Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD

Art Caplan Lecture – Society of Critical Care Medicine

SCCM – Society of Critical Care Medicine:
“Max Weil Honorary Lecture
Arthur Caplan, MD
University of Pennsylvania
Philadelphia, Pennsylvania, USA
Beyond Band-Aids: How to Cure America’s Ailing Healthcare System
Arthur Caplan, MD, argued that the United States healthcare system is broken, and it is important to evaluate the various healthcare reform proposals and their political feasibility. Healthcare professionals should have a prominent place in the discussion to ensure ethical and meaningful reforms.”

Dr. Caplan spent the bulk of his time making the ethical case for healthcare reform. He based his argument on the right to opportunity, or equal opportunity, of all citizens to be free from the encumbrances of illnesses untreated due to lack of personal resources or lack of resources from our social safety net.

Fair enough, but I think this argument will fall flat, of course, to those who oppose health care reform of any stripe, but I think it rings peculiarly hollow to most others as well, including the most fevered advocates for reform.

I will be flagging my ignorance of formal ethics and bioethics here, as I am, like most, simply an amateur (but nonetheless opinionated) ethicist. (But, I am an intensivist, so maybe I am semi-pro?)
I think in addressing health care professionals, it is reasonable to appeal to their professionalism. In the Charter on Medical Professionalism, we are called to advocate for Social Justice:

“Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. “

And this argument does need to be made to specialty physician organizations. Repeatedly. Many of our organizations have devolved into glorified trade organizations, only springing into action when income or clinical territory are threatened. We need to call ourselves and our colleagues to the better angels of our nature.

But this is really only the tip of the iceberg required to make the ethical case for universal healthcare. The real case rests on our common humanity, our common respect for the dignity of man, The Golden Rule.

A recent program aired on Bill Moyers Journal called “Beyond Our Differences”, which explored the common themes of all world religions. It is a terrific program and I advise everyone to watch it, preferably with your family.

Is there a moral philosophy on the planet that does not require us to care for the least among us? Is there one which does not require us to care for the poor, the sick, the hungry to the best of our ability? Is there one that does not require us to respect the dignity of our fellow humans?

I like to joke that there is such a philosophy, Ayn Rand’s Objectivism. Maybe there are other philisophical schools of thought that also reject these tenets, I will let the real philosophers out there correct me. But all religions, east and west, and secular humanism all carry forward this strong ethical mandate. As I look through my “Social Justice” subject tag, quite a lot are covered: Catholics and the Jesuits, Charles Dickens (and Protestants and humanists), physicians, Jews, and even the self-intersted. The “Beyond Our Differences” program covers these and more.

So, how to make the ethical argument? I think we must rely on our common humanity, our common philosphy of honoring the dignity of our fellow humans and doing our duty as citizens of a great country to “promote the general Welfare”.

But better yet, let me sum it up as Uwe Reinhardt would, “Go explain to your God why you cannot do this, and he will laugh at you.”

Medical Professionalism in the New Millennium: A Physician Charter — Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 — Annals of Internal Medicine

Social Justice and a commitment to a fair distribution of finite resources has always been a core of who we are as physicians and as human beings. With the renewed emphasis on professionalism in medicine, it is being reintroduced as part of the core of our values as physicians. This is very welcome, but does not sit so well with some of our more conservative colleagues, as you’ll see below.

Medical Professionalism in the New Millennium: A Physician Charter — Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine* 136 (3): 243 — Annals of Internal Medicine:

“Fundamental Principles:

“Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

“Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

“Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category. “

In the next section, A Set of Professional Responsibilities:

“Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

“Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others.”

Response Letter in Annals of Internal Medicine, by Christopher Lyons, in part:

“In the charter’s preamble, the concept of medicine’s contract with society is discussed. To a large extent, the obligations of physicians to society in that contract are nicely laid out in the subsequent discussion. Given that a contract is usually created between two parties and each party has an obligation to the other, what is society’s responsibility to physicians? As highly trained, caring members of society, aren’t physicians entitled to certain assurances of financial stability? Should we be expected to withstand ongoing efforts to politicize the health care industry in attempts to garner votes while balancing the federal budget? Must we continue to withstand repeated attacks from trial attorneys who have little interest in the facts of a medical case and are interested only in the payoff? “

Another, by Jerome Arnett, in whole:

“I read with interest the article on medical professionalism in the new millennium (1), which proposed a new code of conduct for physicians comprising three principles and 10 responsibilities. As a proposed code of ethics, the charter is untenable for several reasons. Two of the three principles conflict. Patient welfare is predicated on individual rights while social justice is based on group rights (those of “society”). Since individual rights and group rights are mutually exclusive, the physician can follow one of these two principles but not both (2). In addition, at least 2 of the 10 responsibilities (public advocacy and just distribution of finite resources) place the interests of others ahead of those of the patient. Physicians will be less likely to subscribe to an ethical code that does not have the welfare of the patient as its highest objective.

“Equality of outcome is an undesirable and unattainable vision that invariably results in the loss of patients’ rights. Only under socialism (government medicine or corporate socialized medicine) are health care resources finite, so that they must be rationed or justly distributed. Under other circumstances, the provision of services”necessary” or “unnecessary”to one patient does not diminish the resources available for others.

“The commitment to maintaining trust by managing conflicts of interest forbids physicians to pursue private gain or personal advantage. How then is it ethical for a group of physicians such as the Medical Professionalism Project to weaken our code of ethics in order to promote a political agenda (improving “the health care system for the welfare of society,” promoting “the fair distribution of health care resources,” or ensuring social justice)? These proposed changes in our time-honored, patient-centered ethics will worsen, not improve, the dilemma of today’s physicians, who already are challenged by new technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. But even more ominous, medicine without effective, patient-centered ethics is no longer a profession but merely a tradewhich was its status in ancient Greece before the Oath of Hippocrates.

Reference number 2 is:
2. Vazsonyi B. America’s 30 Years War: Who Is Winning? Washington, DC: Regnery; 1998:79.

Two of the authors, Drs. Cruess and Cruess, reply, very diplomatically:
“IN RESPONSE:

“Although Dr. Arnett’s points are well taken, the charter isnot a code of ethics, nor is it intended to detract from orsupplant the Hippocratic tradition that has long enriched medicine’shistory. It is a statement of contemporary responsibilities—medicine’sunderstanding of its obligations under today’s social contract.We strongly disagree that individual rights and group rightsare mutually exclusive and that “the physician can follow oneof these two principles but not both.” We do not underestimatethe difficulty of reconciling the two sets of responsibilitiesbut believe passionately that medicine must attempt to do so.The alternative is for someone without medical knowledge orexpertise to determine the societal rights in health care andhow they are to be reconciled with the rights of individualpatients. Do we really wish this to occur, or do we believethat it is better for individual physicians and their organizationsto use their expertise to try to achieve the proper balance?The charter suggests the latter course. It does, however, statethat physicians must put the welfare of the individual patientfirst, thus reaffirming our traditional fiduciary responsibilities.Our duties to individual patients must be carried out with aknowledge of the impact of our own decisions on the wider society,which we also serve. We also disagree that the allocation ofresources to one patient does not diminish the resources availableto others under a market-driven system. The attempts at costcontainment seen throughout the world, no matter what the natureor structure of the health care system, indicate that this isnot true. There is no question that contemporary physiciansare expected to serve both their patients and society.

“A second point of some importance refers to “equality of outcome.”We are not sure that equality of outcome can be termed “undesirable,”as Dr. Arnett stated, but certainly such an objective is unrealistic.Nowhere does the charter advocate equality of outcome as anobjective.

“Dr. Arnett interprets the charter as forbidding physicians’pursuit of private gain or personal advantage. Nowhere doesit so state. The conflicts of interest section states that physiciansmust deal with these conflicts in an open and transparent way.We cannot eliminate conflicts of interest, but we must ensurethat our integrity is preserved as we cope with and manage themand recognize the consequences of our decisions.

“We agree with Dr. Arnett that without effective patient-centeredethics, medicine is no longer a profession. As already mentioned,the charter is not a code of ethics but a freely given statementof medicine’s commitments and responsibilities, essentiallyoutlining where we should stand in complex times. It is aimedat restoring the feeling of pride in the profession and publictrust that all observers have agreed is so essential to theproper functioning of a profession and distinguishes it froma trade.”

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung-mei cheng | PBS

FRONTLINE: sick around the world: interviews: uwe reinhardt & tsung–mei cheng PBS

Wow. I can’t say enough about this interview. It is so on the mark in so many ways, and it is a pleasure to hear knowledgeable people discuss comparative international healthcare like this.

There are great bits on the real meanings of “socialized” medicine, vs socialized insurance, the German (!) perspective on the dignity of every person, the Canadian perspective on humanism, the leadership of Tony Blair turning around a system on the rocks, how terrifically well America does in training its healthcare providers (especially doctors), but the best is Reinhardt’s take on “Consumer Driven Healthcare“, quoted here:

We’ve heard some people have proposed that a solution for America is something called consumer-driven health care. How does it work? What is it?

… Well, the name “consumer-driven health care” at this time is a deceptive marketing label. What we’re really talking about is an insurance policy with a very high annual deductible — up to $10,500 per family, and less for an individual — and then coupled with a savings account into which you can put money out of pretax income; you don’t have to pay taxes on such income.

Now, this has the advantage … that people faced with this deductible will think twice before going to the doctor for trivial issues or drugs they don’t need, etc. But of course the problem also is that they may not go when they should or may skimp on the drugs they should be using, like a blood pressure drug, so that one would have to be solved by saying preventive services will have first-dollar coverage. So you could solve that problem.

But then what I argue is, yes, it may have the economic effect of cost control, because you then would have to know the prices different doctors charge, and hospitals and pharmacies, and something about the quality. And that information at this time exists only in a few areas. The insurance companies are beginning to work on Web sites that will give you that, but it’s still very primitive and fairly unreliable information. So that is why I compare it really more like thrusting someone into Macy’s department store blindfolded and say, “Go around; shop smartly.” …

The other problem that I see with it, though, is it has ethical dimensions to it that people don’t appreciate. If I make anything tax-deductible, then a high-income person in a high tax bracket saves more than a poor [person]. So supposing a gas station attendant and I each put $2,000 into a health savings account, and we get a root canal — about $1,000, just the drilling. It costs me about $550 because I’m in the 45 percent bracket. The gas station attendant may, in fact, not pay federal income tax because the income is so low but may only pay Social Security, so he saves 8 cents on the dollar. So a root canal will cost me $550; will cost him $920. …

Secondly, think of a family of two professionals, each making $140,000, close to $300,000 income, and they have, say, a $5,000 deductible. Would they deny their child anything that they think the child needs over a lousy $5,000? … But think of a waitress who makes $25,000 with a $5,000 deductible, and her kid is sick. It will certainly make her think twice. She’s likely to say, “Maybe not.” So therefore we’re asking the lower half of the income distribution to do all the self-rationing through prices. …

And the third issue is this deductible. If you’re chronically healthy, you don’t actually ever spend as much as that; you have a tax-free savings account. If you are chronically ill, on five drugs, you’re going to spend that deductible year after year. So the proposal is to shift more of the financial burden of health care from the shoulders of the chronically healthy to the shoulders of the chronically sick.

And I would say, imagine a politician coming to the people with a platform that I just described in ethical terms. … You think that would sell? So they say, “We’ve got to find a better name. Why don’t we call it consumer-driven health care?,” and have all these deceptive labels that even George Orwell wouldn’t have thought of. That is what I find troublesome. Yes, it’s an approach to health care, but could you please describe it to the American people honestly, in all of its dimensions — not just economics but information and ethics? And that’s not done. …

One answer he gave about physicians income left me with more questions that when I started:

Yes, American doctors get paid more, relative to average employees, than doctors in other nations; that is true. It’s about five times average employee compensation, and in England it’s about two, and in Canada it’s about three. So that’s certainly true.

Given the unprecedented income disparity in this country, it is hard to know what to make of these figures. Comparison to the median would have been more helpful, but I think the most interesting would be to see in which decile physicians place in each country. I will try to find that data.

This Frontline Website is a gold mine. Thanks to the indispensable CPB.

The Conservative Beatitudes

And turning His gaze toward His disciples, He began to say, “Blessed are you who are rich, for clearly God loves you best.

Blessed are you who conspicuously consume now, may you always be satisfied.

Blessed are you who live the good life now, for you have clearly earned it. Or inherited it. Or fell into it. Doesn’t matter. Have at it.

Blessed are you when men envy and resent you, because God has bestowed wealth on you and your fathers and your children. Be glad in that day and leap for joy, for behold, your reward is forever, for God finds the Death Tax an abomination

But woe to you who are not-so-rich or downright poor, for you are receiving what you deserve. And don’t be asking for entitlements, for a safety net is an abomination to God also. And besides, it builds character and maybe your children will find favor and wealth with God.

Woe to you who are hungry now, for you shall be hungry until you and your wife both get second jobs.. Woe to you who mourn and weep now, for you must pick yourself up by your bootstraps to be right with God.

Blessed are you when all men speak against you for your avarice, for their fathers used to treat the robber barons in the same way.

But I say to you who hear, screw your enemies, do misery to those who hate you,
crush under your heel those who curse you, pray for those who distrust you, so they may see your rightness with God.

Whoever hits you on the cheek, hire another to smite him severely and teach him a lesson; and whoever takes away your coat, prosecute him to the fullest extent of the law.

Give to nobody who asks of you, for it only encourages them to be lazy and dependent.

Treat others the same way you want them to treat you. Unless it involves taxes or money or any inconvenience to you. Then do whatever you believe God wants, for you are a favored one.

Blessed are you if you love those who love you, for that is impressively wonderful of you. God does not expect you to worry about others, that is God’s job. And if it looks like others are suffering, well that’s not your concern. God will provide (within reason).

If you do good to those who do good to you, what more could God expect?

If you lend to those who are lesser in God’s eyes, make sure you get a good rate, at least 6 over prime. With multiple penalty provisions.

But love those also favored by God with wealth, and do good, and lend, expecting almost nothing in return to them; and your reward will be great, as favors beget favors and you will be most assuredly taken care of.

Be merciful, within reason; don’t go crazy on this one.

Judge harshly those who do not live up to your standards and are clearly not favored by God with wealth and privilege, for they need your tough love to better themselves.

With apologies to Al Franken and Supply Side Jesus…

Addendum:

Render unto Caesar that which is Caesar’s. But only for those things which benefit you, your family or your business interests personally such as defense, transportation, the civil and international courts, and the like. Oppose Caesar’s attempts to use your money to promote the general welfare with a social safety net, healthcare or anything else that you don’t personally need. And do not ask why. God is mysterious and beyond your ability to understand. And render a few bucks to charity now and then. You’ll feel better.