Were the Wisconsin Doctors Engaging In Civil Disobedience?

DrRich | February 24th, 2011 - 10:57 am


A minor firestorm has erupted regarding those doctors in Wisconsin this week who were handing out fake “sick excuses” to demonstrating teachers, Fox news producers, Andrew Breitbart, and, apparently, anyone else who had some use for one.

Indeed, there has been more outrage about this episode than DrRich would have thought. Conservative commentators, of course, were predictably apoplectic about the sight of these callow youths, preening in their white coats, abusing and debasing the sacred trust which has been granted to them by virtue of their profession. There’s nothing surprising about that. But even most of the more mainstream commentators expressed at least a slight bit of discomfort about the actions these doctors were taking, even if they were doing it for a very good and noble cause.

Only a very few seemed to endorse their actions completely, explaining that these doctors are engaging in classic civil disobedience, and that, by standing on street corners in their white coats repeatedly committing felonies with the cameras whirring, their behavior is every bit as deserving of our approbation as the actions we admire so much of Thoreau or Gandhi. DrRich is open to this explanation.

Civil disobedience, of course, is to a) openly and non-violently disobey a certain law that you consider unjust, b) to admit to the operative authority, upon apprehension, that you intentionally broke the law specifically because you consider it unjust, and finally c) to passively accept whatever punishment the authority hands out to you. These doctors have executed step “a” flawlessly, and DrRich waits with interest to see whether they will successfully complete steps “b” and “c.”

Unfortunately, it seems far more likely to DrRich that these young doctors were not engaging in classic civil disobedience. Rather, they were simply exercising their conviction that there are causes far more important than any old-fashioned and outdated notions of professional integrity, and furthermore, that honoring those higher causes is indeed an inherent part of the more modern, up to date formulation of the medical profession’s ethical obligations. DrRich, obviously refers to the fact that since 2002, the medical profession has formally adopted an obligation to work for the cause of social justice, and has given that obligation equal weight (in writing) and more weight (in practice) than its obligation to individual patients, or to certain other classic obligations of the profession, such as always being truthful in the discharge of one’s professional duties.

And that’s just what these doctors were doing. They were weighing the venial sin of writing fake sick excuses (surely a minor infraction by any objective measure), against the much higher cause of social justice.* In this light, the “right thing to do” simply seemed obvious to them. And so they went out, in full medical regalia, to do it. They did not expect criticism, but rather, they expected praise.  And they certainly did not expect to be threatened with punishment.
*DrRich asks his readers to ignore the question of whether the positive feedback loop that has developed between public service unions and public officials, wherein those unions are largely responsible for electing the officials with whom they then engage in “collective bargaining,” actually constitutes social justice, or a subtle form of tyranny. That it is social justice is a fact which Americans are expected to accept at face value, and for the purpose of this commentary (and only for that purpose) let us accept it.

So there was no civil disobedience here, at least, not the classic civil disobedience of Thoreau or Gandhi. These young doctors had no thought of risking their personal freedom, or anything else they hold dear, for a higher cause.  They went forth to show their solidarity with The Cause, with every assurance that their actions were entirely consistent with the New Ethics of their profession. That for many Progressives they have become heroes confirms this conviction.

But the moment it occurred to them that not everybody agreed with what they were doing, or understood why they were doing it, or expressed that perhaps there should be repercussions, they had second thoughts. And they did not remain at their stations, bravely flaunting the law, Gandhi-like, until the authorities showed up to drag them away, but rather, once they understood that they might get into trouble, they hightailed it the hell out of there.

So at this point, sadly, DrRich remains doubtful about the civil disobedience angle.

Grand Rounds 7:22 – Read This Quickly

DrRich | February 22nd, 2011 - 6:02 am

Especially since the events of last week, it would be absurd for DrRich to think that everybody is out to get him. Still, it seems plain that, of late, not all individuals enjoy his efforts here at the Covert Rationing Blog.

Two years ago, for instance, DrRich was “invited” to testify as a witness before a federal grand jury in a matter involving one of his consulting clients. While under oath, DrRich was caused to understand that the Feds (at least certain members of the DOJ) are well aware of this blog, and of the general tenor of its content. The impression left by this experience makes DrRich doubt whether many of his fans come from that particular precinct.

Further, the CRB has been the victim of two targeted denial-of-service attacks just in the last several months. Perhaps this is a common experience for healthcare bloggers, but then again, perhaps not. Finally, there’s the fact that last May (some readers may recall) a nasty hacking exploit completely trashed the CRB at the server level, resulting in the loss of the first three years of DrRich’s endeavors here (which, some have said, is the greatest tragedy to befall posterity since the burning of the Library at Alexandria).

And so, Dear Reader, while DrRich is certainly happy to be hosting Grand Rounds for the fourth time, and is particularly delighted with the quality of postings which he has the honor of featuring this week, it occurs to him that hosting an event with such high (and well-deserved) visibility might draw certain “extra attention” here.  So perhaps you had better read this quickly.


We begin with HealthAGEnda, the John A. Hartford Foundation blog, which is posting a remarkable series of articles by Amy Berman, a senior program officer at that foundation, who has recently been diagnosed with an incurable form of breast cancer. Ms. Berman discusses very openly and frankly both the good and the bad aspects of the American healthcare system she is encountering  as she deals with this likely fatal illness. In this post, the second in a series, Ms. Berman talks about her ordeal in confirming what she already strongly suspected was a very bad diagnosis, and describes the comfort she experienced, while “meeting the enemy,” from compassionate but frank healthcare professionals. She had a much less favorable experience, which she describes in her first post, demonstrating just how devastating it can be for a patient to encounter a one-size-fits all physician. The impact such an encounter has on a patient who needs real medical help is especially relevant in an era in which doctors are being urged (coerced) into following just such an approach. Ms. Berman is an extremely brave and gracious woman, and the important insights she is providing in her efforts to chronicle her illness ought to be read by every health professional.

Henry Stern of Insureblog discusses the documented, systematic mistreatment of the elderly under the British National Health Service. Stern points out that while similar mistreatment of the elderly also happens in the American healthcare system, here it is sometimes not systematic, but rather is most often due to sloppiness or inadvertent error, and further, when it happens remedial actions (such as lawsuits) are often available. In contrast (evidence suggests), treating the elderly badly in the NHS seems to have become virtual policy. DrRich, of course, longtime president and sole member of Future Old Farts of America (FOFA), is confident that nothing of the sort will ever happen here in the U.S. where the government always has our best interests in mind, and he is sure that when government officials refer to the NHS as an ideal to which we should all aspire, they are probably not talking about this part of it.

Writing on a related topic, Julie Rosen of Bedside Manner tells about steps doctors and families can take to resolve disagreements on how aggressive one ought to be when deciding on the use of certain treatments for elderly and mentally incapacitated patients. DrRich finds Ms. Rosen’s recommendations appropriate, since all of them take place at the local level, with full participation of the patient’s loved ones, and do not (explicitly, at least) involve the heavy hand of any Central Authority.

And still speaking of the role of authority in deciding on aggressive treatments, The ACP Internist posts a news report about a court-ordered spinal operation on a 16-year old who was injured during a wrestling competition. Neither the young man nor his parents wanted the operation, which they feared might cause paralysis.  (Apparently, they were actually paying attention during the “informed consent” process.) Further, as the mother apparently demonstrated in a video shown on local TV, her son had a “full range of motion” prior to surgery. Nonetheless, the young man was removed to protective custody, and the court-ordered surgery was performed (apparently successfully, thank goodness, or else this might have turned into a controversial decision). One hopes the judge, in making his determination that the family was not acting reasonably, was not swayed by their expressed partiality to herbal medicine and homeopathy. Wacko as such practices may be, they do not appear particularly relevant in this case, given the family’s seemingly cogent argument that the risk/benefit calculation, as it had been presented to them by medical professionals, simply did not meet their threshold for such aggressive treatment. Apparently, it met the state’s.

The ACP Hospitalist offers a post from a doctor at Grady Hospital entitled: “10 ways to know that the nurses hate you.” These 10 clues as to nurses’ disapprobation are both amusing and true. However, after observing for over 30 years the kinds of behaviors to which nurses are forced to resort when they see that things are greatly amiss, but at the same time they are powerless to directly intervene, DrRich thinks this post more accurately ought to be entitled, “10 ways to know that the nurses think you are killing your patients.” The nurses may or may not actually hate the doctor for it, but they wish he/she would stop – and here are 10 ways in which they may often express that wish.

While some states are big troublemakers (and you know who you are), others are moving to implement provisions of Obamacare just as the Central Authority has decreed. Louise from Colorado Health Insurance Insider tells us that Colorado Senate Bill 168 was introduced last week to create the nonprofit healthcare cooperative which is required by all states under Obamacare. (Shouldn’t somebody tell the Colorado state senators that writing long tracts like this in ALL CAPS is considered impolite, as it is the documentary equivalent of shouting?) Louise notes that the healthcare cooperatives mandated by Obamacare may help to reduce the number of uninsured, but adds that Obamacare “will do little to address a range of other problems, including rising healthcare costs, the unaffordability of healthcare even for people who have health insurance, over-utilization of care, and the problems created when we link health insurance to employment.” While these are all legitimate points, regular readers will know how little DrRich himself goes in for such grousing.

Obamacare, after all, does so much! As a case in point, David Harlow at HealthBlawg writes about Accountable Care Organizations, a new entity which figures prominently under Obamacare, and which will be a chief vehicle for controlling the cost and quality of healthcare (i.e., for controlling physicians’ behavior). A lot of scary things have been written about ACOs (including, truth to tell, things written here at the CRB), but Harlow points out that ACOs might not turn out to be such a bad idea after all. For evidence, he points to some of the successes realized by AQCs (Alternative Quality Contracts) in Massachusetts, under admittedly favorable practice environments, and notes that some of these successes might be translated directly to ACOs. DrRich hopes he is right. But it is a little worrisome that nobody, including Harlow (as he himself allows), really knows what ACOs will end up looking like. Their structure is, as we speak, being fought over by numerous federal agencies (like a carcass being fought over by a pack of dogs), and among these agencies (DrRich shudders to contemplate) is the Department of Justice. But Mr. Harlow knows far more about this stuff than DrRich, so let’s all hope for the best. Short of defanging Obamacare, that’s about all one can do.

Amy Tenderich of Diabetes Mine submits a guest post from Valentine’s Day, written by Wendy Strgar, entitled “Healthy Sex, Healthy Love.” Ms. Strgar, who is known in some circles (circles of which DrRich himself is innocent) as a “loveologist,” and who markets the sexual-aid products to prove it, actually makes a pretty convincing argument that sexual activity can be an important part of reducing one’s risk for all sorts of medical problems. So: Are you one of those folks who has thought about having more sex, but you’re just not sure the pay-off is worth all the trouble? Read this post.

Dr. Pullen at DrPullen.com posts about the problem of anti-personnel mines, which continue killing and maiming innocent people all over the world, and for decades after hostilities cease. He rightly thinks the US ought to do more to resolve this problem, and in particular, he decries apparently serious suggestions some have made that we ought to deploy mines on our southern border to prevent illegal crossings. DrRich agrees with Dr. Pullen, but does not believe that mining the U.S. border will ever become a serious consideration (unless it is to prevent American citizens from sneaking southward to receive black market healthcare).

Doug Perednia at The Road to Hellth is writing a fascinating series on the wonders of Pay for Performance. In this, his second offering, Perednia provides some pretty overwhelming evidence, including evidence from studies which proponents use to justify P4P, that P4P demonstrably does nothing useful. Actually, DrRich should qualify that statement: It does nothing useful in terms of improving clinical outcomes. What it does do (as Perednia demonstrates) is to forcibly distract physicians from listening to their patients, to fully consume all the time allotted for a patient visit, and to actively discourage other forms of doctor-patient interactions which might lead to additional healthcare expenditures. So despite a now-well-documented lack of any improvement in patient outcomes, P4P is in fact achieving its actual designed ends, and thus must be counted a great success.

Dr. Joe Smith, who writes the Dr. Unplugged blog (a Medscape blog which requires free registration), travels the globe seeking out emerging technologies related to wireless healthcare. In his latest article Smith laments the fact that, so far, the healthcare consumer has completely missed out on the ongoing wireless revolution, a revolution that has greatly empowered consumers in virtually every other economic sphere. He concludes that despite this slow penetration, wireless technology inevitably will also transform the lives of healthcare consumers. DrRich agrees that this outcome is indeed inevitable, but thinks it may take a while. Resistance to the empowerment of individual healthcare consumers is deeply entrenched, massively well-funded, extraordinarily powerful, amazingly ruthless, and very widely distributed (from the beltway to the bedside). Such resistance is akin to the all-pervasive power of the Church 500 years ago, a power that was eventually broken, but that required the technology (printing press), the killer app (Bibles printed in the vernacular), the catalyst (Martin Luther’s 95 theses), the poorly-expressed but ultimately deep-seated desire of the populace for the knowledge being offered, and the fortitude to persevere through 300 years of reformational bloodshed. So, yes, history ultimately will win out with regard to wireless healthcare, but one fears it may take more than just the healthcare equivalent of the iPod or Facebook to see it happen.

The anonymous author of The Notwithstanding Blog is a Canadian medical student with a background in economics. In the short time this blog has been around, he (or she) has done some very cogent writing applying economic insights to medicine. The featured post describes why medical ethicists (despite their constant yammering about honoring the autonomy of the individual) almost always decide specific ethical questions the other way, that is, against individual autonomy. DrRich, in his ham-fisted style of analysis, always tends to blame this phenomenon on the fact that Progressives in recent decades have largely taken over the Ethicists’ house, just as they have taken over in most academic fields, and that Progressives as part of their DNA must always come down on the side of the collective. But Dr. Notwithstanding offers what is likely a better explanation, based on economics (the science of human behavior) instead of on political ideology. As you’ll see, in addition to being an original thinker Dr. N is an engaging writer. You should give this blog a try.

In stark contrast to Notwithstanding’s anonymous blog is Carolyn Roy-Bornstein‘s eponymous one. Here she describes one of the absurdities doctors see every day with the modern-day electronic medical records which are being adopted all over the place, with great fanfare (and with public subsidies), to streamline healthcare, reduce redundancy, eliminate waste, and assure quality care. Namely, while these new electronic records may greatly simplify the lives of the federal regulators and the forensic accountants who keep track of which doctors are being naughty and which are being nice, they often gum up the works for the people on the ground who are actually trying to take care of sick people. EMRs can do this in many ways, and Dr. R-B nicely describes one of them: She laments the reams of redundant, boilerplate, tree-killing verbiage these records spit out, each and every day, for each and every patient, a characteristic which makes the formerly simple task of figuring out how the patient’s doing today a constant challenge, a perpetual exercise in patience and persistence. and a powerful attractor for medical errors. She ends by speculating whether it might make things easier to have somebody sing these records to her. A nice thought, but DrRich thinks it would not help. What you’d get is an early Phillip Glass composition, in which the same nonsense phrases are repeated over, and over, and over, and over. . .

The Happy Hospitalist discovers that latex examination gloves (powdered, one-size-fits-all, Spic and Span brand), are available at 10 for one dollar at the local dollar store. His discovery suggests a couple of things. As Happy points out, hospitals which are expected to survive on Medicaid payments now have someplace to shop. And, if you want to bring down the cost of healthcare products and services, simply make them available for direct purchase by consumers.

Carolyn Thomas of Heart Sisters writes of journalist Melissa Mia Hall who died in her Texas home in January after avoiding medical help for her severe and persistent chest pain (regarding which she wrote a running commentary to friends – and ultimately to posterity – via e-mail). Ms. Thomas concludes that had Ms. Hall had health insurance (which she did not), she likely would have done more than just document the progression of her fatal heart attack. DrRich has no personal knowledge of Ms. Hall, and so cannot contradict this conclusion, nor does he wish to. However, a recent survey by the American Heart Association showed that in 2009, only 50% of women (regardless of insurance status) said they would call 911 if they thought they might be having a heart attack. DrRich, who has long lamented the feminization of men in our society, now utters his dismay at the converse – the masculinization of women. Ladies, if you have symptoms suggestive of a heart attack, don’t try to tough it out. Call 911.

Steven Wilkins of The Mind Gap tells how sessions of culturally-sensitive “storytelling” can break down certain cognitive barriers for some patients, and more fully engage them in their medical treatment. Wisely, Wilkins is not suggesting that beleaguered PCPs develop a stable of appropriate yarns they can spin for their recalcitrant patients during the 7.5 minutes the Central Authority has allotted for each “patient encounter.” Rather, he has several helpful suggestions for incorporating such storytelling into existing systems, which would leave the doctors alone to do what they’re paid for – making little electronic chits on Pay for Performance checklists.

Vineet Arora at FutureDocs talks about the universally-recognized phenomenon of the over-ordering of radiological diagnostic tests, which is detrimental both to patients’ health and to the healthcare budget. She discusses the many reasons too many of these tests are ordered. It boils down to the fact that the healthcare system provides physicians with extraordinarily strong incentives, at many levels, NOT to rely on their clinical judgment, but instead, in order to optimize their odds of professional survival, to just go ahead and get the test. Unfortunately the solutions Dr. Arora suggests to this difficult problem do not hinge on restoring the doctor’s clinical judgment as a legitimate decision-making tool. (This is no fault of hers; to restore respect for the doctor’s clinical judgment would require a wholesale change in how the healthcare system now operates.)  Instead, she suggests counterbalancing the strong coercions doctors feel to order too many of these tests, with new, and equally strong, coercions not to. Laboratory rats faced with similar, unresolvable imperatives to respond to two opposite stimuli, of course, quickly die of the stress.

Dinah from Shrink Rap notes that the FDA is about to take an action that may effectively render electroconvulsive therapy (ECT) a thing of the past. Specifically, the FDA is likely to reclassify ECT machines (which have been in clinical use since long before the FDA controlled such things) as Class II medical devices. If so, then for these devices to remain on the market, the two companies that manufacture them would have to conduct expensive new clinical trials to document safety and efficacy within 30 months. Observers judge that these companies would not have the resources to do so. ECT is a highly controversial procedure, and there are vocal groups which are trying to ban it – but for some patients with severe depression, Dinah points out, ECT has been a very effective and potentially life-saving last resort therapy. These unfortunate patients, apparently, can now join all the others whose response to various treatments resides in the tail of the standard distribution curve, and for whom the tailored, individualized therapy they require will no longer be an option.  So they will just have to make do with the guideline-driven treatments that suit the average patient just fine. Nonetheless DrRich predicts this change can be implemented with minimal outcry, since severe depressives, being often imbued with great inanition, likely won’t complain very vociferously about it.

Speaking of shrinks, Philip Hickey of the Behaviorism and Mental Health Blog writes about his observations regarding how and why “mental illness” has become such a growth industry. He says, “’Mental illness’ is a spurious explanatory concept whose purpose is to medicalize for profit the ordinary problems of human existence which our ancestors tackled and resolved without drugs for thousands of years.” While DrRich might not buy his entire thesis, there is much more truth in what Hickey says than one would like to think.  Among other things, when healthcare becomes a right, then the more struggles of the normal human experience we decide to turn into a medical diagnosis, the more it becomes society’s obligation to alleviate those normal struggles. There is a natural endpoint to this process of over-medicalization, of course, but it is not pleasant to contemplate.

Dr. Wes speculates on what is really different about the new pacemaker leads which recently have been declared officially MRI-safe by the FDA. Wes suggests that much of the extraordinarily expensive and time-consuming effort that was made in obtaining the “MRI-safe” label had more to do with the incredible regulatory maze that had to be navigated, than with any actual engineering changes. DrRich, who a few years ago was peripherally involved as a consultant in a similar effort (with a different company), declares Dr.Wes’ speculation to be likely pretty accurate. But fear not, for Medicare will be reimbursing the manufacturer for its regulatory ordeal for many years to come.

The venerable DB of DB’s Medical Rants offers a timely rant about how those who create the clinical guidelines which dictate the practice of modern medicine often do so inadvisedly, and sometimes with their own (possibly cryptic) agenda in mind, and as a result of such guidelines, patients may die. DrRich himself has covered this same topic lately. DB’s commentary hits the mark.

Paul S. Auerbach of the Medicine for the Outdoors Blog provides this post on cholera vaccines. It turns out that cholera vaccination is a little less than straightforward, and given the relatively small amount of vaccine available worldwide, would not be suitable for wide-scale use. So as far as cholera prevention goes, pray for sanitation.

Rich Elmore and Paul Tuten at HealthcareTechnologyNews write the wonderful news that the Direct Project has launched. The Direct Project, they tell us, is an implementation of a secure, health-related e-mail standard designed to “allow health practitioners to securely exchange health data, medical records digitized to be easily shared between doctor’s offices, hospitals, benefit providers, government agencies and other health organizations, all across America.” This sounds like a pretty good idea, except perhaps for the “government agencies” part, since, for many of us, these are the very folks we’d least want looking at our most private personal information. As for the patients themselves, it is not clear whether they also will have ready access to all this extremely secure information about their own health, or whether instead they will have to wait until the information finally shows up on Wikileaks.

February 24 – DrRich has been petitioned by the authors to issue a correction for this last item. In order to do complete justice to them, DrRich reproduces their suggested correction in its entirety:

“The Direct Project encrypts the information being transmitted.  No one other than the intended received can get the information.  There is nothing stored using the Direct Project technologies – it serves only as a transport mechanism to enable, for example, a provider to securely send information to a consulting physician.  The goal is to replace the pervasive fax machine with something more secure, more modern and able to be used by healthcare stakeholders with the most basic technology (internet access and a PC) up to the most sophisticated user of an electronic health record.”

DrRich thanks the authors for correcting any misapprehensions he may have inadvertently introduced.  To be clear, when the Feds get your personal health information, and when you have difficulty obtaining it yourself, that will not be the fault of Direct Project, whose purpose is merely to assure that the data gets sent only to the person/agency which is targeted to receive it, and no one else.  DrRich leaves it as an exercise for his readers to determine whether his original commentary may still offer any value.


Thanks for speed-reading Medical Grand Rounds this week.

Next week Grand Rounds will be hosted by The Examining Room of Dr. Charles.


The CRB Wins Medical Weblog Award – Thanks For Your Support

DrRich | February 17th, 2011 - 7:10 am

It was announced yesterday that the Covert Rationing Blog has won the 2010 Medical Weblog Award in the category of Health Policy and Ethics.

I am deeply gratified and humbled to have won this award, particularly given the high quality of the other nominees this year. Thanks to MedGadget for hosting the awards this year (and every year) in their unfailingly professional manner – and for deciding not to banish me from the competition, given my unusually boorish behavior in this same competition last year.*

And thanks most especially to those of you who read this blog, and still saw fit to go out of your way to cast your vote for the CRB. It is only thanks to all of you that I have not become the Susan Lucci of the medical blogosphere.

*I took advantage of my finalist status last year to publicly challenge another finalist (whose official policy on medical ethics I found to be troublesome) to an on-line “Medical Ethics Smack Down,” and did so in a manner which they could not graciously ignore. The resulting spectacle might have soured the opinion of a less forgiving Medical Weblog Award host – and so hats off to MedGadget for its liberal outlook on the behavior of its nominees.

Overhauling America’s Healthcare Machine – A Review

DrRich | February 15th, 2011 - 6:08 am

Some might wonder why America needs a new book on fixing our healthcare system, now that the the Patient Protection and Affordable Care Act (i.e., Obamacare) has already done that for us. Well, there are several reasons, so take your pick:

1) Obamacare might be repealed.
2) Obamacare might be found unconstitutional.
3) If Obamacare is permitted to proceed into its full glory, it shouldn’t be long before it leads to social upheaval either by: a) exploding the federal deficit far beyond even what we’re seeing today; or b) alarming a critical mass of Americans regarding the new, oppressive powers which the new law grants to the federal government.

If 1 or 2, the process by which our nation will re-address healthcare reform may look much like the contentious, but deliberative, processes we have used in the past to reform certain aspects of our society. If 3, the process may look a lot more like Egypt.

In any case I think there is a reasonable chance that, in the next few years, we may be looking for a completely new way to reform our healthcare system, one that resembles neither Obamcare, nor the alternate and rather tepid “solutions” that have been proposed by the Republican leadership.

When that day comes, you will be very glad you took the time to read Douglas Perednia’s new book, Overhauling America’s Healthcare Machine – Stop the Bleeding and Save Trillions.

Perednia, something of a polymath, is an internal medicine specialist as well as a dermatologist, an NIH researcher, a writer, and an expert in telemedicine and medical informatics (he is a professor of this latter discipline). While he has founded and directed non-profit organizations, he is also an entrepreneur (which explains how he has become “New Zealand’s sole domestic source of boiler cleaner and glue for beer bottle labels”). He admits also to being a tap dancer (not that there’s anything wrong with that). And, as anyone will know who reads his excellent blog, Road To Hellth, he also knows a lot about the healthcare system.

Perednia’s book is a true tour de force – but don’t let that frighten you away. The author’s writing style is clear and conversational, easy to follow and entertaining to read.

In this style, he tells you everything.

Perednia does not pretend that American healthcare isn’t in dire need of the very kind of fundamental change that President Obama says he wants, nor does he pretend that a little insurance reform will do the trick. The healthcare system, he suggests, is on its last legs. It is a machine that is wearing out and bogging down, and it needs to be completely overhauled.

The healthcare machine is far more complex than it ought or needs to be. It is burdened by all manner of extraneous flywheels, gears, and gewgaws that were glommed on during its long history to please one long-forgotten constituency or another, that do nothing useful, but that consume a lot of fuel and deposit a lot of grime. The healthcare machine’s great creaking clockwork grinds away against all this unnecessary friction and accumulated grunge, and for all its strenuous efforts produces an ever-smaller amount of useful work. What this machine needs is more than some bright new attachments and smarter operators to oversee its churnings. It needs to be torn down and rebuilt.

Perednia does not pull his punches. He starts by showing that the American healthcare system, when its output is analyzed objectively and soberly, does not produce nearly as much good as its present apologists suggest. It certainly does not produce very much good in relation to all the money we spend on it. He then moves on to analyze the roles all the big players have within the healthcare system in producing all this waste. He amply demonstrates how the doctors, the hospitals, the insurers, the government (and, yes, the patients), behaving in a manner that is entirely consistent with the incentives the system has provided for them, with no especial evil in their hearts, and with no more than the natural, baseline amount of greed and self-interest that accompanies any human enterprise, operate in a grotesque ballet of waste and excess. He shows how the healthcare machine has reached the point where it simply cannot go much further, and that, like it or not, we’re going to have to do something about it. (Along the way, Perednia clearly demonstrates how Obamacare, far from representing any kind of fundamental departure, simply exaggerates the pathology.)

The strongest part of this book, however, deals with how to fix all this. Perednia begins by establishing what almost anyone would agree ought to be the goals of the American healthcare system – it must deliver effective and efficient healthcare services in a manner whose fairness to all Americans is commensurate with the contributions all American make to it, and it must be financially sustainable – at least to the point that its cost does not drive us to societal collapse. He then outlines a scheme that can achieve these goals.

I would be less than forthcoming if I did not mention that the broad outline of Perednia’s solution, as he graciously acknowledges, derives from my own book. That outline looks like this:

He proposes a 3-tiered healthcare system. The bottom tier, Tier 1, consists of self-pay healthcare. All individuals would be expected to pay a certain amount each year toward their own healthcare, say $2000 per individual, or $4000 per family. The funds for Tier 1 could reside in a Health Savings Account, which the individual would own. People with low incomes would have HSAs funded by the government. But everyone has the opportunity to own an HSA, and everyone controls the first $2000 of spending on their own healthcare (and keeps what money is not spent).

Once the individual exhausts their annual $2000 limit, their healthcare would default to a publicly-funded Universal Health Insurance Plan (Tier 2). The universal health plan – which would cover every American, even members of Congress – would operate under a system of open healthcare rationing, for the purpose of keeping public spending on healthcare on a reasonable budget. Perednia spells out the details on how such open rationing could be accomplished. Obviously, establishing any system for openly rationing healthcare would be a very difficult and exceedingly painful process. It seems very likely that only after experiencing great gouts of pain from our current healthcare system could we Americans be enticed to tackle such a thing. But Perednia (and I) postulate that such a circumstance may become manifest in the very foreseeable future.

Tier 3 is a completely voluntary, self-funded insurance product. Here, the health insurance industry would offer various levels of additional health insurance to people who want it, which will pay for services not covered under the open rationing in Tier 2. Health insurance in Tier 3 would begin to look like an actual insurance product (i.e., one that protects individuals against unforeseen, potentially catastrophic expenses), instead of the soup-to-nuts coverage of everyone’s heart’s desire that now passes for health “insurance.”

Again, this is just an outline. While my book did not take it much farther than this, Perednia takes his solution to the healthcare problem several steps beyond, and provides a very comprehensive plan. He discusses specifics of insurance reform, physician reimbursement, paying for goods and services, physician credentialing, government regulation, malpractice reform, addressing fraud and abuse, implementing electronic medical records that actually help efficient patient care (a particularly strong section of the book), and assuring that innovations in healthcare are encouraged. If you really want to know how to fix American healthcare, it’s all here.

Once Omamacare is repealed or declared unconstitutional, or once it goes forward in tact to accelerate the final implosion of our already-near-terminal healthcare system, smart people will find themselves looking for new ideas upon which to re-build American healthcare. Amidst all the cacophony about healthcare reform, however, there are really only very a few voices that are offering truly novel solutions. Doug Perednia has thrust himself to the front of that short list of visionaries with Overhauling America’s Healthcare Machine.

Please read this book, so that when the time comes you can tell your Congressperson (or perhaps by that point, your local Commissar) about it.


Overhauling America’s Healthcare Machine is available in all bookstores, and at Amazon.

Ethicist-Assisted Suicide

DrRich | February 10th, 2011 - 11:36 am



This is the third in a series of articles on End-of-Life Care and Covert Rationing.  The first two articles can be found here and here.
In his previous post, DrRich attempted to satirize the lame attempts of certain payers to “inform” certain of their “covered lives” that, among all the wonderful options available to them under their truly comprehensive health plans, the medical service of physician-assisted suicide would be compassionately offered and cheerfully paid for. DrRich even offered, thoughtfully as usual, some free though invaluable advice to payers on how they ought to go about marketing assisted suicide as a cost-saving strategy, and to do so in a far more sensitive and less ham-fisted way than they have managed so far.

If the mark of good satire is that at least some readers will have difficulty discerning whether the satirist is serious or not, then DrRich is feeling genuinely Jonathan Swiftian today.  For some of his readers (one of whom e-mailed, “I can’t believe what I just read. This is sick.”) have taken his modest proposal for selling assisted suicide at face value.  This is not the first time DrRich has made unfortunate impressions upon readers through his (possibly inept) use of irony. Sadly, it almost certainly will not be the last.

But assisted suicide being such an important and ethically charged topic, DrRich feels obligated to clear things up once and for all. So what follows is DrRich’s honest assessment of the advisability of physician-assisted suicide, in which he will attempt to forgo entirely any satire or irony (though he admits to having great difficulty in controlling his sarcasm).

DrRich believes that physician-assisted suicide is a very, very bad idea.  He has two major reasons for this belief.  On a purely practical realm, embracing and systematizing physician-assisted suicide under any healthcare system that is actively engaged in rationing (whether overtly or covertly) will almost surely lead to some terrible abuses of the practice. In this regard you can either use your imagination, or read the history of Europe in the first half of the 20th century.

His second objection to physician-assisted suicide is based on a consideration of ethics. DrRich admits to being on shaky ground here because: a) he is not formally trained in ethics, and b) it appears for all the world that those who are formally trained in ethics have universally concluded that physician-assisted suicide is perfectly OK in every way.

Debating with modern medical ethicists, at least if you are merely a layperson, is mostly a losing proposition.  This is not because ethicists are intellectually (or even ethically) superior, but rather because they are adept in couching their arguments in arcane twists of logic and webs of jargon that make their arguments difficult if not impossible for the uninitiated to follow.  This technique, of course, places novices like DrRich in the position of having little choice but to accept the ethical bottom line without really understanding how the bottom line was reached. It reduces medical ethicists to a priesthood, and medical ethics to received knowledge.

But DrRich maintains that advancing unintelligible ethical arguments is, well, unethical.

So DrRich will now present his understanding of the chain of logic by which modern ethicists justify physician-assisted suicide – and its close cousin, euthanasia.  (If any of you actual ethicists out there object to this analysis, and can explain where DrRich is wrong in clear language, DrRich will be all ears. Absent the clear language, though, you can pound salt.)

Modern ethicists argue as follows:

Point 1: Our society has already decided that the autonomy of the individual patient is the overriding ethical consideration in making end-of-life decisions. We formalized this determination when we decided – by overwhelming consensus – that an individual has a right to refuse medical treatment even if that treatment is very likely to save their life. Therefore, individual autonomy is the universally agreed-upon controlling ethical precept.

And in adopting this controlling precept, we have already firmly decided that passive euthanasia – allowing nature to take its course by withholding treatment at the request of the patient – is ethical.

Point 2: There is no ethical distinction between passive euthanasia and active euthanasia. That is, whether we let death occur by withholding effective medical care, or by actually doing something to help death along a bit, we’re taking an action that hastens death either way. Ethically, both of these actions are equivalent. So, once we decide that individual autonomy is the overriding concern, we must also allow for active euthanasia when a patient wishes it.

Point 3: Once active euthanasia is deemed ethical, there can be no further ethical objection to the lesser act of physician-assisted suicide.  If it is ethical for a doctor him/herself to bring on the death of a patient who requests it, there can be no objection to doctors preparing the suicide machine and handing the patient the switch.

The striking thing here (to DrRich, at least) is that in establishing the ethical case for physician-assisted suicide, we necessarily also establish – as a veritable pre-condition – the ethical case for physician-provided euthanasia. Whether the patient says, “Help me to take my own life,” or “Take my life for me,” modern medical ethics supports the physician who replies, “Roll up your sleeve.”

For those who don’t see a problem with this, DrRich refers you to the Dutch system, where, in full accordance with modern medical ethics, the rules permit both physician-assisted suicide and active euthanasia for patients who request it. Reports on the results of the Dutch system (reports which both sides have used to bolster their respective opinions on either the glories or the travesties of such a system) do point out one striking finding – hundreds of times each year, acts of *involuntary* euthanasia are occurring. That is, patients are being killed under the Dutch healthcare system at the hands of their doctors, without their explicit permission. All these patients, it is claimed, are being euthanized for entirely humane reasons.

What do our friends the medical ethicists have to say about such involuntary euthanasia? Well, it turns out that it’s OK with many if not most of them. Ethicists don’t like to tell us that their chain of logic doesn’t end with Point 3.  But once we make the principle of individual autonomy the overriding consideration in determining end-of-life ethical issues, the same chain of logic takes us directly to Point 4.

Point 4: Since honoring the ethical precept of individual autonomy makes voluntary euthanasia available for patients with intractable suffering, it would be unethical to withhold the same benefit from suffering patients who are too incapacitated to give their permission. Their incapacity should not restrict them from a good that is available to others, for to do so would be discriminatory and inhumane. To cure this problem, the boon of active euthanasia can and must be performed, even without the patient’s explicit permission, in incapacitated patients whom “reasonable people” would agree are suffering too much. Therefore, involuntary active euthanasia is also ethical.

This conclusion, of course, leaves us in a place where others (i.e., “reasonable people,” like doctors or other agents of the Central Authority) can decide for an individual what constitutes intractable suffering, and further, can decide when such an individual is simply too incompetent to know that euthanasia is the best thing for them. Some of you, of course (hello, ethicists!) think this is just a fine idea. Most apologists for the Dutch system apparently do.

But DrRich maintains that under our system of covert healthcare rationing, where doctors are under extreme pressure to do the bidding of the third party payers (private insurers and the government) who determine their professional viability, and where the payers are under extreme pressure to reduce cost, and have already displayed in numerous ways their willingness to permit suffering and death among their subscribers in order to do so, then opening the door for physician-assisted suicide (let alone physician-administered euthanasia, whether the patient requests it or not), would inevitably lead to some nasty abuses, and would ultimately serve to undermine our civil society. DrRich is too politically correct to use the “other” N-word, but he will take this opportunity to remind his readers that such a thing has already happened, in what recently had been perhaps the world’s most cultured and educated society, within the memory of millions of living people.

DrRich believes that the principle of individual autonomy is vitally important, and indeed it is the foundation of American culture. However, no single ethical principle, no matter how important, can be allowed to overrule all other ethical principles in all other circumstances.  By nature, ethical precepts are often in conflict, creating what is called an ethical dilemma. And (DrRich humbly submits) it is supposed to be the job of ethicists to help us work through those ethical dilemmas, to find the right balance between competing principles, and not simply declare that no dilemma actually exists, because Ethical Precept A is the only one we need to pay attention to.

Individual autonomy is critically important to American culture – and the fact that we must fight to preserve individual autonomy in the face of covert healthcare rationing is indeed the underlying message of this blog – but in no other aspect of our culture do we let it absolutely rule. The autonomy of individuals needs to be checked, and we indeed limit it. This is the fundamental reason that governments are necessary in the first place.

The reason we have laws (supposedly) is to make sure that the behavior of individuals acting in their own interest, especially those who have accrued power (for instance, by accumulating great wealth, by acquiring large weapons, or by becoming heads of state), does not abrogate the natural rights of other individuals. Indeed, most of the political fights we have – between Democrats and Republicans or progressives and conservatives – are to determine where to place those limits, on individuals and on the collective, to best encourage a robust society that honors individual autonomy but that also encourages reasonably equal opportunities for individual fulfillment (i.e., “happiness.”) The main purpose of our public discourse, then, is to find the right balance between the rights and needs of individuals and the rights and needs of society as a whole.

So for ethicists to say, “Individual autonomy is all there is to it, and we have no choice but to follow that principle to wherever it may lead us,” is not only completely irresponsible and dangerous, it also flies in the face of our culture’s history and our everyday experience.  The cost to society not only should but must be taken into account as we consider institutionalizing physician-assisted suicide (let alone voluntary or involuntary euthanasia).  In DrRich’s opinion, ethicists who argue that we need not consider the cost to society in making end-of-life policy have declared themselves unworthy of the title and they ought to be completely ignored.

The cost to our society of institutionalizing and systematizing physician-assisted suicide, especially while we are still covertly rationing healthcare, would be severe and potentially lethal. Within the next decade or two, if things do not change, we likely will be facing cost pressures emanating from our healthcare system that will gravely threaten the survival of our culture. With an existential threat such as this, can we really refrain from slowly transforming the request for assisted suicide from an option to a duty? Can the Central Authority really stay its hand when it has the capability of directing its agents at the bedside to perform euthanasia on unfortunate (and unproductive) citizens who are too “incapacitated” to understand it’s the only thing to do?

DrRich, who opened this post with a promise to avoid irony, apologizes. For when all is said and done, it is deeply ironic that by steadfastly clinging to the ethical precept of individual autonomy at the end of life, within in a paradigm of covert healthcare rationing, we will very likely end up by completely devaluing the inherent worth of individuals.

At least until we solve the fiscal problems within our healthcare system, we simply should not embrace assisted suicide – no matter what we may think of the ethics of the act itself – and we should fight efforts to make it acceptable. The cost to our society would be far too high.

If people want to commit suicide and if medical ethicists insist that assisted suicide is OK, then let the ethicists do the assisting. DrRich has relatively little to say against ethicist-assisted suicide. But, at least as long as covert rationing is the chief operating principle of the American healthcare system, for the love of God keep the doctors out of it.

Get Perednia’s New Book For Free On Kindle, Through Feb. 12

DrRich | February 10th, 2011 - 9:31 am

You can get a free Kindle edition of Douglas Perednia’s excellent new book, Overhauling America’s Healthcare Machine from now through February 12, at this link. This is an offer you should not pass up.

Perednia writes the very fine Road to Hellth blog, and is a well-known author, researcher, medical practitioner, and entrepreneur.  His new book is a post-Obamacare view on what we really ought to do to reform our healthcare system in a way that will actually work, and will actually reduce costs.

DrRich will be posting full a review of Overhauling America’s Healthcare Machine here next week, but he can assure you right now that it would be well worth your time to read it. (And if you’re going to read it, why not get it while it’s free?) It is comprehensive, extremely readable, and convincing.

Again, through February 12, get the free Kindle edition here.

How to Sell Assisted Suicide

DrRich | February 7th, 2011 - 9:51 am



This is the second in a series of articles on End-of-Life Care and Covert Rationing.  The first article can be found here.


In the summer of 2008, the Oregon Health Plan (the Medicaid plan in Oregon) injudiciously sent a letter to lung-cancer patient Barbara Wagner denying coverage for the expensive chemotherapy her doctor had recommended, and offering instead to cover palliative care “including doctor-assisted suicide.”

Despite the fact that there were plenty of distractions at the time (including a presidential election and the world’s economy on the brink of Armageddon), that letter unleashed a firestorm of public outrage. (If you have forgotten the outrage, simply Google the search terms “Barbara Wagner” and “suicide.”) Indeed, the outrage was sufficient to penetrate even the dulled sensibilities of the Oregon Health Plan’s executives. One Jim Sellers, a spokesman for the Oregon Health Plan, admitted to ABC News that “the letter to Wagner was a public relations blunder and something the state is ‘working on.’”

It is clear that the Oregon Health Plan executives were at least a little blindsided by the general reaction to their ham-handed denial letter. Denial letters, after all, are a routine activity, and they always list (as an aid to the patient) services which the third party payer judges to be reasonable alternatives to the denied care. While in this case the denied service which Ms. Wagner sought offered some reasonable hope for prolonged survival, and the service being held out by the Oregon Health Plan as an alternative (to say the least) did not, that’s really not so much different from the content of more “routine” denial letters. The difference is one of degree, and not of substance. So, Oregon Health Plan executives must surely have wondered, “What’s the big deal?”

One must try to be understanding of such insensitivity. It is a fundamental task of health plans – whether run by Medicare, Medicaid, or private insurance companies – to deliver unpleasant news to people whose lives are at stake, and it is normal (even necessary) for those who are charged with this task either to grow thick skin or to develop the traditional indifference of bureaucrats. It is perfectly predictable that such thick skin or indifference might dull one’s ability to discern subtle differences in degree among various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Health Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appeared to say, was the only problem in the case of Ms. Wagner. The solution, he therefore suggested, is certainly not a substantive change in any policy, but better public relations.

Those who ran the Oregon Health Plan must have been particularly disheartened to learn that even vocal proponents of physician-assisted suicide immediately began criticizing their ill-considered denial letter. To so blatantly juxtapose the reality of healthcare rationing with the “option” of assisted suicide seriously undermines the chief argument advanced publicly by the end-of-life movement, namely, that assisted suicide is merely an individual autonomy play, and is not in any way a cost-saving tool.*

*Preserving the ethical precept of individual autonomy is the basis upon which modern utilitarian ethicists always build their defense of doctors ending the lives of their patients, whether it be by physician-assisted suicide, passive euthanasia, active euthanasia, and even involuntary active euthanasia. DrRich will elaborate on this ethical defense in a future posting.

In other words, whether or not you embrace physician-assisted suicide, everyone seems to agree that offering it up as a covered medical service at the same time you are denying potentially life-prolonging therapy is both insensitive and unseemly.

And so – as a public service to those in the government and the private sector alike who are running healthcare organizations and thus who are (as a matter of course) severely challenged in trying to understand simple human emotions, to patients like Ms. Wagner who may suffer true physical harm by exposure to such institutional callousness, and to the rest of us who simply would appreciate not being confronted so blatantly by the dark abyss that underlies our healthcare system – DrRich offers the Central Authority and private insurers some friendly advice on the right way to sell physician-assisted suicide.

1) Don’t Seem So Anxious.

Sure it’s easy to get excited about physician-assisted suicide. All you need to do is look at your own data. Whether you are trying to make ends meet over at CMS, or running a private health plan, it’s likely that a huge proportion of your spending goes to patients who are in the last year of life. Enticing these end-of-lifers to choose assisted suicide (which you can accomplish in a sufficiently tasteful way for about $100) is such an attractive proposition that it’s indeed become very hard to make yourself appear reasonably circumspect about it. At the very least, if you run an organization like the Oregon Health Plan, where assisted suicide is “available” at no additional cost to patients who choose it, it’s difficult not to push the idea when the opportunity arises. Otherwise how can you be sure the patients will know all their options for end-of-life care?

But doing even that much is a mistake. If you don’t believe that, simply look at the small firestorm the Oregon Health Plan created with their straightforward and helpful “reminder” letter to Ms. Wagner. As a result of the Oregon Health Plan’s inept attempt at informing patients of their options, neighboring states that appeared ready to pass their own assisted-suicide laws immediately had second thoughts about it. It should now be clear even to health plan bureaucrats that seeming overly interested in assisted suicide, or even mentioning the option to patients (at least while simultaneously denying potentially lifesaving therapy) is a very counterproductive idea.

A much more subtle approach is required.

2) Publicly Disavow Any Interest In Assisted Suicide.

Think about Tom Sawyer whitewashing the picket fence. Ole Tom didn’t get all his friends to paint that fence for him by asking for their help, or by overtly trying to sell or cajole them on the idea. Instead, he got them to do the job by pretending he wasn’t the least bit interested in having them do it, by ignoring them altogether, and making himself seem completely absorbed in the delightful task. By the time Tom was done, his friends were begging for a turn, and even giving him wondrous gifts (such as dead cats on a string) to bribe him for a chance to participate.

What you need to do is pretend that encouraging assisted suicide – even if it’s a covered service that patients ought to be made aware of – is the farthest thing from your mind. Instead, you are completely invested in and insistent upon providing full-service end-of-life care, with all the bells and whistles and no holds barred; and – while patients of course have the option to exercise their individual autonomy as they see fit – you take great pride in squeezing every last instant of life out of those elderly, used-up, chronically ill bodies that present themselves in your ICU, no matter what the cost to the patient and family in terms of pain, suffering, humiliation and anguish. It is your mission to stave off death to the bitter end, come what may, and you’re proud of it.

3) Have Somebody Else Push It.

In the meantime, clear the path for agencies and interest groups which are dedicated to the end-of-life movement. There are plenty of them out there. Have them do the selling for you.

Make sure they have access to your patients and patients’ families, especially in the ICU setting. Allow them space for educational displays; provide them some private space where they can talk to interested patients and families; see that hospital social workers are aware of and will enable their activities. In the meantime, make it clear that you do not endorse or encourage their efforts, and indeed wish they would go away, but you are providing such groups with access in your dedicated interest of full transparency, and your commitment to patient choice. If patients choose to avail themselves of such information, you will do nothing to stop them.

4) Make the Advantages To Assisted Suicide Seem Real.

There’s no need for you to talk up the advantages of assisted suicide – let the end-of-life proselytizers do the talking for you. All you have to do is to make their arguments seem accurate. The great part is, that’s just a matter of maintaining business as usual.

The end-of-life zealots will tell patients that assisted suicide is a way of asserting some measure of control over the dying process, of holding on to some level of personal dignity at the very end. So simply make sure your end-of-life care continues robbing patients of any semblance of dignity and control.

They’ll tell patients that assisted suicide will end pain and discomfort and suffering when all hope of recovery is gone. So simply continue with inadequate pain control** and half-hearted comfort measures, and keep the ICU as hectic, loud, scary and impersonal as possible.

**Maintaining inadequate pain control will continue as a matter of course as long as the Central Authority continues sending the DOJ after the occasional pain-management doctor. Whether the target physician is actually engaging in analgesic excesses is unimportant to the goal of making any American doctor afraid of aggressively controlling their patients’ pain, for fear of becoming a target themselves.

The end-of-life proponents will tell the patients themselves that assisted suicide will finally bring comfort to their long-suffering family and friends, whose lives have been “so disrupted by your prolonged illness.” And make sure all those family and friends continue suffering long, by keeping those ICU waiting rooms hot, cramped, noisy, uncomfortable and smelly.

You get the idea. Simply make sure the arguments of the end-of-life proponents have teeth. You’re good at that.

5) Tell Patients to Consult With Their Doctors First.

That’s right. Refer patients to their doctors, their supposed personal advocates, the selfsame individuals you yourself have long since fatally compromised (by grabbing control of their individual professional viability). Assuming you have placed sufficient cost-cutting pressures on doctors, then their willingness to encourage (or at least not discourage) assisted suicide will be substantial. So when patients do consult with their doctors, the doctors will not undermine your subtle efforts, but will become your partners in convincing those approaching end-of-life to just be reasonable.

6) Make Physician-Assisted Suicide Legal, But Not Reimbursable.

You’re going for the Botox model here. You do not want physician-assisted suicide to be merely another hush-hush medical procedure, conducted quietly and almost secretly in a typical doctor’s office, so that people can pretend it doesn’t exist. Rather, you want to establish it as something that’s front and center, something people will want and ask for and go out of their way to seek. You want to encourage doctors to establish inventive business models for assisted suicide,  just as the dermatologists have done with their Botox clinics.

Accomplishing this, of course, will require assisted suicide to be made legal everywhere (and not just in Oregon and a few other progressive states), but at the same time will require you to NOT make it a reimbursable medical service. For once it’s made reimbursable it will become subject to typical Medicare price controls, which thus will keep prices high and limit innovation. And in this once instance, you will not want to limit innovation.

Just think of the possibilities: One envisions physician-assisted suicide becoming established as a “life cycle event” like a wedding or Bar Mitzvah, where the right atmosphere, the right spirituality, and the right tone come together to create an unforgettable, uplifting experience for everyone. Some assisted suicides will take place in a doctor’s office, of course, but why not in a place of worship, a favorite city, a resort, a mountain top, a rocky coast – a casino? Why not allow the prospective decedent to actually hear the eulogies and experience the tearful tributes before actually engaging (ritually) in the Act? Why not partner with the new deathcare industry you will be unleashing (talk about job creation!) to wrap this final “healthcare service” into a comprehensive package along with funeral services, grave sites and headstones, elaborate obituaries, and full coverage on Facebook, Twitter, and UTube?  Why not engage American media to celebrate the event with a new mode of reality programming (one that is sure to garner a massive share of viewers)? Why not, at last, GUARANTEE every American their 15 minutes of fame (even if it’s their last 15 minutes)? Why not convert what is today an antiseptic, impersonal and frightening process into one that makes everybody say, “Yes! That’s the only way to go!”

The beauty is that this sort of model will convert what is today, at best, merely the option for assisted suicide into something that’s expected – a true destination event, a natural part of life. Indeed, not opting for assisted suicide, at a certain point in one’s life, will come to be seen as unusual, unreasonable, greedy and selfish. And when granny begins to spend more time in a doctor’s office or (worse) in a hospital, where frequent visitation is expected and other family inconveniences are generated, some loving grandchild will pat her precious wrinkled hand, and say, “Granny, you know, it’s getting to be about that time. Wouldn’t a last weekend in Vegas be just the thing?”

So, if you play your cards right – passively encouraging the end-of-life movement in its effort to spread the word, while making the alternative (i.e., not committing suicide) as nasty and foul an option as possible, and also while coercing doctors and encouraging families to view assisted suicide as the most advantageous modus exodus one could ever imagine – well, the “right” to assisted suicide will shortly become the expectation and even the duty for assisted suicide.

If you who run government or private health plans will just follow DrRich’s simple program, you will have accomplished all this without seeming crass and self-serving, as you most certainly do each time you send somebody a letter like the one you sent the unfortunate Ms. Wagner.

Can Advance Directives Be Salvaged?

DrRich | February 3rd, 2011 - 7:29 am



This is the first in a series of articles on End-of-Life Care and Covert Rationing.  The second article can be found here.


It is easy to have missed it, because it went by so quickly.

On January 1, the White House announced a new policy that would have paid doctors for discussing end-of-life planning during their Medicare patients’ annual “wellness visit.” Under this policy, physicians would be paid to encourage their patients to establish an advance directive, which would guide medical care if the patient became incapacitated from illness, and could no longer make medical decisions for him/herself.

But on January 5, the new policy was suddenly revoked. It was revoked, CMS lamely explained, because it had not been implemented using the correct process. But, as anyone would know who watched Congress make Obamacare the law of the land, this could not possibly have been the real reason.

The real reason, of course, has to do with the firestorm this new policy threatened to unleash, just as the House of Representatives was about to be taken over by the cretinous opposition party.

As regular readers will recall, the Obamacare bill originally included similar language on advance directives. Physicians were supposed to urge their patients, repeatedly if necessary, to establish advance directives, and their success in extracting advance directives from their patients was to be one of the “performance measures” by which doctors would be judged to be in good or bad standing with the Central Authority.

But then Sarah Palin said “death panels,” and a furor ensued. The provision on advance directives was quickly removed from the Obamacare legislation, as if Congress was admitting that Ms. Palin had been correct and they had been caught out.* Similarly, the effort last month to reinstate the provision failed to stick for fear of criticism at a bad time.

*The original advance directive provision in Obamacare, of course, had nothing whatsoever to do with “death panels,” since there are no panels of any sort involved in establishing advance directives. Rather, the entities that some might call death panels, and which DrRich has chosen to call GOD panels (Government Operatives Deliberating) – that is, panels of distinguished experts that will determine, by means of “guidelines,” which patients will get what, when and how – remain fully operative within Obamacare.

DrRich has nothing against advance directives, and indeed, thinks they are a good idea – in concept, at least. Advance directives allow patients to establish beforehand, usually by a written document, what kinds of medical treatment they would or would not want should they fall victim to a serious, life-threatening illness that leaves them unable to express their wishes. Advance directives are supposed to work by providing guidance to their physicians, who, in their fiduciary capacity, are charged with acting in the patient’s best interest.

A well-constructed advance directive allows patients to choose to spare themselves from demeaning, undignified, painful or otherwise undesirable medical procedures and treatments, should they become incapacitated at a later date. “Well-constructed” implies that the advance directives are clearly and concisely written, that they honor the ethical and legal norms approved by society, and that they provide the physician with clear guidance.

But it is more difficult to write a “well-constructed” advance directive than might at first meet the eye. The major problems are two-fold: Advance directives often express imperfect knowledge, and they are often imperfectly expressed. These limitations mean that in appropriately exercising an advance directive, often the physician cannot follow them to the letter, but must interpret them according to the circumstances at hand.

A healthy and relatively robust individual cannot always know how he or she will feel years into the future, when illness strikes and it is time to exercise an advance directive. Every doctor has seen critically ill patients who, despite having advance directives to the contrary, unhesitatingly choose to be attached to a ventilator when the time comes, for instance, rather than face certain imminent death. So experienced doctors know that advance directives do not always indicate what patients will actually choose to do when the time to make a choice is upon them.

They also know that, while conscious patients have the opportunity to repeal their advance directives, unconscious or incapacitated patients do not.** So, in exercising an advance directive, the conscientious physician interprets that directive in light of many other factors, such as, her personal knowledge of the patient, the opinions of family as to what the patient would want done, and the chances of a long-term recovery if the therapy being considered is used. Then she will negotiate with responsible family members an approach that appears to meet the patient’s presumed desires.

**Conscious patients can repeal their advance directives in theory. DrRich has witnessed actual doctors, however, arguing vociferously against using a medical therapy that a sick patient now desperately wants, because years ago the patient signed an advance directive expressing aversion to that therapy.

Therefore the advance directive in many cases is an important part of the decision-making process, but it is not the only part. The appropriate use of an advance directive requires the doctor to behave as a true patient advocate, to selflessly place the desires expressed in the directive in context with everything else that might affect the patient’s true and current wishes, and then make a recommendation that, to the best of his or her ability, honors those wishes.

Unfortunately, doctors can no longer act primarily as their individual patient’s advocate. Indeed, physicians are officially enjoined (by the New Ethics formally adopted by their own professional organizations) to give the needs of society at least equal consideration. And so, as has demonstrably happened with other “guidelines” in medicine, it is inevitable that advance directives will be reduced to a legal edict, which must be followed to the letter if the physician wishes to remain clear of the Department of Justice.

The likelihood that there will be no room for interpretation means that constructing just the right kind of advance directive for yourself – one that will be precisely suitable to any contingency that may occur – has become extremely difficult. If you get the details just a little bit wrong for the circumstances that actually arise, the price you pay may be very heavy. It would be better to have no advance directive at all than to have one that is misleading or ambiguous. Advance directives must be written with extreme care, and only after long, thoughtful consideration.

That is not how the government would have it, however. For many years now, the Feds, under the Patient Self-Determination Act, requires hospitals to inform patients about advance directives at the time of every hospital admission, and to invite them to sign one. To say this is a less than ideal time to implement an advance directive would be something of an understatement. Asking a patient to sign an advance directive at the time of hospital admission, often by including it in the pile of routine and mind-numbing legalistic documents which patients must sign if they want to receive medical care, and often with no more guidance than that provided by the admissions clerk (who might explain, “This tells the doctors you don’t want to be kept alive on a machine like a vegetable,”) tells us something about whether the true motive for advance directives is to protect the patient’s autonomy – or to reduce costs.

Having the discussion in a doctor’s office these days, sadly, might not be much better. The Central Authority knows that squeezing what really ought to be at least a 30-minute discussion into a 10-15 minute office visit already packed with Pay for Performance requirements (while providing the added threat of punishment if the physician fails to extract an advance directive from the patient), will yield, at best, a signature on a boiler-plate document.

But despite the slap-dash method by which such a document may be implemented, it is a document whose language – when the time comes – will be exercised with all the legalistic exactitude of a contract attorney by any doctor who knows what’s good for him.

DrRich thinks that Americans are right in being suspicious of the big push they are seeing to urge advance directives upon them. Invoking “death panels” in this regard is utterly inappropriate, but the end result will suffice. It is good that we have all been given pause.

Still, the concept of advance directives is a good one, and DrRich thinks most Americans might do well to have one. Despite the damage that is being done to them, DrRich thinks advance directives can be salvaged. To this end, DrRich suggests several steps we can all take in executing an advance directive that will actually do what we want it to do:

1) Don’t be pressured into implementing an advance directive by anybody whose career depends on keeping the Central Authority happy. Unfortunately, this likely includes your doctor if you are not paying your doctor yourself.

2) Don’t sign a boiler-plate document. These likely will have been drafted with the interests of the Central Authority in mind, with the help of very smart lawyers, and when these documents are called into use in all probability they will be interpreted for the convenience of the Central Authority.

3) Try to keep your advance directive from showing up in an electronic medical record. Write it yourself, and store it where your loved ones can find it when they need it. Give a copy to your spouse, your children, and perhaps (if you have a direct-pay doctor who works only for you) your physician. This way, since your advance directive will not be immediately available to hospital personnel if you are suddenly incapacitated, no unfortunate and irreversible decisions regarding the aggressiveness of your medical care can be made until your loved ones are notified.

4) Write your advance directive as a general guideline, with as few specifics regarding particular types of medical care as possible. You should assume that any type of treatment you mention in a negative light will be withheld under any and all circumstances, including circumstances you may not be aware of in which you would want that treatment.

5) You are not writing your advance directive for the doctors (it is most tragic that we can no longer trust doctors in this regard!); you are writing it to help your loved ones make the right decisions for you, perhaps despite the doctors. So your goal should be to clarify your general desires for your loved ones. Discuss your advance directive with your loved ones after you have written it, and ideally, before you have written it. Your written words will remind them of your wishes when the time is right.

Lest you think, Dear Reader, that  DrRich is merely being sarcastic  here (and why would anyone think so?), he is not. DrRich himself has an advanced directive that attempts to follow these rules. The document is stored at home with his important papers. Mrs. DrRich knows where to find it, and knows DrRich’s general feelings regarding these matters. With the guidance he has provided, DrRich trusts her and his children to make these important decisions for him. For anyone who is interested, DrRich’s advance directive is reproduced, in its entirety, at the end of this post. (The general language, which has been adapted and revised by DrRich for his own use, was originally suggested to him by a good friend who is a superb internal medicine practitioner.)

So. Advance directives are a very good idea, but unfortunately, have been identified by the Central Authority as a potentially powerful cost-cutting tool. Even before Obamacare, certain HMOs were refusing to reimburse hospitals or doctors that provided medical care that seemed to go against specific language contained in an advance directive. That, of course, was child’s play. Now that the Central Authority has gotten hold of them, advance directives will likely be treated the same way as other guidelines are now treated in medicine, that is, as edicts, and thus as vehicles for the criminal prosecution of medical personnel who deign to “interpret” them.

This means that if you wish to take advantage of the benefits which advance directives can provide, you will have to proceed very, very carefully.


DrRich’s Advance Directive:

If I am able to communicate my wishes by any means whatsoever, then I wish to make my own decisions regarding my own healthcare. If, despite my ability to communicate, my condition makes it inconvenient to fully inform me of my situation and all my treatment options, then until such time as it becomes sufficiently convenient to do so, I want everything possible to be done to sustain my life and effect a recovery.

In the event of an incapacitating illness in which I cannot communicate, the basic guideline initially should be to do everything possible to sustain my life and effect a recovery.

After a reasonable period of time (in general, I would consider a week to be reasonable) if no progress has been made in the recovery of my mental function, and the likelihood of mental recovery is judged to be small, then withdrawal of life-sustaining care should be strongly considered. To help my wife and/or children with this decision, I would like to have an evaluation by a neurologist to help clarify the prognosis.

If improvement in my mental status has been made, then efforts to sustain my life and affect a recovery should be continued.

If at any point in my care there is a period of at least two weeks in which I am persistently unable to carry out meaningful communications sufficient to make my own wishes known (in the opinion of my family members and the neurologist), and the likelihood of mental recovery is judged to be small, then I would consider the withdrawal of life-sustaining care to be a blessing.

From Medical Miracle to Abomination

DrRich | February 1st, 2011 - 10:43 am

The implantable cardioverter defibrillator (ICD), an incredible feat of visionary medical science blended with cutting edge engineering, a device responsible for saving thousands of lives a year, has gone from being a prototypical American success story to a symbol of healthcare excess. Today the ICD is widely castigated by the press, the public, the insurers, the government, and even most doctors as the poster child for expensive and wasteful medical technology. Consequently, the ICD and the doctors who implant them have become fair game for whatever the Central Authority wishes to throw at them. DrRich has explored this fascinating phenomenon in this series of articles;

How ICD Implantation Guidelines Are Being Abused

The DOJ Investigation of ICD Implanters, and What It Means

How the ICD Became an Abomination