Tuesday, August 23, 2011

Healthcare system lecture....bleargh...

Today we had a lecture by the immediate past president of the AMA. Very interesting. Very scary.

Much of his lecture was focused on the history of nationalized healthcare and healthcare as a right. He went through the AMA principles of medical ethics. I remember discussing these at TAC--they were the first substrate of the TAC Medical Society's discussion series. We contrasted them to the Hippocratic Oath. Contrasted them. To my mind, they do subtle harm to the duties of a physician. (That is probably another post.)

Much of his lecture was based on audience-response technology (instant voting through our laptops/phones). I think most of his questions were frustratingly vague and slanted. Here are the most interesting of them, along with the class' responses (n~200 first-year medical students).
  1. Is healthcare a right or a privilege?
    67% voted "right"
    33% voted "privilege"

  2. What is the most important unalienable right of an individual?
    54% voted "life"
    30% voted "liberty"
    15% voted "pursuit of happiness"

  3. Would you order a medically unnecessary test to pay the bills?
    4% voted "yes"
    96% voted "no"

  4. Does AMA Principle III obligate every physician to be involved in the American political system?
    47% voted "yes"
    53% voted "no"

  5. A patient presents with an emergency condition and needs medical care that is against the personal beliefs of the physician and there is not time ot find another physicain. Should the physician provide the medically necessary care?
    86% voted "yes"
    14% voted "no"

  6. Equitable care eliminates disparity. A major driver of disparity is lack of health insurance. Thus, all Americans must have health insurance to eliminate health disparities.
    52% voted "yes"
    27% voted "no"

My thoughts and the lecturer's comments:
  1. The lecturer seemed appalled that so many of us voted "privilege" (I did). But this question is vague. What is a "privilege?" To the lecturer, it implies arbitrary and unjust exclusion of some parties from a good. To me, it means healthcare is provided to those who are able to seek it, just like quality groceries or a college degree. Problems: inexhaustive division, potential equivocation.

  2. The lecturer was disturbingly noncommittal about the correct answer here, although finally I think he implied that life was a more basic right than liberty. The question is poorly put, however. What does "important" mean? The most basic right is life. But liberty resembles the perfectly free will of the virtuous man, and happiness is the end of all ethics! The lecturer gently mocked those who chose "the pursuit of happiness," and I bristled. They should not be laughed at because the question was vague. Problem: potential equivocation.

  3. The lecturer was pleased with us, and I am, too. I hope we adhere to what we claimed here.

  4. The lecturer rebuked us for voting "no" because, to his mind, a physician is part of the system and must endeavor to make the system better. This is one of the topics the TAC Medical Society spent some time on. The physician as physician does not engage in politics (even to vote); he heals patients. The physician as citizen may vote, or as politician may make policy. We TACers concluded that this AMA principle was misguided, attaching something accidental to the physician's essential duties.

    But a very popular area of discussion nowadays (outside of TAC) is public health, and how the physician should be concerned with the health of the community/nation/world, not just the patient in front of him. I do not disagree, but this does not require the physician to engage in politics. Problem: fallacy of the accident.

    (Parenthetically, I should mention that I voted "no," although as I type, I realized that the answer to the question is in fact "yes." The question I answered "no" to is: "ought the physician be involved...?")

    (EDIT January 2013: and what does "involved in the...political system" mean? I vote, and that is the duty and privilege of a citizen. I won't pretend to be more.)

  5. Did the overwhelming majority of my class just vote out conscience rights? I am not sure: this question is too vague to tell. What would be "medically necessary" and against someone's beliefs? All that people usually complain about is "emergency contraception" (not medically necessary), elective abortion (not medically necessary), and unnecessary sterilization (not medically necessary).

    The lecturer was displeased with the 14% of us (which I believe included myself; I may have abstained from this question out of ire). In his tone of voice, I perceived incredulity: how could we place belief above medical necessity? How did we get this far [i.e. to medical school!] and not have this straight? Oh, what horrible doctors we will be if we don't shape up!

    There is an underlying ethical crisis here. Ethics is the art of what should be done to form the conscience and become perfect. If the physician places any mortal good above his conscience, he is acting unethically. In the lecturer's eyes, "personal beliefs" are cheaper than earthly life; in the eyes of Plato, Aristotle, the saints, Christ, and thousands of others, earthly life is misery compared to "what God has ready...."

    Problem: prefers the apparent good.

  6. I carefully copied the question word for word, but this is not a syllogism. The first sentence is accessory and the question is asked based on the second and third. The lecturer was aghast at the 27% of us (including myself) and asked us to take a break while he thought about how to address us. But look at the words! The question states that lack of health insurance is "a major driver" of healthcare disparities; it is not the only creator of disparity, so providing everyone with it will not "eliminate" disparity. Perhaps the lecturer meant:
    1. Equitable care eliminates disparity. 
    2. A major driver of disparity is lack of health insurance. 
    3. Thus, all Americans must have health insurance to provide equitable care.
    (Even so, this is two or three syllogisms, but because the human intellect so readily syllogizes, this is understandable. St. Thomas does this frequently.) But this helps very little, because even if this were valid logically, it is not true: the "must" is too strong. There are other ways and other systems of providing compassionate and equitable care. One example is charity.
    The lecturer mentioned charity healthcare in his historical comments, noting that medical students and residents used to provide free care (he did not mention the hundreds of years of religious orders, nor did he mention nurses). He did not entertain charity as a viable option for healthcare
    What got mentioned? Teddy Roosevelt in 1912, FDR, WWII employer healthcare policies, and Obama. I prefer privatized, voluntary charity to government-managed, enforced charity. The former improves the character of the citizen and the culture of the country; the latter involves overhead and provides an opportunity for leeches in the distributing bureaucracy and the receiving poor.
    Problems: possible typo, invalid conclusion
I left the lecture feeling slightly slapped and very dissatisfied with our culture. So many good intentions, so much poor thinking! The culture, represented by the lecturer, is not curious about what doctors ought to do, what medicine was for, and what would be good for anyone's character.

The culture may insist that it wants those things, but I know better. It sees this life as our only one, so it wants healthcare for every need: any hole in coverage is a great travesty. Health, for this culture, is not a mortal good. It is entwined with life and confused with happiness and becomes one of the highest goods. As a result, the importance of medicine becomes inflated: medicine protects this great good! Therefore, the culture desperately cries "healthcare for all!" as desperately as a Saint prays grace for all.

But medicine is not that important. It is only a mortal good, and not necessary in life for our celestial purpose.


  1. I am not well-versed in philosophy/thought, so I have some questions:

    1. All have a right to life. In many discussions I've been a part of, this has been extended to include a right to healthcare. Why might this extension be unjustified?

    2. What do you think about EMTALA, the law that mandates emergency care for anyone, regardless of ability to pay?

    3. So I agree that voluntary charity is far better than enforced charity. But, given that we are in a sinful world, should some charity be enforced to save lives (extreme case)?

    On another note, I find #5 illuminating. I have been extremely confused regarding why there is a debate about conscience rights, especially in our relativistic society. But, it seems that people don't realize that a truly medically necessary treatment is never against a doctor's conscience. Perhaps more energy should be put into defining "medically necessary"?

    The more I learn, the more I frightened I become of the state of healthcare ethics. Thank God for grace, for only grace can save us now, I think.

  2. 1. Thank you for pointing this out! I did not know this. This extension is unjustified. While the goods of life and health are related, they are not the same. (I alluded to this in the post when I said health was "entwined with life." I should've been more clear: many think "life" and "health" are identical.) The purpose of medicine is not to prolong life; it is to heal.

    As an aside, this is made abundantly clear by medical nonfiction (Singular Intimacies and Complications come to mind, although I don't have the books in front of me to double-check) and fictional pieces like Kurt Vonnegut's "Fortitude," and similar exaggerated short stories.

    2. The lecturer thought EMTALA was a very important landmark. He said that when it was passed, healthcare ceased to be a privilege and "became a right...." This position leads me to think he does not believe that rights are inherent or unalienable. They do not stem from what man is or what man ought to be; they stem from the law. (To be charitable: perhaps he only meant that healthcare was recognized as the right it is.)

    Regardless of what my lecturer said, here is what I think: EMTALA is compress, a remedy for a problem that serves as a fix but does not treat the symptoms. If a trauma victim has a deep laceration, a compress will stop the bleeding, but will not close the cut; he needs stitches and time/dressings/nutrition so that his skin and tissue can close.

    The problem EMTALA addresses are "wallet biopsies." Someone comes to the ED, and the staff ask to see their insurance, to make sure that the ED will be reimbursed for the person's care. EMTALA was passed to stop this new phenomenon. (In my analogy, wallet biopsies = bleeding.) But wallet biopsies had not existed eighty years before EMTALA, because

    ♦ the insurance industry had never been so robust, and maybe also
    ♦ medical technology had never been so accessible and expensive
    ♦ (I posit this very gingerly) medical providers had never been so self-interested. In the 1700s, 1800s, and early 1900s, much of healthcare was Catholic hospitals and nuns. This changed with WWII.

    (In the analogy, the above two items = the laceration causing the bleeding.) EMTALA does not address either of these. It is not a cure, it is a temporary fix (at best) and masking symptoms or causing septicemia (at worst). We must realize that much of our healthcare legislation is a compress before we begin to clean and stitch (and heal!) the wound in our culture.

    3. Very good point. I see that enforced charity for grave emergencies is more justified than enforced charity for well-woman checkups. I do not know what the appropriate mix is between voluntary and enforced charity.

    I am glad #5 was helpful, and I agree with your suggestion. More communication between those who want to defend "conscience rights" and those who don't should focus on the definition of "medically necessary." And I agree 10^9% about your last sentence.