struggling healthcare system. Resistance was so intense during the 1990s among doctors and consumers, that it may help all of us to remember some of those ethical concerns. It’s also helpful to remember that, after decades, evidence of benefits of capitation and managed care remains lacking.


Experience of cost containment reforms

The United States has been blessed with abundant resources over the last half of the 20th century. While the healthcare system has meant limited access and poorer health outcomes for some, wrote Dr. Charles K. Francis, M.D., “for the majority of the population, however, health care in the U.S. has been characterized by an abundance of technology, physician manpower, pharmaceutical advances and an environment of nearly unlimited support for research and discovery.” The perception sold to the public was that the health care system was “guilty of unbridled spending and profligate resource allocation.” This effectively built support for “healthcare reform” and the advent of managed care.

“Managed care was envisioned as a system that would reduce expenditures on inappropriate or unnecessary health care and thus increase the availability of funds to improve the overall health of society,” he said. “Managed care, in a wide variety of iterations, has become the dominant health care delivery system in the U.S… However, as experience with managed care has grown over the last several years, patients and physicians have expressed a litany of concerns. These have included sub-standard quality of care, denial of necessary diagnostic or therapeutic procedures, adverse effects on the patient-physician relationship, improper financial incentives for physicians and restriction of information to patients regarding service limitations.”

Rather than address the specific issues affecting healthcare for some, reform affected the delivery of healthcare for all. And the evidence has failed to support the claimed benefits, as he explained:

The hypothesis that managed care would ultimately improve the health care system for all has been tested and not proven. Despite great economic prosperity, health care costs are increasing, employers are cutting back on coverage, the numbers of uninsured are growing, and the rights of patients are threatened. The imposition of economic incentives in the clinical decision making of physicians has undermined patients trust in their physicians and in the medical profession…

Arguments that managed care helps in meeting social needs because resulting health care cost savings may be transferred to other socially responsible functions or programs are, at a minimum, disingenuous. Experience has shown that much of the early benefit of the new health care paradigm accrued to share holders and company executives rather than the general public.

Since managed care has become the dominant health care delivery system in the United States, the number of uninsured persons in the population has increased… Real progress toward removing racial and ethnic disparities in access to health care remains a largely unfulfilled promise. Numerous examples of racial disparities in access to care and health outcomes have been described. For example, in a study of Medicare recipients [covered under government managed care] the rate of mammography use was lower in black women compared to white women and lower in less affluent women than in more affluent women regardless of race… Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America, and especially its role in access to health care and the delivery of medical services.

Dr. Francis went on to describe numerous studies showing disparities in health outcomes among minorities and socially disadvantaged, as JFS has also examined, regardless of whether or not they had health insurance or government provided coverage and access to healthcare. Managed care and healthcare reform, while seemingly to equalize access to healthcare to disadvantaged, marginalized and discriminated groups, doesn’t address the core prejudices and social-economics behind health disparities. And the ethical issues it brings to the practice of medicine doesn't make it a more ethical way to deliver healthcare.

Naturally, people are nervous about the effects of profit motives on the quality of their medical care. But when medical professionals strongly hold the traditional medical ethics that place their duties first and foremost to the best interests of the patients in their care, patients can trust their doctors to make ethical decisions on their behalf. But beliefs that managed care would reduce profits for those providing medical care served to shift them to insurance companies. Third-party payers and insurance companies have different objectives from those of doctors and patients.

Clearly, the potential for conflicts of interest in patient care exists in all forms of medical care systems, wrote Dr. Norman G. Levinsky, M.D., in a 1995 issue of The American Journal of Managed Care. In traditional fee-for-service practice, the possibility of personal economic gain may influence a doctor, consciously or subconsciously, to deliver excessive medical services. But without an economic incentive, he pointed out, salaried physicians may also provide less-than-optimal personal effort and poorer care. “Obviously, economic factors also influence the schedule of the fee-for-service practitioner,” he wrote, but with fee-for-service, “ultimately, the balance between income and practice standards is set by the physician alone.” If a doctor chooses to spend more time with a patient, as is fundamental for creating a bond with his patient and treat them as a whole person, he could.

Managed care, however, adds a third master. Doctors are expected to serve the financial goals of managed care plans, in addition to caring for the medical needs of their patients, he explained. “Pressures to decrease expenditures in the care of individual patients…now are focused sharply by specific mandates from managers of health maintenance organizations (HMOs) to limit expenditures.” In most plans, a primary care physician is charged with serving as a gatekeeper to limit access of patients to diagnostic studies, therapeutic alternatives, specialists and hospitalization. For patients, it means that their doctor is less free to take time with them, do the tests and provide the care they might feel best for them. “Working on schedules set by management, primary care physicians also may be required to reduce their own services to patients to suboptimal levels, especially that most precious component of primary medical care, their own time.” This is a little understood difference between doctors paid by the services they provide versus capitated managed care.

Managed care has changed the mindset of healthcare from what’s best for the patient to what’s best for the bottom line. “From the perspective of professional ethics, two key features of managed care that are of great concern are incentives or pressures on physicians to limit clinical services and mechanisms by which nonprofessionals can control physician behavior,” wrote Dr. Levinsky. “In fee-for-service practice, physicians struggle only with their own consciences. In managed care entities, managers can impose their standards on physicians.” And, as is slowly becoming more realized today, the role of many clinical practice mandates isn’t as much to save costs as it is to make money for the third-party payer, such as in pharmacy benefit management schemes.

While capitation “theoretically creates an incentive to provide care efficiently,” wrote Dr. Pamela K. Mulligan, Ph.D., in Canadian Family Physician, “experience and analysis suggests this experiment is likely to yield very different results.”

Like last week’s Massachusetts’ proposals, under Canada’s capitation, doctors were also required to join provider networks to offer predefined services and each patient had to sign a contract agreeing to obtain services only from that network. “From physicians’ perspective, signing contracts and restricting patient choice recasts the doctor-patient relationship from a personal, fiduciary relationship to a legalistic, quasibusiness affiliation,” wrote Dr. Mulligan. These contracts penalized doctors when patients went outside their network, discouraged doctors from working in rural areas where income potential and ability to pool risk was reduced, and created an administrative and financial burden. Just developing, monitoring and enforcing the contracts drained resources from medical care. “In Britain, introduction of a ‘contract culture’ (under the failed internal market reforms) led to a marked increase in administrative costs,” she wrote.

“Capitation is a nasty proposition, which, by design, rewards doctors for withholding services, creates an adversarial relationship between doctors and patients, promises no reduction in costs, and moves us closer to privatization,” she wrote. Canadian health policy experts advises that under capitation, “policy makers should not assume there will be cost savings in the short or longer term,” she reported. “They are correct. Ontario’s capitation-funded HSO program failed to achieve its primary goal: lower costs through reduced hospital use.”


Ethical discussions

“Physicians are in a lose-lose situation under capitation,” she wrote. “Guided by personal and professional ethics, they want to give the best possible care but find themselves locked into a system where their own financial well-being conflicts with their patients’ best interests.”

Most troubling to medical professionals was what Dr. Mulligan called the “dark side of capitation.” Capitation gave providers an incentive to underprovide services, she explained. It was called skimping or stinting and even Canadian health policy makers acknowledged it was “an inherent feature of capitation funding,” she pointed out. “This feature of capitation continually places doctors in uncomfortable conflicts of interest that compromise patient care.”

By transferring risk to doctors, incentives are also created for cream-skimming and taking relative healthy, low-cost patients while discouraging enrollment of high-cost, high-maintenance patients, she said. Despite regulations against refusing care or enrollment on the basis of health status, “evidence shows that capitated organizations can cream-skim in subtle ways to circumvent regulations that prohibit them from denying membership on the basis of health status. These strategies include deliberately establishing practices in areas with healthy populations and providing poor service to high-risk patients, thereby encouraging them to withdraw from the roster.” Because of concerns about cream-skimming by Ontario’s capitation-paid health services organizations, the government decided not to expand this program, she said.

There is no such thing as kinder, gentler capitation, said Dr. Mulligan.

“If a patient's employer or health insurer walked into a physician's office while the patient was waiting to be seen and offered the physician money to withhold services from the patient, the physician would probably give a frosty refusal,” wrote Dr. Harry P. Selker, M.D., in a 1996 issue of Annals of Internal Medicine. “To do otherwise would be contrary to the physician's role as trusted advocate for the patient's best interests. And yet, this conflict of interest is central to capitated care,” he said.

Unfortunately, many persons now believe in or promulgate the fallacy of "black or white:" If the existing system, which gives incentives for excessive treatment, is bad, then its opposite, a system that provides incentives for giving less treatment by putting the provider at financial risk for the costs of care, must be good. However, a health payment system in which incentives are based solely on this premise is only "managed cost," not "managed care."

As he pointed out, a RAND Health Insurance Experiment found that HMO insurance equally reduced both inappropriate and appropriate treatments. This demonstrates that the primary concern with managed care is reducing costs, whether or not it’s really clinically appropriate. It is easy to understand why third party payers would want to adopt managed cost systems, Dr. Selker wrote. It is “clearly in their financial self-interest.”

This abuses our patients’ trust and that of the public, he explained.: “One wonders if this trust would survive a local newspaper headline such as ‘Physicians Accept Money To Deny Their Patients Medical Care’ (or something more colorful). And how would we feel about our own roles as physicians when asked about his headline by our own patients?” That front page test helps us to know if we’re doing the right thing and is perhaps the most telling of the ethics of capitation.

“Do physicians accept the moral hazard of capitated care because they are confident that their own moral fiber will enable them to resist financial incentives?” he asked. Some justify withholding care because they wrongly adopt the black-and-white belief that “something has to be done about healthcare costs,” he said. Other claim that financial incentives don’t really work, so there’s no need for concern. “This is clearly specious. If such incentives did not work, they would not be used by those who are trying to manipulate physicians' behavior. The fact that such incentives are used, and more and more widely, is clear evidence that they do work: Physicians are restricting their patients' access to medical services in exchange for financial rewards.”

In “Some Thoughts on Ethics and Capitation,” published by the Maryland Psychiatric Society in 1997, Dr. Marianne Benkert, M.D., examined both the claims of advocates and critics of capitation. Capitation was the centerpiece of healthcare reform at that time, too, with industry increasingly relying on it to reduce rising costs in unwanted areas and in efforts to increase profits were driving down capitation payments to healthcare providers. “The essence of capitation is a shift in financial risk from insurers to providers, the potential to lose or earn less money, or spend more time without additional payment,” she said. “This puts more intense pressure to restrict patient access to expensive specialty and diagnostic services.”

In explaining the business philosophy behind capitation, she wrote:

It rests on the narrow model that assumes financial incentives alone shape human behavior. Business philosophy assumes that capitation will lead physicians to alter their routine office and treatment patterns in a way that will tend to be consistent with their economic incentives... The fact that managed care companies and capitated practitioners earn profits by withholding services, or by substituting less expensive for more costly care, raises suspicions about their motives. This is a debate about trust. One’s position probably depends on one’s belief that companies, managers, and clinicians, operating under capitation limits and profit incentives in managed care, will manage in one’s best interests.

When we consider medicine as “commodity versus service,” we see a change in vocabulary. "Commodity, customer, provider, vendor" all demean the professional aspect of our calling.

She went on to quote an article by John H. McArthur, DBA, and Francis D. Moore M.D. in the Journal of the American Medical Association, discussing the ethical dilemmas for medical professionals imposed by capitation:

“The current trend toward the invasion of commerce into medical care, an arena formerly under the exclusive purview of physicians, is seen by the authors as an epic clash of cultures between commercial and professional traditions in the United States. The fundamental act of professional medicine is the assumption of responsibility for the patient’s welfare. The essential image of the professional is that of a practitioner who values the patient’s welfare above his or her own and provides service even at a fiscal loss and despite physical discomfort or inconvenience. There is no outside invested capital seeking returns from the physician’s work.

The fundamental objective of commerce in providing medical care is achieving an excess of revenue over costs, while caring for the sick, ensuring profit for corporate providers investors, or insurers... When a corporation employing physicians seeks profit by selling their services, the physician employees cease to act as free agents. Professional commitment to patient care is subordinated to the rules of practice that assure the profitability of the corporation. Physicians can then be placed in a severe ethical dilemma. Shall they follow their conscience and the good practice of medicine or shall they save money for their employers and in some cases of capitation for themselves?”

During that earlier era of healthcare reform and capitation, medical professionals vehemently resisted managed care reform and its focus on costs. Commercializing medicine, wrote Dr. Benkert, “even for the sake of choice and efficiency, runs a great risk of subverting [medicine]. Markets have no capacity to set wise social priorities or to adhere to the goals of medicine. The integrity of medicine itself is at stake.”

Ethical concerns over managed care during the 1990s sparked a wave of government regulations to protect patients. In 1996 alone, one thousand pieces of legislation to regulate or weaken HMOs were introduced in state legislatures and 56 laws were passed in 35 states.


What’s changed between then and now? Then:

Around 15 years ago, most of the medical discussions over the problems doctors fought with managed care and capitation repeated a theme that is strikingly more absent today. That theme was the long-standing tenets of medical ethics.

At its deepest soul, the practice of medicine has been founded on the moral commitment of every medical professional to heal and protect patients, especially the most vulnerable. Medical professionals have been guided by codes of ethics for millennia. Chief among the moral obligations under the Hippocratic tradition of medicine calls for doctors and medical professionals to do everything they can to help the patients under their care and that they are duty bound to look out for the best interests of their patients.

The American Medical Association was so troubled by the effects of healthcare reform proposals on doctors’ primary ethical duty to advocate for their patients interests and needs under their Hippocratic Oath, that medical staff at its 1994 Annual Meeting recommended adopting a Resolution called “Assertion of the Professional Hippocratic Fiduciary Ethic in the Face of Health Care Reform Proposals.” This resolution was published in June, 1995, resolving: “That the American Medical Association continue its efforts to ensure that health system reform proposals maintain the primary ethical responsibility of physicians to advocate for their patients’ interests and needs.”

As covered here, four core ethical principles have guided the professional practice of medicine around the world, including experimenting on people. These were born of the 1946 Nuremberg doctor’s trial. These principles of bioethics that have underpinned medical ethics are:

Respect for autonomy — “patient choice” where patients can freely give their informed consent and have autonomy over their own bodies

Non-malfeasance — “do no harm” and balancing benefits and harms

Beneficence — an obligation to benefit the individual patient under one’s care

Justice — the fair and appropriate provision of services

Nearly a decade ago, the Position Statement adopted by the American Academy of Dermatology stated: “Any system of health care delivery must meet the test of the adherence to these principles or society will suffer.”

“The widespread implementation of capitation, as an integral part of the attempt to reduce or stabilize the cost of health care, creates an ethical dilemma for the medical profession that has never been faced before,” their Position Statement said. “It is the view of the Academy that the four basic tenets of ethical medical practice are in serious jeopardy under capitation.”

The inclusion of the managed care organization into the social contract for health care services creates a wedge between the physician and the patient, that being the fiduciary considerations of the physician on behalf of those sharing the risk, be they fellow physicians or the managed care organization. The physician’s dilemma of “serving two masters” can result. Capitation poses a definitive dilemma — the constant choice between cost-efficient service and medically necessary treatment…

The Academy further concludes that by maintaining the four tenets of non-malfeasance, beneficence, autonomy, and distributive justice as the foundation on which physicians function, physicians hold to an honorable medical profession that will not jeopardize the trust and confidence of the public who are served.

The Academy supported the early recommendations of the American Medical Association’s Council on Ethical and Judicial Affairs (CEJA), which issued its own statement in 1994 on the “Ethical Issues in Managed Care.” It was published in the July 1995 issue of the Journal of the American Medical Association. [It has since been deleted from the JAMA archives Table of Contents for that issue.] This document began by stating that the primary concern of medical ethicists for some time has been the effects of healthcare reform, “with its emphasis on managed care and managed competition, health care reform will greatly increase the ethical concerns.”

Managed care, be it under government or other third parties, replaces a doctor’s fundamental ethical obligations to his/her patient with the managed care plan’s goals. Implicit in managed care is denial of services to cut costs, it stated, adding:

Managed care can compromise the quality and integrity of the patient-physician relationship and reduce the quality of care received by patients. In particular, by creating conflicting loyalties for the physician, some of the techniques of managed care can undermine the physician's fundamental obligation to serve as patient advocate. Moreover, in their zeal to control utilization, managed care plans may withhold appropriate diagnostic procedures or treatment modalities for patients.

If physicians no longer hold their patients’ best interests foremost and patients can no longer trust them to care for them, patients are left more vulnerable than ever and without true advocacy. Managed care plans are increasingly for-profit companies, wrote the CEJA, with cost considerations determining the guidelines physicians must follow and what services should be offered. But rather than their primary responsibility to their patients, under managed care doctors are put into a compromising and “morally dubious” position of being gatekeepers to reduce costs. They must now become engage in “bedside rationing” and decide whether a patient will be granted further access to the health care system, including referrals to specialists and diagnostic tests.

In 1997, the CEJA issued a separate document, “The Ethical Implications of Capitation,” which noted that doctors practicing under capitation “typically experience significant pressure to stay within an allotted budget from colleagues who share the resource pool and from insurance companies, employers, and other third-party payers.” Regardless of whether it changes physicians’ practice of medicine to be cost-conscious, the Council stated, “capitation successfully shifts the mentality of practicing physicians” to make decisions based on cost. More so, it alters the role of the doctor, it stated.

Medicine has long held that the primary obligation of physicians is to advocate for the interests of each individual patient. In a capitated environment, however, patients covered by the same pool have overlapping interests…As physicians under capitation assume many of the roles traditionally held by insurers, however, these decisions could be brought to the bedside…It is difficult for payment rates based on either purely economic or legal premises to reflect the appropriate goals and aims of the profession, including the provision of necessary care and the preservation of ethical practice.

“There are two important ways in which financial incentives to limit care compromise the physician's duty of loyalty to patient care,” the CEJA said.:

First, [under capitation] physicians have an incentive to cut corners in their patient care, by temporizing too long, eschewing extra diagnostic tests, or refraining from an expensive referral…Second, even in the absence of actual patient harm, the incentives may erode patient trust as patients wonder whether they are receiving all necessary care or are being denied care because of the physicians' pecuniary concerns.

The pressures of cost containment on primary care physicians, the CEJA wrote, “may encourage some physicians to try to manage cases longer than they should. Physicians may feel compelled to stretch their competence in order to keep patients at the primary care level and conserve resources. Inappropriate treatment and improper or missed diagnoses are potential outcomes of such decisions to delay or deny referral.”

It is true that financial conflicts are inherent in the practice of medicine, regardless of the system of delivery. But it’s also true that physicians have generally been able to maintain their duty to patient welfare despite those conflicts. However, incentives to limit care as in managed care’s capitation, are more ethically problematic than incentives to provide care, the CEJA said.

First, financial incentives to limit care exploit the financial motive of physicians, making the physician's financial self-interest indispensable for the success of the managed care organization. Second, financial incentives to limit care are less likely than financial incentives created by fee- for-service to coincide with patients' interests, because patients generally prefer the risk of too much care to the risk of too little care. Third, the effects of incentives to limit care are less likely to be noticed by patients. When a physician recommends a course of action under fee-for-service reimbursement, the patient can seek a second opinion. However, when a physician does not offer an intervention under managed care, the patient may have no idea that a treatment option was withheld and therefore not recognize the need for a second opinion.

This violates the fundamental principle of medical ethics: patients’ right to informed consent and a patient’s freedom of choice. Doctors, as patient advocates, have duties of disclosure and to ensure that patients are told of all treatment options, regardless of costs, the council explained. Patient autonomy does not guarantee the right to have all treatment choices funded, they said, but in order to fully exercise their autonomy, patients also need to be fully informed of conflicts of interest of their doctor. And doctors have a duty to disclose financial incentives. “Regardless of any allocation guidelines or gatekeeper directives,” they added, “physicians must [also] advocate for any care they believe will materially benefit their patients.”

… [I]t is important to consider what is at stake. The foundation of the patient-physician relationship is the trust that physicians are dedicated first and foremost to serving the needs of their patients. In the Oath of Hippocrates, trust is a central element in almost all of the ethical obligations of physicians: physicians must keep patients' private information confidential, avoid mischief and sexual misconduct, and give no harmful or death-causing agent. Patients can expect that physicians will come to their aid even if it means putting the physician's own health at risk, and they can trust that physicians will do everything in their power to help their patients. It is this trust which enables patients to communicate private information and to place their health, and indeed their lives, in the hands of their physicians. Without trust, the success of the healing process would be seriously diminished.


Now: A new medical ethics

If medicine becomes, as Nazi medicine did, the handmaiden of economics, politics, or any force other than one that promotes the good of the patient, it loses its soul and becomes an instrument that justifies oppression and the violation of human rights. — Dr. Edmund Pellegrino, M.D., Annals of Internal Medicine, 1997

Healthcare, managed by the government and other third-party payers, along with political and economic interests, has served to alter the very meaning of medical ethics for some. Over the past fifteen years, medical ethics has steadily become distorted into something disturbingly different. “The physician is no longer the independent decision maker guided solely by a professional code, a paradigm that has dominated theories of medical ethics,” wrote doctors Katherine Swartz, Ph.D., and Troyen A. Brennan, M.D., JD, MPH in 1996.

Gate keeping and serving as guardians of the financial interests of third party payers “has been defended on moral and ethical grounds on the premise that funding would be available for others purposes beneficial to society,” wrote Dr. Francis. “Recently, the claim that consequent harm is ethically irrelevant when physicians serve the state or other third parties… [S]ome might consider the assertion that clinical work for the state is beyond the scrutiny of medical ethics to be an echo of the distorted medical ethics of the Nazi era.”

“Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based market driven managed care,” he wrote, “provide important lessons.”

The work of Dr. Edmund Pellegrino, M.D., has been mentioned several times at JFS, along with some of the ethical discussions from the President’s Council on Bioethics. As regular readers know, Dr. Pellegrino, Professor Emeritus of Medicine and Medical Ethics and Adjunct Professor of Philosophy and Director of the Center for Bioethics at Georgetown University, has been widely respected and trusted in the medical community for his lifelong devotion to promoting ethics in the practice of medicine and the importance of intellectual honesty and fidelity to patients. No one in our lifetime has equaled his contribution to the bioethics field and his appointment as chair of the President’s Council on Bioethics was widely supported.

For medical providers, “there is no absolute moral principle except the injunction to act in the patient’s best interest,” he wrote. In 1997, he spoke to doctors at a medical ethics conference on the ethical challenges in the era of managed care, sharing a troubling observation of the changing face of medical ethics today — one that was departing from the Hippocratic oath of a healing relationship between the doctor and patient that puts the best interests of their patients first. In describing what he saw evolving in medicine, Dr. Pellegrino warned that medicine was increasingly being used for purposes other than the good of the sick, and was failing to be stewards of sound medical knowledge.

In his famous 1997 Annals of Internal Medicine editorial, “The Nazi Doctors and Nuremberg: Some moral lessons revisited,” he cautioned doctors about the fragility of medical ethics and how easily they can be led to do the most unthinkable things, while believing themselves to be ethical and reasoned. Even today, he warned, the moral lessons of the Nuremberg Trials have not been learned and it is wrong to believe such atrocities could never happen again.

“If medicine becomes, as Nazi medicine did, the handmaiden of economics, politics, or any force other than one that promotes the good of the patient, it loses its soul and becomes an instrument that justifies oppression and the violation of human rights,” he wrote. “Subversion becomes a greater danger whenever medicine comes too close to the power of the state.”

In an article entitled “Guarding the Integrity of Medical Ethics-Some Lessons from Soviet Russia,” he shared two lessons from the subversion of medical ethics he saw: corruption will afflict any health system not designed with care of the patient as the its primary driving force; and medical ethics must be independent of political exigency. "[A] morally responsive profession is an indispensable safeguard for the sick against the statistical morality of utilitarian politics, even in democracies,” he wrote.

The Nazi doctors justified their actions by what they believed to be moral reasons and we see the same premises being repeated today, he cautioned: “that law takes precedence over ethics, that the good of the many is more important than the good of the few, that national emergencies supersede ethics, and that some persons can lose their claim to humanity.” Moral lessons must be repeatedly relearned, he said.

In the “new medical ethics” that came with managed care, discussed here, quality of care was redefined to mean the greatest good for the greatest number within the collective the doctor belonged. In just a little over a decade, medical ethics has been turned upside down. Every day brings us closer to precisely what he warned against. It should disturb each one of us to our very souls, that Dr. Pellegrino’s warnings about a “new medical ethic” are playing out so clearly.

Nothing better shows how medical ethics has been altered than to compare the very first Principles of Medical Ethics issued by the American Medical Association on May 16, 1903 with the current version. I urge you to read the original Principles of Medical Ethics. It is a beautiful document, although 7-pages long, and compassionately describes the heart of medical ethics that have generally guided medical professionals for the past century. Its guidance for medically ethical behavior, unencumbered by political or outside interests and devoted to the patient’s well-being, can offer valuable insights today. These are the sentiments which brought many experienced healthcare professionals to make healthcare their life’s work. It begins:

Physicians should not only be ever ready to obey the calls of the sick and the injured, but should be mindful of the high character of their mission and of the responsibilities they must incur in the discharge of momentous duties. In their ministrations, they should never forget that the comfort, the health and the lives of those entrusted to their care depend on skill, attention and fidelity. In deportment, they should unite tenderness, cheerfulness and firmness, and thus inspire all sufferers with gratitude, respect and confidence. These observances are the more sacred because, generally, the only tribunal to adjudge penalties for unkindness, carelessness or neglect is their own conscience.

Every patient committed to the charge of a physician should be treated with attention and humanity, and reasonable indulgence should be granted to the caprices of the sick. Secrecy and delicacy should be strictly observed; and the familiar and confidential intercourse to which physicians are admitted, in their professional visits, should be guarded with the most scrupulous fidelity and honor…

The physician should be a minister of hope and comfort to the sick, since life may be lengthened or shortened not only by the acts but by the words or manner of the physician whose solemn duty is to avoid all utterances and actions having a tendency to discourage and depress the patient. The medical attendant ought not to abandon a patient because deemed incurable; for continued attention may be highly useful to the sufferer, and comforting to the relatives, even in the last period of the fatal malady, by alleviating pain and soothing mental anguish…

There is no profession from the members of which greater purity of character and a higher standard of moral excellence are required than the medical: and to attain such eminence is a duty every physician owes alike to the profession and to patients. It is due to the patients, as without it their respect and confidence cannot be commanded, and to the profession because no scientific attainment can compensate for the want of correct moral principles…

It is incompatible with honorable standing in the profession to resort to public advertisements or private cards inviting the attention of persons affected with particular diseases; to promise radical cures; to publish cases or operations in the daily print [media], or to suffer such publication to be made; to invite laymen (other than relatives who may desire to be at hand) to be present at operations; to boast of cures and remedies; to adduce certificates of skill and success, or to employ any of the other methods of charlatans.

It is equally derogatory to professional character for physicians to hold patents for any surgical instruments or medicines; to accept rebates on prescriptions or surgical appliances; to assist unqualified person to evade the legal restrictions governing the practice of medicine; or to dispense, or promote the use of, secret medicines, for if such nostrums are of real efficacy, any concealment regarding them is inconsistent with beneficence and professions liberality, and if mystery alone give them public notoriety, such craft implies either disgraceful ignorance or fraudulent avarice. It is highly reprehensible for physicians to give certificates attesting the efficacy of secret medicines or other substances used therapeutically…

It is the duty of physicians, who are frequently witnesses to the great wrongs committed by charlatans, and of the injury to health and even destruction of life caused by the use of their treatments, to enlighten the public on these subjects, and to make known the injuries sustained by the unwary from the devices and pretension of artful imposters….

These are not the new medical ethics. Compare those long-standing medical ethics with today’s principles. More importantly, compare them with proposals under healthcare reform at the beginning of this article.


Will people figure out what’s going on?

More than ever, our society needs doctors and medical professionals, who pledge some Hippocratic oath of medical ethics, to be guiding us on ethical issues that affect medical care — not lawyers, politicians or corporations.

The President’s Council on Bioethics, chaired first by Dr. Leon Kass, M.D., Ph.D., and then Dr. Pellegrino, had been tasked with advising the government and our society on the ethical issues related to advances in biomedical science and technology. It has issued some of the most thought-provoking ethical discussions in modern medicine, and that I’ve ever read as a medical professional. Over the years, it’s given me a deeper, richer understanding of the ethics in medicine and public policies and altered what I thought I believed to be true more than once.

Take a look at a few of their recent papers, such as one on the ethics of genetic testing and public policy and one on the history and ethical issues surrounding newborn screening, covered here. Others that are especially relevant to today’s considerations of healthcare reform included an unsettling discussion on medical care and the common good which examined problems in the American healthcare system, of healthcare access and the uninsured, healthcare costs, quality of healthcare, and whether healthcare should be a commodity or a right; and another on the ethical questions in reforming medical care. Reading them will leave you feeling mad to inspired. We won’t agree with each viewpoint, nor should any of us. But most importantly, they force us to think about all sides of an issue, take a hard look and think through the consequences of decisions, and consider things we would never have thought about before.

Stakeholders don’t want us to think. Encouraging society, the public and medical professionals to educate themselves, understand history and think about things that might feel uncomfortable, before we act to do things that will change the future for each one of us and for our children, is a threat to ideologies and agendas.

Last month, with one day’s notice and shortly before they were to issue a number of new papers, the President’s Council on Bioethics was told by the White House that their services were no longer needed. Instead, the White House press officer said the President plans to appoint a new bioethics commission “with a new mandate that offers practical policy options.” Robin Alta Charo, JD, a law professor and member of Obama’s transition team, was quoted saying that a new commission should focus on helping the government form ethically defensible policy.

Just as sound science doesn’t change with the political wind, ethics doesn’t either. Medical ethics doesn’t work backwards or reinvent itself to create an argument in support of a governmental agenda. We are entering a new ethics, as Dr. Pellegrino warned.


© 2009 Sandy Szwarc


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