Health Care Reform: Turning Physicians Into Drone Bureaucrats?
The New England Journal of Medicine
, in addition to publishing important scientific and medical reports, is highly political. It supports assisted suicide, for example, and even respectfully published the Groningen Protocol
--the Dutch check list to determine which babies can be murdered for eugenic reasons based on terminal or disabling conditions.
Not surprisingly, the NEJM has published articles weighing in on the great health care reform debate, such as this one by Michael E. Porter, a Harvard Business School professor. Porter says the answer to the current mess is the establishment of a "value based system." From the article
What we need now is a clear national strategy that sets forth a comprehensive vision for the kind of health care system we want to achieve and a path for getting there. The central focus must be on increasing value for patients — the health outcomes achieved per dollar spent...True reform will require both moving toward universal insurance coverage and restructuring the care delivery system. These two components are profoundly interrelated, and both are essential.Achieving universal coverage is crucial not only for fairness but also to enable a high-value delivery system.
But what does this mean? Would "universal" coverage include illegal aliens? If so, half of Mexico and points South can be expected to try to get across the border. Is it going to include abortion? How about expensive procedures such as IVF, pre-implantation genetic diagnosis, etc.? Beyond the political difficulties, having expansive "universal" coverage will quite literally break the bank. How about assisted suicide? Now there's a "treatment" where value is very cheap to provide!
The article promotes some things with which I agree, for example allowing private health insurance companies (and public) to compete nationally. But Porter also says everyone should be forced to buy health insurance whether they want it or not. So much for "choice." But here's the thing: The proposed system, as described by Porter, makes the old Hillary Health Care plan seem simple:
[W]e need to move to integrated practice units that encompass all the skills and services required over the full cycle of care for each medical condition, including common coexisting conditions and complications. Such units should include outpatient and inpatient care, testing, education and coaching, and rehabilitation within the same actual or virtual organization. This structure, organized around the patient's needs, will result in care with much higher value and a far better experience for patients.
And this part really raised my hackles (my emphasis):
In order to achieve a value-based delivery system, we need to follow a series of mutually reinforcing steps. First, measurement and dissemination of health outcomes should become mandatory for every provider and every medical condition. Results data not only will drive providers and health plans to improve outcomes and efficiency but also will help patients and health plans choose the best provider teams for their medical circumstances...
Outcomes must be measured over the full cycle of care for a medical condition, not separately for each intervention. Outcomes of care are inherently multidimensional, including not only survival but also the degree of health or recovery achieved, the time needed for recovery, the discomfort of care, and the sustainability of recovery. Outcomes must be adjusted for patients' initial conditions to eliminate bias against patients with complex cases. We need to measure true health outcomes rather than relying solely on process measures, such as compliance with practice guidelines, which are incomplete and slow to change. We must also stop using one or a few measures as a proxy for a provider's overall quality of care. Performance on a measure such as mortality within 30 days after acute myocardial infarction, for example, says little about a provider's care for patients with cancer. Active involvement of the federal government will be needed to ensure universal, consistent, and fair measurement throughout the country, like that already achieved in areas such as organ transplantation.
But organ transplants are relatively rare procedures, numbering in the thousands. We are talking here about measureing hundreds of millions of procedures and outcomes! Talk about turning doctors into paper shufflers! Think of the number of people that will be required just to gather and input the data from the tens of millions of people who receive health care every day. And in the end, it would be about Big Brother, or perhaps Big Triplets, exercising rigid centralized control:
Some new organizations (or combinations of existing ones) will be needed: a new independent body to oversee outcome measurement and reporting, a single entity to review and set HIT standards, and possibly a third body to establish rules for bundled reimbursement. Medicare may be able to take the lead in some areas; for example, Medicare could require experience reporting by providers or combine Parts A and B into one payment.
Hello utilitarian bioethics enforcers!
Health care cannot be controlled centrally by the Feds. It's too big a sector. Setting up "modules" and trying to measure "value" will turn us into a pretzel--but to mix my metapohrs, one with teeth
. Good grief.
Check Out My New A Rat Is A Pig Is A Dog Is A Boy Blog
With Amazon listing my upcoming book A Rat Is A Pig Is A Dog Is A Boy
for presale, I thought I should set up a blog solely devoted to the animal rights issue. We discuss those matters here at SHS, of course, and will still. But it is only one piece of the human exceptionalism pie--albeit, an important piece--and I have found it difficult give the matter proper consideration here given all the other issues coming down the pike. So, as if I didn't have anything else to do, I launched it today.
For anyone interested, here's the link
Global Warming Fundamentalism
What can only be called a fundamentalist wing has developed within the global warming movement. One attribute of fundamentalism is a focus--and for some, an hysterical obsession--with end-of-the-world fear mongering, as in the warning just issued by "Nobel Laureates" that the dangers of climate change are as dire as those of a nuclear war between the Soviet and the United States. From the St. James Palace Memorandum
issued at the St. James' Nobel Laureate Symposium
, May 26-28, 2009:
The solutions to the extraordinary environmental, economic and human crises of this century will not be found in the political arena alone. Stimulated by the manifesto of Bertrand Russell and Albert Einstein, the first Pugwash gathering of 1957 united scientists of all political persuasions to discuss the threat posed to civilization by the advent of thermonuclear weapons. Global climate change represents a threat of similar proportions, and should be addressed in a similar manner.
Really? A nuclear war could literally have destroyed all but the most rudimentary life on the planet. The earth has been much warmer before than now, and life thrived.
The theme of the document is "the fierce urgency of now,
" so every time the word "now" appears, it is underlined, as in:
We must recognize the fierce urgency of now...A zero carbon economy is an ultimate necessity and must be seriously explored now...A long-term commitment under the United Nation Framework Convention on Climate Change (UNFCCC) is now urgently required.
Since hysteria is the watchword of the day, why didn't they just write the whole thing in capital letters?
This isn't science, it is ideology, scientism run amok, that undermines science. Not surprisingly, the shebang was hosted by Prince Charles--long live the queen! (Was Al Gore part of the preparation of this screed? It sure emits his sweaty pheromones.) No wonder an increasing number of people are growing more skeptical of the threat and proposed solution to the "crisis."
My Upcoming Animal Rights Book Now Listed on Amazon
The economy has slowed the release of my upcoming book criticizing the animal rights movement, but it is moving forward. It is now listed on Amazon. The title comes from PETA's Ingrid Newkirk's most famous quote: A Rat is a Pig is a Dog is a Boy: The Human Cost of the Animal Rights Movement
. The book cover is still being worked on, and I will link it here when it is available.
What do I hope to accomplish? This excerpt from the introduction explains:
It is not my purpose in this book to act as a defender of of animal industries. Rather, my goals are primarily to expose the anti-human ideology of animal rights/liberation, expose the movement's many deceptions, and warn against the sometimes violent tactics of the animal rights/liberation movement. I will also defend the propriety of using animals as necessary and proper to promoting human welfare, prosperity, and happiness. Finally, I will mount an unequivocal defense of the belief that human beings uniquely stand at the pinnacle of moral worth--a concept sometimes called human exceptionalism.
I am very well aware that these positions—once nearly universally accepted—have, in recent years, become intensely controversial. Indeed, few issues generate such intense emotionalism or fervent support by its adherents as does “animal rights.” Thus, I want to make it very clear at the outset—as I will throughout the book—that I love animals and like most people, I wince when I see them in pain. Moreover, I believe strongly that as enlightened people, we have a profound moral and ethical obligation to treat animals humanely and with proper respect—a core obligation of human exceptionalism—and by all means, to never cause them to suffer for frivolous reasons. I also strongly support laws against cruelty to animals and support strengthening them when appropriate. Indeed, I believe that animal abuse is a terrible wrong, not only because it causes the victimized animal to suffer, but also because cruelty to animals diminishes our own humanity.
Now, consider why I felt it necessary to make such an unusual disclaimer: Over the past thirty years, the concept of “animal rights” has seeped deeply into the bone marrow of Western culture. (This is especially true among the young.) Part of this support is based on a very loose use of the term “animal rights” as about being nicer to animals. It isn’t—although sometimes animal rights groups engage in animal welfare-type activism. Rather, animal rights is actually a belief system, an ideology, and for some even a quasi-religion that both implicitly and explicitly seeks to create a moral equivalency between the value of human lives and those of animals.
I expect the book will generate a lot of controversy. That's fine. But I think a lot of it--as in some of my previous books--will be about what I didn't write rather than what I did. In any event, we are on our way. Stay tuned
Anti Humanism’s Threat to the Environmental Movement
Environmentalism is changing. It once was a distinctly humanistic movement, pushing conservation as a way of ensuring prosperity to our posterity, cleanup of pollution, protecting of habitats and endangered species, etc.--all certainly human duties arising from human exceptionalism. But in recent years, environmentalism has been trending toward an explicit anti-humanism that sees "the planet" itself as having the highest value and people-- because of our unique ability to impact the environment--as the enemies of the biosphere.
A recent entry in The Sustainable Dwelling Blog
illustrates my point. The author improbably analogizes GM's financial problems to the hard limits that he believes humans must accept to our activities and flourishing. He attacks American Exceptionalism--about which we need not be concerned here--but then turns to his true target; human exceptionalism. From the post
As GM attempts to pull itself from the ashes of bankruptcy and politicians around the world promise the oxymoron of “sustainable” growth, nearly 7-billion humans are still mostly blind to the reality of ecological limits and harsh retribution of overshoot and collapse. This is the ultimate hubris—the hubris of human exceptionalism.
But this is nonsense. It is precisely human exceptionalism that provides the answers to the problems about which the author worries, it is not the cause. What other species imposes limits on itself to protect the environment or for the benefit of other species? None. What other species has the duty to be environmentally responsible? None. Indeed, if being human isn't what requires proper ecological behavior, what does?
Of greater concern is the nihilism and pessimism--an acceptance of the premises of deep ecology-- that seems to increasingly drive the new environmentalism. It is about reducing our prosperity, limiting our flourishing, and indeed, elevating "the planet" above the well being of human beings. If this anti humanism continues to subsume a healthy environmentalism centered in human exceptionalism, destitute people will remain mired in poverty, living standards will shrink, and human welfare will be generally diminished. Worse, since our behavior and policies tend to be based on our beliefs, this ideology could induce us to turn on ourselves--resulting in untold human suffering.
Sometimes I think this is where we are heading:
Patience Please: Comments Function Will Soon Work Properly
I am sorry for all of the people who have been participating in the interesting conversation about the murder of Dr. Tiller. The comments have been lost, but hopefully will be found. I am told we should be completely out of the woods in this regard tomorrow. We apologize for the inconvenience. Or to quote the IT guy: "Aaargh!"
Update: The comments function seems to be working now. We will try and catch the ones lost tomorrow. Comment from the "comments" link at the bottom of the post. Thanks.
Up-Update: Most of the Tiller comments have been captured. That conversation can continue for those who would like to continue to engage.
Comments Function Now Working
Good news: The comment function is now working directly from the "comments" link at the bottom of the page. We are definitely almost through the woods.
Suicide Is Not a Necessity
Once again assisted suicide is being presented by its supporters as somehow a necessity. That being so, they argue, legalizing assisted suicide would extend rather than shorten lives. From the story
The ban on assisted suicideis forcing terminally ill people to cut their lives short, the House of Lords heard today as MS sufferer Debbie Purdy continued her controversial case to clarify the lawat the UK's highest court.
Purdy, 46, from Bradford in West Yorkshire, who suffers from primary progressive multiple sclerosis, claims her human rights are being violated by the lack of a clear policy from the director of public prosecutions as to whether her husband, the Cuban jazz violinist Omar Puente, will be prosecuted if he accompanies her to the Dignitas clinic in Switzerland.
"It is ironic indeed that the more likely it is Debbie Purdy's husband will be prosecuted for assisting suicide, the sooner Debbie Purdy will end her life to avoid that danger," David Pannick, Purdy's barrister, told the panel of five law lords. "We therefore have the bizarre position that a policy designed to protect sanctity of life will have the effect … of shortening the life of a terminally ill person such as Debbie Purdy".
But that is nonesense. Nobody is forcing Purdy to fly to Switzerland to kill herself. That she might wish to do it someday does not make it a "necessity." Indeed, accede to this sophistic argument and the whole potential for suicide prevention flies out the window. After all, anyone who wants to commit suicide can claim that if they know they can attend a euthanasia or suicide clinic, they might hang in longer. The House of Lords should reject this emotional blackmail.
Comments Will Soon Be Back
Some of you might have noticed that the comments have disappeared again. This is a temporary condition, I am assured. I have also been told that the comments from the old site of SHS will soon also be imported. Thanks again for your patience.
Slap on Wrist for Illegal Dutch Assisted Suicide
The Dutch don't enforce their "protective" euthanasia guidelines in any meaningful way if the doctor does the killing. But if a non physician assists a suicide, there will be a (minor) consequence. Several years ago, for example, a nurse assisted a suicide and received a two month sentence. Now, a layperson has received a similar sentence for the same crime. From the story:
A Dutch court sentenced the chairman of an assisted suicide lobby group Friday to 10 months in jail, eight suspended, for helping a sick, 80-year-old woman kill herself.
The woman died in November 2007 after taking a lethal dose of phenobarbital, which prosecutors said was supplied to her children by the lobbyist after doctors refused to help her. Her children helped administer the drug, but were not charged.
The lobbyist, who is not named in court documents, was found guilty of having contravened Dutch euthanasia rules, which determine that only a doctor may perform such acts.
This story illustrates the power of the culture of death. Family members encourage killing as an answering to (sometime their own) suffering. Even if a doctor thinks the case does not warrant euthanasia, activists are more than happy to get involved.
Still, there might be a minor deterrent affect here. But if that is the point, why keep the criminal's name a secret?
On Exterminating the Bugs
If all goes as planned--which of course is never a sure thing--this week should see a material improvement in the bugs in the system. I am particularly eager for commenting to be fixed so that the permalink doesn't have to be opened.
Re comments: I have to approve all comments now, which I didn't do before. My policy is to allow people to say what they want--including caustic criticisms of me--but to never use cussing or ad homonym. I have always been impressed with the SHS commenters' maturity and decorum--certainly not true of many blogs-- and so I am sure hitting the "approve" link will be all but pro forma.
This switch seems to be accomplishing what I hoped. The older SHSers remain and we are gaining new pals.
Thanks all for your patience. Over and out.
Dutch Euthanasia: Going Up
Dutch euthanasia cases have risen 10% in the last year. From the story:
A total of 2,331 people made official requests for help with killing themselves under euthanasia legislation last year, a 10% increase on 2007, Nos tv reports on Friday.
The figure comes from the annual report published by the five regional euthanasia monitoring committees. In total, 10 cases of assisted suicide were found not to have followed official guidelines and have been referred to the public prosecution department and health inspectorate for their comments, chairman Jan Suyver told Radio 1.
Well, that investigation and six bits will buy you a cup of coffee. Nothing ever meaningful is done to doctors who violate guidelines, including when they kill patients who never asked to be euthanized, known in the parlance as "termination without request or consent." Remember too that several studies show that about 40% of cases aren't reported and that doctors sometimes intentionally overdose with morphine rather than formally euthanize with barbiturates and a curare like drug. Remember too that some doctors are now terminally sedating patients, meaning they don't have to be present for the death or report it, and that "autoeuthanasia," is also provided by some doctors when their patients don't qualify for euthanasia. What is autoeuthanasia? A how to commit suicide book. Perhaps Derek Humphry could get a medical license in the Netherlands.
Murder is Wrong: No Excuses in Killing of George Tiller
The inexcusable murder of George Tiller, the controversial Kansas doctor who performed late term abortions, got me to thinking about one of my biggest heroes, the great abolitionist William Lloyd Garrison. Pro lifers believe that their cause is a great civil rights issue. Abolition was no less so. Garrison's genius was his eloquent and unyielding condemnation of that great evil. This is perhaps Garrison's most famous quote, a favorite of mine that I sometimes use to close my speeches. From the opening editorial of The Liberator, January 1, 1831:
I am aware, that many object to the severity of my language; but is there not cause for severity? I will be as harsh as truth, and as uncompromising as justice. On this subject, I do not wish to think, or speak, or write, with moderation. No! no! Tell a man whose house is on fire, to give a moderate alarm; tell him to moderately rescue his wife from the hand of the ravisher; tell the mother to gradually extricate her babe from the fire into which it has fallen; -- but urge me not to use moderation in a cause like the present. I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.
But, he was also unequivocal in eschewing violence in the cause of overcoming this profound injustice. Thus, the December 4, 1833 constitution of the American Anti Slavery Society declares:
This Society shall aim to elevate the character and condition of the people of color, by encouraging their intellectual, moral, and religious improvement, and by removing public prejudice, that thus they may, according to their intellectual and moral worth, share an equality with the whites, of civil and religious privileges; but this Society will never, in any way, countenance the oppressed in vindicating their rights by resorting to physical force.
Most people, whatever their views on abortion's legality, view late term abortion as an odious wrong. Murdering its most notable practitioner was no less odious in that it not only took human life, but if it was motivated by the abortion issue, it was vigilantism of the worst kind. Let no one justify this terrible crime
Proposal in House of Lords Supporting Suicide Tourism
Assisted suicide advocates are attempting to bootstrap onto legislation that would outlaw Internet suicide predation, a clause explicitly permitting suicide tourism. Here's the proposed amendment--look for "Exceptions to Offence of Assisted Suicide":
Notwithstanding sections 49 to 51, no offence shall have been committed if assistance is given to a person to commit suicide who is suffering from a confirmed, incurable and disabling illness which prevents him from carrying through his own wish to bring his life to a close, if the person has received certification from a coroner who has investigated the circumstances, and satisfied himself that it is indeed the free and settled wish of the person that he brings his life to a close.
This is really shameful--trying to legally boost people to take their ill and disabled friends or relatives to Switzerland in order to return home in the baggage compartment. And of course if this were to become law, it would be no time at all before the usual suspects started agitating for formal legalization. After all, if people are going to be sanctioned for assisting in suicide, the argument will go, why not let it be done at home?
Note that the law, if passed, would not be limited to the terminally ill. (Like I always say.) And what makes anyone think coroners are trained to determined whether someone's suicide desire is his or her "free and settled wish." Coroners aren't mental health professionals. Good grief!
Culture of death? Wesley, what
culture of death?
Not Dead Yet Asks for Discipline Needed in a True Coalition
Diane Coleman and Steve Drake from Not Dead Yet are speaking. Coleman discussed the problems people with disabilities face in the health care context.
Drake then took the microphone and told a touching story about his birth:
The doctor told my parents that the good news was 100-1 that I would not survive. The bad news was that I might survive. If I did, I would be a "vegetable."
When a doctor uses that word it is a "goal directed" term. When they do, it means they want "storage" or "disposal." Fortunately, my parents have a healthy disrespect and distrust of authority and demanded that I be treated properly.
Drake then left his prepared prepared script and asked that people in an anti-euthanasia coalition not bring up other issues that could drive potential members away--meaning while people are meeting and/or working together on that particular problem. He mentioned abortion, stem cell research, and the War in Iraq as examples. I think he is right about that. Why risk alienating people who are needed for the struggle? That is not to say that people shouldn't engage these other issues as they see fit. They should--but in the proper place and at the proper time. That is how coalitions are built and succeed.
Drake also pointed out that the assisted suicide forces have no intention of limiting "death with dignity" to the terminally ill--which longtime readers of SHS know is a constant theme of mine. He pointed to an article in the Hastings Center Report
in which the incrementalist approach that is clearly being pursued is explicitly laid out. I haven't read the article yet, but I link it here for those who may be interested, and will comment on it myself at a later time. Here's the link
Bobby Schindler Castigates Media Bias Against His Sister and People with Disabilities
Bobby Schindler, Terri Schiavo's brother, has become a righteous advocate for the vulnerable and defenseless since his sister's untimely demise. He opened today's session of the euthanasia symposium with a stirring critique of media bias and the prevalent anti-disability attitudes that are reflected in the way these stories are reported, which he believes, adversely impacts the overall culture.
As an illustration, he quoted a recent Rolling Stone
"satire" for its crude language and crass attitude toward his sister--put in the mouth of President Bush in a faux
interview--but really reflecting the writer's and publication's own state of heart. From the article:
Let's talk about some of the low points of your second term. Why did you make such a big deal out of intervening in the whole Terri Schiavo thing?
Well, Jeb calls me up one day and says, "A bunch of Jew lawyers are trying to pull the plug on some broad down here. I think we can spin it that they're doing it because she's Christian." I ask him what he means, and he tells me the story. I tell Karl, and Karl says to me, "Mr. President, I am fully erect. This is a winner all the way." He says we can jam up Bill Nelson down there for his Senate race by forcing him to take sides with the husband in the story, who's like this Mike Ditka-looking atheist guy who wants to starve his wife to death while he's running around knocking up other chicks.
Politics is all about forcing people to make simple choices, that's what my dad always told me, and this one was an A+ choice for us. Karl, you should have seen him, he was on the phone day and night, telling every news director in the country that he wanted to see that Schiavo lady's face "on every channel, like it's the State of the Union address." So sure enough, we're watching TV later that night, and CNN just has her and her drooling-ass, doped-up smile on this endless loop. Karl is literally jumping up and down with excitement at the sight of her. "She's the best thing since Old Yeller," he's saying. "I want to see every liberal in the country on Larry King campaigning to yank her feeding tube. Get Ben Affleck on there, Sean Penn. Show them side by side with her looking fat and helpless with those dead-fish eyes of hers, split-screen. She'll get us 10,000 votes an hour Too bad she died.
Too bad she died: Yeah. Karl was almost inconsolable when she passed. He kept looking for a replacement. Karen Hughes called it his "vegetable hunt." He'd call long lists of registered Democrats, asking if they had a brain-dead wife they wanted to pull the plug on.
That's not only crude, it's not funny. More to the point, Bobby noted:"People write and publish these kinds of articles with no concern for the pain it causes to the parents and relatives of people who are in these disabling conditions."
But Bobby: They're the "compassionate" ones, remember? Disgusting.
A Blast From the Past: Good News About Lauren Richardson
Longtime SHSers will recall the case of Lauren Richardson, the pregnant woman who had a catastrophic brain injury. After giving birth, the family was pressured to pull her feeding tube and Lauren's parents ended up in court over the issue with Randy Richardson, fighting to save his daughter's life. (Full disclosure: I had some significant contacts with Randy behind the scenes at his request.) Enough time elapsed and Lauren's parents reached an accord to care for their beloved daughter. All hatchets have been buried and the family is acting with one accord in mutual love and respect.
I just met Randy at the euthanasia symposium. He told me some behind the scenes details and how some people from outside the family maintained the drive to end Lauren's life even after
her parents reached agreement. Unbelievable.
Someday, that tale will be told. But in the meantime, the good news is that Lauren will be going home with her mother very soon. She is no longer unconscious, but remains minimally responsive. She still has a feeding tube but after some speech therapy, can swallow and take a little bit of sustenance orally. (This is the same kind of therapy the Schindlers wanted for Terri, but were refused by Judge Greer.) Once Lauren is home, more therapy is planned. Meanwhile, her daughter, now age-two, is thriving.
Good news in a world in which these cases too often go in the other direction.