Enjoying the Financial Crisis So Far?
September 23rd, 2008 by DrRich
For a while last week, apparently, the American financial system bordered on a complete collapse, one that threatened not only to bankrupt the remaining major investment banks, but that also threatened to freeze all lending and borrowing across the entire American economy. According to some, we were within a day or two of seeing major brand-name non-financial corporations being unable to operate, and all American commerce essentially coming to a grinding halt. Apparently we were about to go, in very short order, from a global economy that functions at Internet speed, to one that works instead on the principle of bartering, if not hunting and gathering. (At last Mr. McCain’s choice of a running mate becomes clearer.)
And so, on Wednesday evening, stunned congressional leaders listened to Mr. Paulson and Mr. Bernacke tell them that, unless they rapidly passed a massive federal bailout for all the bad loans, then “Heaven help us all.”
The subsequent announcement of the proposed government bailout package has stabilized things for the time being, and has injected sufficient confidence into the financial markets to allow normal commerce (of a sort) to continue. But however this whole mess turns out, whether it leads to another Great Depression, or whether it turns out to be just a really bad quarter, when it’s all over the American taxpayer is going to be saddled with a new debt burden of at least $700 billion, and that some say may reach $2 trillion. That’s a sizable increase to our total national debt, which today is “only” about $9.7 trillion. Once they’re old enough to figure out what we’ve just done to them, our children and grandchildren will be pissed.
Even before we reach any kind of resolution of this current fiscal crisis, the blame game has commenced. It’s too much de-regulation by Republicans vs. too much social engineering by Democrats. This blame game is potentially a good thing, because unless we objectively assess how this financial crisis happened, we will (as is our habit) devise “solutions” that will just make the next financial meltdown even worse. Unfortunately, the likelihood that we can be objective about assigning blame, especially in an election year, seems slight.
DrRich’s take is that there is plenty of blame to go around. As he sees it, the root of the problem is fourfold:
1) Our government decided that for purposes of fairness and diversity, mortgage firms should be “encouraged” (and to the government, this means “forced”) to make loans to individuals who, by any reasonable risk standards, simply did not qualify for loans.
2) The federal reserve made money very cheap, and borrowing relatively easy.
3) Fannie Mae and Freddie Mac, companies created by government and not subject to normal market forces, bought up the risky mortgages in huge amounts, then repackaged them in complex instruments which it sold to investors all over the world. Investors (such as the big-name brokerage houses, huge conglomerates like AIG, and the Chinese) bought up the risk-laden instruments, and from them they assembled even more convoluted high-risk investment instruments, which they traded back and forth until nobody knew who owned what, or how much worthless debt everybody had on their books. This, of course, is where the “free market” went wild, magnifying a very bad problem into an astoundingly dangerous one. The unrestrained wildness was at least partly encouraged by the assumption that, since Freddie and Fannie were quasi-government entities, ultimately the whole mess would be backed up by the U.S. government. (Turns out they were right.)
4) Mortgage firms, fully realizing that the government really wanted them to lend to unqualified individuals and was happy to buy up all the bad loans they wrote in the process of doing so, nearly killed themselves inventing new and creative ways to entice anybody who could sign a name (and in recent years, not necessarily even their real name, what with the introduction of Alt-A loans - the so-called “liars’ loans”) to take on exotic new mortgages.
So there’s plenty of blame to go around, from the well-meaning but naïve government policymakers who apparently will never “get” the law of unintended consequences; to the Congresspersons of both parties who fought against tighter oversight of Fannie and Freddie (in exchange for major contributions and other perks given to them by F & F) and insisted against all evidence to the contrary that these agencies were fiscally solid; to the arrogant Wall Street magnates who dived head-first into the great feeding trough (whether they were lipsticked-up or not) and allowed their firms to become highly leveraged with disturbingly questionable instruments; to avaricious local mortgage companies who ended up giving houses away and sending the bill to Freddie and Fanny; to the delusional individuals themselves who inexplicably took on hundreds of thousands of mortgages they had absolutely no chance of paying off. All these players should have understood that you can repeal laws of man but you cannot repeal laws of economics, that sooner or later the tipping point would be reached, that the bubble would burst, and that all the players who thought they were winners would suddenly be revealed as major losers.
That tipping point, it appears, came last week. And so, the American taxpayers, many of whom take great pains to live within their means and don’t borrow money they cannot pay back, are the only ones left to rescue the greedy and the stupid and the craven.
Assuming our economy does not actually collapse over the next few months, and thus does not wipe out our entire social contract (to the extent that we will have to start all over, and thus render moot any concerns over any future fiscal crises our current social contract promises to bring us), DrRich would like to point out that, compared to what is coming, the economic crisis we are now experiencing is merely a trifle.
The current crisis, DrRich repeats, was brought about by well-meaning government policies that attempted to repeal laws of economics in order to achieve a social good, backed up by government programs that strongly encouraged private companies to behave as if economic laws did not apply. And now, with the inevitable dénouement, the private companies are being variably liquidated or absorbed or socialized, top executives are being variably rewarded or (one can only hope) jailed, and the taxpayer is being invariably screwed.
Regular readers will recognize in the previous paragraph a description of our current healthcare system - and a description of where it is headed. Our government has striven to devise policies that will provide unlimited healthcare to all Americans whenever they need it, a policy that requires the repeal of basic economic laws, and one that has resulted in a convoluted system of partly governmental and partly private healthcare that rations healthcare covertly (since the unavoidable limits on healthcare cannot be acknowledged), that eschews transparency, that systematically multiplies waste and inefficiency - and that is inevitably building to a dénouement.
There is one big difference, however. Whereas the newly-burst mortgage bubble has left us with an unfunded liability of merely (we think) something less than $2 trillion, our unfunded liability for Medicare alone, over the next several decades, is estimated to be between $25 trillion and $55 trillion. Considering the fatal damage our current, relatively trivial financial crisis apparently came within a few hours of triggering, this sounds like a lot of money.
When this massive bubble bursts, not even the stolid American taxpayer will be able to backstop the crash. Unfortunately, heading off this coming healthcare tsunami will require us to acknowledge that healthcare rationing is unavoidable, and to come up with an equitable and efficient way to do it. Since our leaders were unable to make themselves publicly recognize, and take steps to deflate, the equally obvious and much more tractable housing bubble when they had the chance to do so, it is difficult to be optimistic.
So try to enjoy our current fiscal crisis, because some day we’ll look back at it with as much nostalgia as we now do the so-called “crash” of 1987.
Preventing Never Events - A Tip For the New York Yankees
September 21st, 2008 by DrRich
Two American milestones are taking place in the next few days.
First, the New York Yankees have their final game in the venerable Yankee Stadium today, September 21.
This summer DrRich took his son to New York City to see the Yankees play one of their last games in the House that Ruth Built. It was a remarkable experience. (Cut and paste standard paean to baseball, tradition, competition, summer, youth, etc., etc., here.)
In addition to being struck by all the things he fully intends to cut and paste into the previous paragraph, DrRich was also struck by the fact that the nearby and almost-complete New Yankee Stadium looks just like Old Yankee Stadium. Presumably, this is so New Yorkers will be able to attend Yankees games in the coming decades, on very nearly the same spot they’ve been attending games for 85 years, and imagine that they’re still in the same building where Ruth and Gehrig played. It is apparently a Karma-preservation strategy.
The striking similarity and proximity between the New and the Old Yankee Stadia brings to DrRich’s mind the second milestone which Americans are facing today - the impending implementation by CMS of their much-heralded “Never Events” policy. Under this policy, of course, hospitals will no longer be paid if certain unallowable complications should occur in hospitalized patients.
The purpose of the Never Events policy is, by pretending that these complications would never, ever occur but for somebody’s incompetence or negligence, to encourage hospitals to take extraordinary steps to reduce their incidence, and then to avoid having to pay when they occur anyway.
In the spirit of the new Never Events policy, and out of respect for the New York Yankees Baseball Club (which, for all its storied history has yet to beat the Pittsburgh Pirates in a World Series), DrRich has the following tip for Yankees management:
When you’re done with the ballgame today, get a big Magic Marker and write on the Old Yankee Stadium in very large block letters: KNOCK THIS ONE DOWN.
You’re welcome.
The Duty To Abort
September 15th, 2008 by DrRich
There are, it would appear by reading newspapers and watching TV, many reasons not to like Sarah Palin, and even more reasons not to approve of her. Indeed, on the very day Governor Palin was announced as Senator McCain’s running mate, DrRich said to his own lovely bride of these past 35 years, “I hope Ms. Palin has Clarence Thomas’ phone number. She’s going to need some advice.”
Clarence Thomas, of course, is the Supreme Court Justice who is masquerading as an African American (his credentials as an actual black person having been thoroughly and systematically discredited by the diversity establishment, by virtue of his conservatism, during his confirmation “hearings”).
“Why, whatever do you mean?” asked DrRich’s sweet-hearted spouse.
“Just look at her,” DrRich replied. “There she stands: Sarah ‘Jesus, Babies and Guns’ Palin. Why, she’s the embodiment of the rubes Senator Obama talks about, the ones that cling in their misery to their Bibles and their varmint guns, and that keep making babies because they’re just too dim to figure out how to prevent it, and probably even too dim to figure out what causes them in the first place. In other words, she’s conservative. So by definition she’s no more a woman than Clarence Thomas is black. If she’s allowed to pass herself off as a legitimate (much less celebrated) embodiment of American womanhood, it will set the Movement back to the days of Ozzie and Harriet. So she’d better put on some thick skin because it’s going to get very nasty and very ugly very quickly.”
All of this, of course, has since come to pass. Why, Wendy Doniger, who is a Professor of the History of Religions at the University of Chicago’s Divinity School, and so who has the formal authority to rule on such things, has even established in her Newsweek blog that Ms. Palin is not actually a woman. (”Her greatest hypocrisy is in her pretense that she is a woman.”) You can’t actually be a card-carrying woman, you see, and say and do the stuff that Ms. Palin says and does. Any educated person can see that, and it’s good that the very well educated are taking the time to inform the rest of us.
So, like DrRich says, there are many reasons not to approve of Sarah Palin, some based on facts and some confabulated from a general knowledge of the kind of things primitives like her might believe, and all of them are being well and thoroughly (and desperately) documented for the public record by a panicky media establishment, with every hope and confidence that, once fully informed, no thoughtful person could ever actually vote for one such as she.
But as cynical as he is, and as savage as he expected the attacks to be, there is one criticism being made of Ms. Palin that took even DrRich by surprise. DrRich refers to the criticism she is receiving for failing to abort the latest addition to her family, her little son Trig, even though she learned while pregnant that he would likely have Down syndrome.
When DrRich was in medical school oh so many decades ago, children with Down syndrome were still largely institutionalized from birth. So when DrRich was being taught about Down syndrome he was shown pictures and movies of drooling children who were unable to speak or communicate meaningfully, and who were unable to feed themselves, use toilets, or interact as humans.
But of course, if you were to place any of today’s Baby Einsteins in such an institution from birth, they would end up much the same way. And once the era of institutionalization ended, and many Down children were raised instead with their families, amazingly we learned just how normal these kids could become.
When Down children are raised in the home by loving and caring families, it turns out that most of them become highly functional. DrRich knows people with Down syndrome, and finds them to be good-natured (most of the time), articulate, thoughtful and even witty, and they are not only quite capable of providing for themselves their basic human needs, but also of earning a living. Above all, they are happy to be alive, and their families are as happy to have them as they are any of their other children and they love them just as much. Of course, they do have problems, including a high incidence of cardiac abnormalities that need to be surgically corrected, and a relatively high risk of developing leukemia and infectious diseases. But these are fully-realized humans who enjoy their lives and have much to offer.
So if a pregnant woman finds out she is carrying a Down child, she has a lot to think about. There are a lot of potential problems with these special-needs children, and not every family is prepared to deal with these problems. But on the other hand, the experience of raising a Down child can be extremely rewarding - for everyone. So as DrRich sees it, the decision to deliver a Down child and welcome him/her into the family is at least a reasonable one, if not a blessed one.
So at first DrRich was a bit puzzled by the criticism being heaped upon Ms. Palin for keeping Trig. At first, he thought this unreasonable complaint was simply one of the many things being caught up in the pile of indiscriminate criticisms being leveled against her during that first mad rush to discredit her, to shame McCain into dropping her from the ticket immediately. Surely, nobody could really hate her for intentionally delivering a Down child.
But even when the mainstream media realized that it had overplayed its hand a bit, and began to settle down to some of the more reasonable criticisms of Ms. Palin (her inexperience in foreign affairs, for instance, which is every bit as troublesome as Mr. Obama’s), the issue of her having chosen not to abort her Down child did not go away.
The complaints, of course, are couched in terms of concern. A mother with a special-needs child should devote her efforts to the child, so it is clearly inadvisable for such a mother to seek the Vice Presidency. But while they express concern for the wellbeing of the child, their underlying tone is clearly one of approbation, and the criticism rings of false indignation. Since when does the women’s movement become so vociferously exercised because a working mother is not spending enough time with her children, whatever the needs of the children?
Besides, DrRich respectfully reminds critics of Ms. Palin that the Vice Presidency is famously a job with no responsibilities whatsoever (unless the President dies, of course, in which case a new VP is tapped to sit around and do nothing). In practical terms, being VP is the perfect job for any mother with a special-needs child, and it will certainly allow Ms. Palin to spend more time with her family than she ever could as Governor of Alaska, or even as Mayor of Wasila. Only being a Senator would approach the suitability of this job for a mother with family responsibilities, judging from (as demonstrated by Senators Obama, McCain and Biden) the massive amounts of time for which it is apparently perfectly OK not to show up for work. In fact, mothers with special needs-children ought to be harshly and publicly condemned if they do NOT seek the Vice Presidency of the United States.
No, there is clearly something more going on here than mere indignation that Ms. Palin is seeking a job that will take her away from her family. And gradually, DrRich has figured out what that is.
Ms. Palin had a duty to abort Trig, and she failed to discharge that duty. By so failing, she has abandoned, by her own choice, any claim she may have had to the title “woman,” and certainly any claim she may have had on the sympathy, much less support, of other women.
It is one thing to deliver a special-needs child who cannot be identified prenatally as having special needs. Women with such children are simply victims of the draw, and are to be pitied and supported in every way possible, with whatever public funds that may require. Women should not be punished with such an unforeseen and unpreventable burden, foisted on them by chance, or, if there is a God, then by the divine MCP (which is one reason why the notion of a divinity is so abhorrent to so many of the leftward persuasion - if God exists, he’s certainly stacked the cards against everyone except white males). Such a child is one of the worst things that can happen to an independent, self-actualized, competitive modern woman. Any real woman who cares about the child, who cares about herself, and who cares about doing what’s best for all women would abort that child whenever possible.
The idea that a woman who actually had a choice would cheerfully choose to have a child with Down syndrome seriously undermines the argument. Such a woman is clearly ignorant or stupid, and must have (through their ignorance or stupidity) bought into the old-fashioned, male-dominant paradigm that we enlightened folks have fought so hard to overcome. When women like this do their thing in Wasila, Alaska, one merely shakes one’s head at the backwardness of it all, and consoles oneself that, some day, the truth will filter out even to these bush people.
But the idea that a woman, once making such a poor decision, would then not just quietly slink along through her life, privately bearing the burden of her poor choice; the idea that such a woman indeed would allow herself (and even seek) to become well-known, and to run for public office, much less seek the second highest office in the land; the idea that such a woman could become not only popular but publicly acclaimed and even adored - why, such an idea is utterly anathema. This woman calls into question the fundamental tenets of the Movement.
This explains one aspect of the approbation being heaped upon Sarah Palin for choosing to give birth to a Down child. She has made mortal enemies of the extreme women’s movement, and they need to destroy her at whatever the cost.
But another aspect of it (and one that finally resonates with the theme of this blog), is that Ms. Palin is setting an example that, if followed by admiring women, will cost the healthcare system a lot of money. Down children, for a variety of reasons, often need a lot of expensive medical care. And by actively campaigning to encourage women to abort their babies if pre-natal testing suggests a high risk of Down syndrome (by describing to the stunned mother-to-be the institutionalized Down child of the 1960s, by outlining the horrors of heart surgery and other medical issues that may occur, and by neglecting to mention that Down children most often become completely fulfilled and completely lovable people who bear their trials with grace and humor, and who actually have a lot to teach us), obstetricians in the US, Canada and many European countries have succeeded in sending over 90% of Down pregnancies to abortion in recent years. Sarah Palin, especially if she remains popular, and most especially if Trig grows up in public view and becomes a beloved example of the potential of Down children, threatens to cause many women to consider their options more carefully. And that will cost society big time, as a prominent Canadian obstetrician has pointed out.
Women who have chosen to deliver their Down babies are today being subtly scorned by society. Women have a duty to their gender and to society to abort those babies, and when they choose otherwise they are displaying serious psychopathology and sociopathy. It is becoming very difficult for women to do otherwise.
Sarah Palin threatens to change the paradigm. Perhaps she already has. The duty to abort has been hard fought and hard won. Palin has got to be stopped.
And that explains at least some of the passionate attacks from people who, one would think, would normally celebrate the ascendancy of a strong woman who has succeeded at a man’s game while remaining an admirable wife and mother.
DrRich will end by pointing out that the duty to abort disabled children (a duty that, thanks to Sarah Palin, is obvious today for all to see), is really no different than the coming duty to accept assisted suicide or euthanasia. Observing the attacks on Ms. Palin has made DrRich realize that we are farther along that road than he had thought.
Ethicist-Assisted Suicide
September 8th, 2008 by DrRich
In a previous post, DrRich attempted to satirize the lame attempts of certain healthcare 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. (Note to the policy experts who direct politically-acceptable healthcare terminology: Is the term “covered lives” even appropriate any more when we’re finally dabbling in the realm of covered deaths?) 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, while David Hamilton of BNET seems to get the concept of satire, some of his readers (”I can’t believe what I just read. This is sick.”) do not. This is not the first time DrRich has made unfortunate impressions upon readers through his (possibly inept) use of irony. It will certainly 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 trouble 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 necessarily lead to horrific abuses of the practice. DrRich attempted to touch upon some of these entirely predictable outcomes of such a policy in his previous post. For other negative outcomes that are likely or at least possible, you can either use your imagination, or read the history of Europe in the 20th century.
His second objection to physician-assisted suicide is based on 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 formally trained ethicists have universally concluded that physician-assisted suicide is perfectly OK in every way.
Debating with modern medical ethicists, at least if you are merely such a one as DrRich, is 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 laypeople like DrRich in the position of having 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. Otherwise, you can pound salt.)
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 made this determination when we decided that a patient has a right to refuse medical treatment even if that treatment is very likely to save their life. Therefore, we have already firmly decided that passive euthanasia - letting nature take its course - is ethical.
Point 2: There is no ethical distinction between passive euthanasia and active euthanasia. 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 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 still don’t see a problem, DrRich refers you to the Dutch system, where the rules permit both physician-assisted suicide and active euthanasia for patients who request it, in full accordance with modern medical ethics. 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 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 autonomy of the individual 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 capable patients. To fulfill this right, the boon of euthanasia can and must be performed, without the patient’s explicit permission, in incapacitated patients whom “reasonable people” would agree are suffering too much - that is, involuntary euthanasia is also ethical.
This conclusion, of course, leaves us in a place where others (i.e., “reasonable people” like doctors) 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 only thing to do. Some of you, of course (hello, ethicists!) think this is just a fine idea. Most apologists for the Dutch system apparently do, for instance.
DrRich maintains that under a system of covert healthcare rationing, where doctors are under extreme pressure to do the bidding of the third party payers (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 lead to horrible 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 had been perhaps the world’s most cultured and educated society, during the last 100 years.
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. Ethical principles 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 to declare that no dilemma actually exists, because ethical principle X is the only one we need to pay attention to.
Individual autonomy is critically important, 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. The reason we have laws (supposedly) is to make sure that the behavior of individuals who have accrued power (for instance, by accumulating great wealth, by acquiring large weapons, or by becoming heads of state) does not abrogate the rights of other individuals, and to make sure that individuals acting in their own interests do not create too high a cost for our society as a whole. Indeed, most of the political fights we have - between Democrats and Republicans, liberals and conservatives - are to determine where best 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 opportunity. 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. We simply should not do it, and we should fight efforts to make it so.
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 paradigm of the American healthcare system, for the love of God keep the doctors out of it.
*Despite the clear value of this advice, DrRich still awaits his first “thank you” from Aetna or United HealthGroup or even the Oregon Health Plan. This shows us once again that, unless they’ve paid expensive consultants a few hundred thousand dollars for it, big companies and big bureaucracies are utterly incapable of recognizing even obvious truths, truths that any of their middle managers could usually give them for free.
Back Next Week - Emptying the Nest
August 27th, 2008 by DrRich
DrRich will be preoccupied for the next week or so, packing, driving, unpacking, etc. his youngest child off to year 1 of college, then trying to come to terms with the utter strangeness of how quickly it all goes by. Before too long, he hopes, he will come to see blogging as an aid in his recovery process, and at that point he will return.
Taxpayer Support of the Evil Drug Companies
August 25th, 2008 by DrRich
Demonizing the drug companies is a necessary and indispensable strategy under a healthcare system that covertly rations healthcare. Quite simply, it is necessary because drug companies are in the business of developing expensive new products that doctors and sick people will demand for themselves.
If we can paint the pharmaceutical industry as being sufficiently evil and corrupt, then we can justify constraining drug companies so as to limit the introduction of these expensive new products. We can, for instance, build daunting regulatory hurdles or legislate “windfall profits” penalties. Fortunately for us, drug companies are indeed not the most fastidious members of the corporate community, and their actions and methods provide us with many fruitful avenues for demonization.
One such avenue is to show how the corrupt pharmaceutical industry feeds at the trough of the American taxpayer. As an example of this reprehensible behavior, the New York Times has pointed us to the case of Dr. Laszlo Bito and the anti-glaucoma drug Xalatan.
In the early 1980s Dr. Bito, a researcher at
Subsequently, the pharmaceutical giant Pharmacia purchased the rights to Bito’s discovery for a mere $150,000. Based on Bito’s tax-supported work, eventually Pharmacia released the anti-glaucoma eyedrop preparation Xalatan. Xalatan rapidly became a worldwide best-seller, yielding as much as $500 million in sales per year. For their part in this wondrous success story,
Meanwhile American glaucoma sufferers are forced to spend upwards of $50 every six weeks for a tiny vial of the drug, which costs the company only a small fraction of that amount to produce, and whose discovery the glaucoma sufferers paid for with their own tax dollars. And, as if to guild this already brazen injustice, Pharmacia makes Xalatan available in
It seems, the Times points out, that the American taxpayers are the only parties in this little scheme who reap no financial return on their investment. All they got were some expensive eyedrops.
And so, drug-company demonizers would have us conclude, this is a particularly egregious example of how the evil pharmaceutical industry is ripping us off. Not only are the drug companies mercilessly profiteering from sick Americans (which, after all, is their openly-admitted business model), but they are also picking the pocket of every American by using our tax dollars to invent new drugs, then selling those drugs back to us at exorbitant prices. This, one could reasonably argue, is at least as sociopathic as anything the tobacco companies ever did. (The tobacco companies, in contrast, at least had the good graces to eventually stop claiming that they were a major boon to the public health.)
And (we are all supposed to agree), if this reprehensible behavior doesn’t give our government the right to control the prices charged by drug companies, one would be hard pressed to say what does.
To all this, of course, DrRich says, “Bosh.”
DrRich certainly doesn’t want to absolve the pharmaceutical industry of all responsibility for drug prices that seem obviously too high, or for the striking pricing disparities we see between the
There is much not to like about high drug prices, or the fact that people in other countries reap the benefits of American research for far lower prices than Americans do. And it is reasonable for us to seek to address these pricing issues. But as we address certain inequities in drug pricing, we should be careful that in doing so we don’t throw the baby out with the bath water. So if we’re going to alter the arrangement we have with the pharmaceutical industry, let’s be clear on how that arrangement works, and why we set it up in the first place to operate as it now does.
Consider once again the glaucoma drug Xalatan, and consider how Dr. Bito’s discovery was actually used by Pharmacia.
Bito did not discover a finished product. Instead he discovered a new concept for reducing intraocular pressure (that is, for treating glaucoma), and demonstrated that it could be effective - but the specific compound he discovered was not marketable. In fact, it was so highly irritating when applied to the eye that it was simply not suitable for clinical use. Indeed, Bito’s discovery was offered to and rejected by a host of drug companies as being completely infeasible.
When Pharmacia finally agreed to pay for the rights to Bito’s patent, they took on an expensive risk that, some estimated, had less than a 5% chance of achieving success. Pharmacia assumed the difficult task of developing a brand new synthetic molecule that would have all the benefits described by Bito, but at the same time would not have the prohibitive side effects. There was no assurance that such a molecule could be found. Then, they would have to shepherd their new compound through a time-consuming and costly regulatory gauntlet that proves fatal to most new drugs, and pray that it would gain FDA approval. That their efforts were ultimately successful does not diminish the fact that, when they agreed to invest the time, money and opportunity cost to develop Dr. Bito’s discovery, they were taking on a large risk with no assurance of making a profit or even recouping their losses.
Bito’s (tax supported) idea was a promising one, but the challenge of developing that idea into a product that was useful to patients and that could be brought to market was very expensive and highly risky. Pharmacia took on that risk (all of which was borne by its shareholders, and not by taxpayers) only after difficult, internal corporate soul-searching. If not for the prospect of making enormous profits if this risk worked out, the company (like several other drug companies did in this particular instance) certainly would have walked away.
Before 1980, it is likely none of this would have happened. The Bayh-Dole Act of 1980 was passed expressly to encourage the further development of federally financed, university-based basic research. Until then, a large proportion of basic university research was never “translated” into useful medical products. Such translation of basic research was recognized by Congress to benefit society not only by advancing the practice of medicine, but also by stimulating the overall economy. So industry was actively encouraged to take on the risk of developing promising ideas that came out of federally-funded research. And the profit that greeted successful enterprises was designed to be the one thing that would lure industry into taking that risk.
So when the Times “discovers” a company “profiteering” from work done with tax dollars, it should not be a revelation, nor should it be an unmistakable sign that the company is inherently evil or dishonest, nor does the company’s activity in this regard give us the right to arbitrarily restrict its profits. Rather, that’s simply the deal we taxpayers made with the drug industry (through our elected officials). We made this deal because we felt, in the long run, that it would benefit American society, and quite probably, us as individuals. If we want to change that deal now, so be it. It is within our rights to do so.
Without Bayh-Dole, perhaps patients with glaucoma would still be getting surgical therapy and wearing those coke-bottle lenses instead of just using eyedrops. And if we want to put the brakes on such medical advances (in order to prevent unseemly profiteering), we certainly can.
But we shouldn’t vilify the drug companies for taking us up on the deal we offered them.
The End-Of-Life Movement and Medical Ethics
August 18th, 2008 by DrRich
Last week DrRich offered some friendly advice to health plans that would like to take advantage of the cost-saving potential of assisted suicide. DrRich was moved to help in this way upon witnessing the initial, typically ham-handed forays which health plans are making into this promising new arena of High Quality and Efficient Healthcare.
Among the sage recommendations which DrRich so kindly provided to directors of American health plans was the admonition to tone down their overt enthusiasm for assisted suicide, and to let the robust end-of-life movement do the selling for them.
DrRich finds the end-of-life movement to be an extremely interesting social phenomenon. These folks purport to act solely on the behalf of the autonomy of the individual, that is, to help people to preserve their freedom of choice, sense of control, and personal dignity when faced either with inevitable death, or with a life that is no longer worth living. They see the medical-industrial complex as an insensate machine which, for its own purposes (i.e., profit), will inevitably act to prolong the suffering and indignity of these unfortunate patients for as long as possible, long past the point where the individual sufferer would wish it to stop.
As with most passionate social movements, there is more than a grain of truth to their underlying premise. However, their own actions with regard to the three major issues they have taken up – assisted suicide, advance directives, and medically futile care – should make us suspicious of their true dedication to the precept of individual autonomy.
The stance the end-of-lifers have taken on advance directives and assisted suicide, of course, is entirely consistent with supporting the autonomy of patients who wish to forgo aggressive medical treatments, or even to hurry death along. It’s with the issue of medically futile care that the end-of-life movement reveals that its true motivation lies elsewhere.
For, when patients or families insist on continued medical care that even the insensate healthcare machine agrees is very likely to be unavailing, an end-of-life movement dedicated to preserving the autonomy of the individual would want that care to be offered anyway (since that is the explicit desire expressed by the affected individual). But instead, the end-of-life movement strongly favors withholding such care from these individuals, and indeed, seems anxious to expand the sorts of medical services that are to be considered futile.
One can argue logically about whether the position of the end-of-life movement with regard to medical futility is reasonable or not. But one cannot argue logically that this position is based on preserving individual autonomy. It is not.* Instead, their position is most consistent with wishing to limit spending on healthcare. Cost cutting, and not individual autonomy, accurately predicts the position the end-of-life movement takes on all three of its signature issues.
When reducing cost and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy.
(DrRich chooses to attribute the specific positions taken by the end-of-life movement to a desire to control costs, rather than to the other possibility suggested by their actions. Namely, he is reluctant to consider these fine people to be a death cult, of simply being in favor – due to some pathological or morbid fascination with death – of whichever action hastens it. DrRich is far too charitable to believe that.)
DrRich understands utilitarianism, though he most often does not agree with it. However, he finds it dangerous, and nearly reprehensible, to disguise utilitarianism as an ethical argument. If we as a society want to debate the hastening of death as a method of reducing spending on healthcare, then let’s have that debate.
But what the end-of-life movement seems to be doing is attempting to cut off this debate before it starts by claiming an ethical high ground that is actually inconsistent with its own positions. We should not treat the ethical argument advanced by proponents of the end-of-life movement any more seriously than they do themselves.
And we should avoid embracing assisted suicide (and other end-of-life solutions to the problem of healthcare rationing) until we’ve carefully considered the real ethical implications of doing so.
*Medical ethicists are actually much more subtle than this argument allows, and indeed have come up with an ethical system that permits us a way of preserving individual autonomy by (get ready) ignoring the clearly expressed desires of individuals! DrRich will address the medical ethicists’ support of the end-of-life movement in a later posting.
How to Sell Assisted Suicide
August 10th, 2008 by DrRich
In July, the Oregon Health Plan 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.”
The firestorm of outrage this letter triggered (to see the outrage for yourself, simply Google the search terms “Barbara Wagner” and “suicide”) penetrated even the dulled sensibilities of the Oregon insurance 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.’”
DrRich expects that the Oregon Plan executives must feel at least a little blindsided by the general reaction to their ham-fisted denial letter. Denial letters, after all, routinely list (as an aid to the patient) services which the insurance company judges to be reasonable alternatives to the denied care. While in this case the denied service offered some reasonable hope for prolonged survival, and the service being offered 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 Plan executives might be thinking, “What’s the big deal?”
One must try to be understanding of such insensitivity. It is a fundamental task of health plans 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 to grow thick skin. It is perfectly predictable that such thick skin might dull one’s ability to discern subtle differences in degree between various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appears to say, is the problem in the case of Ms. Wagner. The solution, consequently, is not a substantive change in any policy, but better public relations.
Those who run the Oregon Health Plan must be particularly disheartened to learn that even vocal proponents of physician-assisted suicide are criticizing their ill-considered denial letter. To so blatantly juxtapose 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 primarily an individual autonomy play*, and not primarily a cost-saving mechanism.
In other words, whether or not you embrace physician-assisted suicide, everyone seems to agree that offering it as a covered medical service immediately after denying potentially life-prolonging therapy is both insensitive and unseemly.
And so – as a public service to insurance executives in both the government and the private sector who are severely challenged by 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 some friendly advice to health plans on the right way to sell physician-assisted suicide.
How Health Plans Should Sell Assisted Suicide
1) Don’t be so anxious.
Sure it’s easy to get excited about physician-assisted suicide. All you need to do is look at your own data. Whatever sort of health plan you are running, 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, it’s difficult not to push the idea out there to your subscribers. Otherwise how can you be sure they 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 simple and helpful “reminder” letter to Ms. Wagner. As a result, neighboring states that appeared ready to pass their own assisted-suicide laws are now having second thoughts about it. It is clear that for a health plan to seem overly interested in assisted suicide, or even to mention the option to their subscribers, is a very counterproductive idea.
A much more subtle approach is required.
2) Publicly disown 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 their presence. In the meantime, make it clear you do not endorse or encourage their efforts, and indeed wish they would go away, but are providing such groups with access in the interest of full transparency and your dedication 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.
They’ll tell patients that assisted suicide will finally bring comfort to their long-suffering family and friends. So make sure family and friends suffer 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-lifers have teeth. You’re good at that.
5) Tell patients to consult with their doctors before making this choice.
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 your doctors, then their willingness to encourage (or at least not discourage) assisted suicide will increase substantially. So when patients do consult with their doctors, the doctors will not undermine your subtle efforts, but will be 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 dermatologists have done for 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 healthcare price controls, and you will severely limit the possibilities.
Think of those 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 deathcare industry to wrap the final healthcare service into a comprehensive package with funeral services? 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 convert what is today an antiseptic, impersonal and frightening process into one that makes everybody present say, “Yes! That’s the 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 being 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.
And if those who run health plans will just follow DrRich’s 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.
*Preserving the ethical precept of individual autonomy is the basis upon which modern utilitarian ethicists build their defense of physician-assisted suicide, passive euthanasia, active euthanasia, and even involuntary, secret euthanasia. DrRich will elaborate on the ethicists’ defense of doctors killing people in a future posting.
**This will simply require the government to continue severely and very publicly prosecuting 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.
***You may need to fashion the payment model so that assisted suicide is paid for in the case of hospitalized patients, and for patients in Medicaid programs. The point is to make assisted suicide a highly-desired self-pay service for anybody with enough money for a decent car or central air conditioning.
More Guidelines - Fighting For the Children
August 4th, 2008 by DrRich
A few months ago, DrRich addressed certain disadvantages that will arise from a policy of forcing physicians to practice medicine by guidelines. Essentially, once we decide to measure physician quality and determine physician pay according to how well they “perform” in following handed-down clinical guidelines, we will open a Pandora’s Box of dysfunctional and contradictory guidelines that will make the IRS code - or even the Medicare policy manual - seem straightforward and logical.
Payers are placing much hope in guidelines. They envision great cost savings through the simple expediency of adopting guidelines that leave out certain medical services they would like to avoid paying for.
But the payers have made the grave strategic error of fully embracing the “guideline movement” before securing for themselves control of the guideline development process. Apparently they missed the obvious fact that, if the practice of medicine is is reduced to following sets of guidelines, then any healthcare group and any medical organization with any stature whatsoever will begin manufacturing guidelines that direct doctors to do whatever it is that advances that organization’s agenda. That is, if guidelines determine who gets paid for what, then guideline development will become the chief byproduct of the healthcare system. We are beginning to see this chaotic process in action now.
DrRich, who delights in attempting to tease order from chaos, has suggested several specific categories of the dysfunctional guidelines that will inevitably flow from such a process. One of these categories he labeled “predatory guidelines.”
As an example of predatory guidelines, DrRich pointed to the recent recommendations advanced by the American Heart Association (AHA) urging that children with ADHD be screened with ECGs before they are placed on stimulant medication. Those ECGs, the AHA went on to explain, should be interpreted not by the pediatrician, but instead by “a pediatric cardiologist or a cardiologist or a physician with expertise in reading pediatric electrocardiograms.”
In making this recommendation the cardiologists of the AHA have attempted to encroach upon the turf of the pediatricians, ostensibly to save the lives of innocent children, but in a manner that will inevitably increase business for cardiologists by a) generating hundreds of thousands of ECGs for them to interpret at $25 - $50 a pop, and b) generating tens of thousands of echocardiograms and other cardiac tests that will be necessary to evaluate all the equivocal (and to a very large extent false positive) ECGs that will result from this routine screening, while c) explicitly leaving the pediatricians themselves out of the process.
DrRich predicted at the time that the pediatricians would not allow this invasion of their turf to stand, and that they would find it necessary to counter with their own set of guidelines. And so, what began as “predatory guidelines” from cardiologists would likely degenerate into “dueling guidelines” between cardiologists and pediatricians.
DrRich is delighted to report that his prediction has now come to pass.
The American Academy of Pediatrics (AAP) has just released a policy statement suggesting that the AHA is guilty of promulgating bad advice. Indeed, the AAP finds, it is not necessary to perform routine ECGs on children with ADHD prior to giving them stimulant medication. Further, the AAP pointedly demonstrates that the AHA’s recommendations were based on faulty science (that is, the AHA failed to follow the principles of evidence-based medicine), and that those recommendations give at least the appearance of being self-serving. Finally, the AAP notes that since routine ECG screening produces many false positive results, which themselves require further cardiac testing, this screening actually produces more harm than good. So, the AAP concludes, not only is there no need to do routine ECG screening, but also doing the screening would produce net harm. The AAP statement stops just short of accusing the AHA of malfeasance.
And so, DrRich would like to thank the AAP for so clearly bearing out his prediction that “predatory guidelines” will always tend to yield “dueling guidelines.”
Needless to say, the cardiologists are not happy about this new development. Dr. Steven Nissen (famous of the Cleveland Clinic, and also famous for producing inflammatory statements pretty much on cue) tells TheHeart.org (professional registration required) that “the AAP statement is misguided.” Nissen also suggests, perhaps a bit gratuitously, that the pediatricians (and their friends, the detestable shrinks) are tossing amphetamines around like candy. He says, “This is the second time in a few weeks where the AAP has issued poorly thought out guidelines that promote inappropriate drug use in children. The previous statement promoted statin use in children as young as 8 years of age.”
(DrRich is sympathetic to the notion that the diagnosis of ADHD might be a tad overdone these days, to the point where being a boy is all but an official disease, for which drug therapy is frequently urged and often prescribed. But still, in the debate over whether children diagnosed with ADHD should have ECG screening before being drugged, the assertion that they are being overtreated in the first place is actually beside the point.)
Both sides in this now-very-public debate seem to have some valid points, and to DrRich’s estimation neither side is obviously completely right or completely wrong. Cardiologists are correct in pointing out that stimulant drugs do have cardiovascular effects, and it is logical to think that kids who are susceptible to cardiac arrhythmias might be at higher risk on these drugs, and that screening these kids might save some lives. But the pediatricians are correct in pointing out that the data that has been collected so far does not show any increase in sudden death in kids on drug therapy for ADHD when compared to the general population, that the same cardiovascular effects caused by these drugs are also caused by everyday activities such as running, jumping, and the sort of emotional outbursts that children with untreated ADHD may have from time to time, and that, besides, doing ECGs on all these kids has a known downside in terms of unnecessary procedures and increased cost.
So, in addition to being unseemly, these dueling guidelines create a dilemma (instead of guidance) for doctors who are actually attempting to care for children with ADHD. One set of guidelines says that screening is necessary to save lives; the other (from an equally regarded professional organization) says that not only is screening unnecessary, but also harmful. Whatever the doctor does, if there is a bad outcome the plaintiff’s attorney will come pre-armed with one set of guidelines or the other which will prove that, no matter what the doctor did, it was the wrong thing.
These dueling guidelines also demonstrate that many important medical questions are simply not suitable subjects for guidelines. Guidelines are fine when a medical issue is resolved, that is, when there is substantial agreement among experts (of all relevant factions) as to how patients with a certain medical condition ought to be managed. But guidelines are helpful only when the clinical question is sufficiently ripe. Premature guidelines - the ones promulgated for some other reason than that the optimal clinical pathway has been resolved - will cause harm (and often, ironically, will increase cost).
Nonetheless, the notion that the practice of medicine can be completely reduced to sets of guidelines (a notion vitally attractive to insurance companies and government bureaucrats), now has been broadcast with great fanfare across the land. It is through guidelines that we will finally homogenize healthcare, and establish the tools by which clinical excellence can be tabulated and costs can be controlled. So, as a consequence of this generally agreed-upon fiction, swarms of guidelines are now flying out of the medical establishment like bats out of a cave. We can expect many of these guidelines to be created not because clinical science warrants them, but instead to covertly ration care, to protect professional turf, or to aggressively extend one’s interests onto entirely new turf.
And so, spectacles like this one, where cardiologists and pediatricians have become engaged in a rather nasty turf battle (fighting for the children, as it were), will be repeated countless times across the medical landscape.
Cry havoc, and let loose the dogs of guidelines!
Skin in the Game
July 30th, 2008 by DrRich
The New York Times recently took dermatologists to task for creating a two-tiered system of dermatology - one for patients with skin disorders, and one for “cosmetic dermatology.”
As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, old magazines, unruly children of other patients, and surly office personnel. Eventually her name is called by a not-necessarily-pleasant nurse practitioner who will “triage” her to the appropriate category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), have her strip in order to fully expose the large surface-area organ (the skin) for which she has sought assistance, give her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, shoving into the patient’s arms her bra and other structural and non-structural equipage, the doctor pushes her out into the hall, as the formal interview is over.
Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.
Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.
The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of those who are about to appear in public, say, at an impending dinner party. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a formal assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, agreeing, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitation and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the results.
Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?
DrRich has a word of advice for the commentators and reporters of the New York Times and any other concerned Americans worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.
Allow DrRich to support this friendly recommendation with two observations.
1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. The second tier, like the poor, will always be with us.
2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re widgets on an assembly line, then goes to her other, better office on Wednesday, treating the merely cosmetically-challenged like minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, she is practicing real, true, prescribed-by-society, by-the-book American healthcare on Tuesday, and doing Something Altogether Different on Wednesday.
Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.
Furthermore, when one looks objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, folks would do just fine with it.
Of course, doctors in general (and dermatologists in particular) have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing - which, in contrast to Botox injections, is an actual surgical procedure which results in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious offense.
And consider this. Dermatologists could just as easily have taken up a somewhat different well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the skin itself than Botox injections (which actually do not affect the skin itself at all, only the muscles under the skin), but they chose not to. DrRich speaks, of course, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly-technical skill like that.
The point, of course, is that injecting Botox does not involve intrinsic skill, knowledge, difficulty, risk, or any other objective characteristic that necessarily renders this a medical procedure while ear-piercing and tattooing are not. Viewed from this perspective, one must conclude that declaring the injection of Botox to be a medical procedure, which cannot be performed by anyone not having a medical license and years of specialty training, is an entirely arbitrary determination.
Fundamentally, then, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine. Rather, it is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.
Doctors engage in this sort of thing all the time. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some go to graduate school (usually for MBAs). Still others have opted to work part time in order to raise their families.
Society generally finds such activities acceptable, and - to this point - does not insist that all doctors forego all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty, it has not reached this point quite yet.
Until society sees fit to legislate otherwise (which, DrRich supposes, could happen as early as the next president’s administration), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming retainer practitioners.
One last word of advice for dermatologists: Have fun with your Botox clinics, fellas, but please don’t become too invested in them. Injecting Botox is not exactly cardiac electrophysiology. This is definitely a shallow-moat business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control - say, Congress or the FDA - could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots - but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.
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