Monday, July 13, 2009

Playing God: Bioethics and National Health Care

We have all seen the stories- Michael J. Fox, an actor I really like and admire, stricken with a serious disease, Mary Tyler Moore and diabetes. We’ve seen the tragedy of spinal cord injuries such as those suffered by Christopher Reeves. We see the famous and not so famous that clutch in desperation for any straw that offers them hope. This has been the impetus behind stem cell research. The controversy comes when the stem cells from fetuses, unborn children, are used. Studies have shown that adult stem cells react in the same way, but the controversy continues. Why should you care about this topic? Because it is one of the many covered under the umbrella of bioethical concern.

Bioethics is a branch of medical philosophy that weighs the ability to act against the assumed quality of life. In short, this is doctors playing God. And as we move towards a more controlled or as some say, rationed, measure of care, we need to be very specific in what we are getting into.

Consider this story:

“...When fetal stem cells are publicly discussed, three diseases—often represented by their celebrity spokespersons—lead a list of potential therapeutic applications. They are Parkinson Disease (Michael J Fox), paralysis as a result of spinal cord injury (previously the late Christopher Reeve), and Diabetes Mellitus, type 1, (either Mary Tyler Moore or Ron Santo). The media packages the information as foregone conclusions: fetal stem cells are a veritable source of untapped, and then implied, “unlimited” therapeutic uses. A stunning recent series of setbacks in the context of fetal stem cells and Parkinson Disease (PD), however, has not received equivalent publicity. It appears that the promise of this controversial, and as of yet unproven, therapeutic modality for an estimated one million persons with PD, has been scientifically exposed and found wanting.

The journal Nature Medicine published three articles in May 2008 analyzing eight patients from three separate cohorts who received human fetal midbrain tissue transplants 9-16 years earlier for PD.1 The published results led to two insightful editorial commentaries. The studies have dispelled the myth that fetal stem cells are a straightforward panacea for PD. In addition, they propose a plausible theory that these cells, even with continued research, may never work in this regard....

To translate, the researchers are finding that in their application of the proposed stem cell therapies, the reaction is NOT as they anticipated and in further examination, may never reach the goals that so many are intent on throwing millions of dollars in support. But let’s assume that these disabilities and injuries don’t impact your life directly. Why should you care? You should care because groups that support such research and efforts are politically placed in such a fashion through either their celebrity sponsors or their PAC’s to demand millions of dollars from the proposed healthcare bill in terms of research. But if we are going to be honest about the quality of research, should we not also be willing to admit that it is possible that the proposed “cures” may not work?

This is not the first instance of such politicizing of medical research for funding purposes. Consider the amount of money given for AIDS research. AIDS is a devastating disease and due to research those who have this disease are living longer, fuller more productive lives. Yet, they represent a small number within the population of people who are dying for a cure. Heart disease and cancer are the top two-and AIDS by relation of Karposi’s Sarcoma would fit in that category. But generally speaking, cancer, except in tragic circumstances is usually the disease of old age.

So this brings up another problem. If we have a finite amount of service slots available for medical care under a nationalize system, and we have more people needing services than there are slots, who gets priority? If you follow the bioethical limitations, you serve the younger and healthier in society before you serve the sick and aged. To bioethicists, this makes sense. But there is the slippery slope. Once you begin to codify procedure and medications into
narrow absolutes, you are in danger of ignoring the humanity of the patient. Consider the following excerpt from an NYT interview with President Obama:

“...THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting....”

In addition, the president has stated that if his wife or children were in medical peril, he would want the best care. “Quality of Life” assumptions aside, who would NOT want their family members to get the best of care. But what if that level of competency becomes unattainable due to the defacto rationing of services that a nationalized health care system would require. Please remember, the UK and Canada have both had to resort to allowing private insurance on top of what is assessed in taxes in order to allow everyone to get services on a somewhat timely basis. And even then, the wait for common ailments such as gall bladder disease and kidney stones lag far beyond what the majority of Americans would tolerate.

While the “best” care doesn’t always translate into the most costly care, it sets up a system where some people will get the “best care” and the rest of us will settle for what the government legally allows us to have. Congress has not shown itself willing to adhere to the less costly, and less special type of medical system that they expect the rest of America to embrace. In addition, there are plans to exact a penalty for those who choose private care from their employer in terms of an additional payroll tax. So responsibility will be punished, medical facilities compensated less and who wins here? The people who win are those who don’t pay into the system. But the unfortunate aspect of that is that many of the self-proclaimed “uninsured” qualify for medical care under already existing government programs. All they have to do is sign up. But the hurdles to that is the amount of paperwork. If this new program also involves paperwork, then what will we do when these same populations STILL don’t have coverage.

Then there is problem of penetration. Even the most optimistic of supporters of this nationalize healthcare system realizes that not all people will be covered. As a sort of microcosm of a possible program, we can look at what Massachusetts has done with their state health care system. Here’s an excerpt of what is going on in that program:

“...The Massachusetts law, which was championed by former GOP Governor Mitt Romney, imposed an individual mandate, requiring nearly all residents to buy health insurance or else pay a penalty. (The exceptions are those who qualify for the state's public program.) This was supposed to cover everybody and save money too. We've written before about how costs have exploded, but it also turns out that consumers have other ideas.

For 15 years Massachusetts has also imposed mandates known as guaranteed issue and community rating -- meaning that insurers must cover anyone who applies, regardless of health or pre-existing conditions, and also charge everyone the same premium (or close to it). Yet these mandates allow people to wait until they're sick, or just before they're about to incur major medical expenses, to buy insurance. This drives up costs for everyone else, which helps explain why small-group coverage in Massachusetts is so much more expensive than in most of the country. Mr. Romney argued -- as Democrats are arguing now -- that the individual mandate would make that problem disappear, since everyone is always supposed to be covered.

Well, the returns are rolling in, and a useful case study comes from the community-based health plan Harvard-Pilgrim. CEO Charlie Baker reports that his company has seen an "astonishing" uptick in people buying coverage for a few months at a time, running up high medical bills, and then dumping the policy after treatment is completed and paid for. Harvard-Pilgrim estimates that between April 2008 and March 2009, about 40% of its new enrollees stayed with it for fewer than five months and on average incurred about $2,400 per person in monthly medical expenses. That's about 600% higher than Harvard-Pilgrim would have otherwise expected....”

There are lots of numbers thrown around, but in helping my daughter find individual healthcare, she was able to find insurance for less than $100 a month with pre-existing conditions. As with any other budgetary concern, families can choose to spend their money any way they want. For example, it alwasy amazes me how some students don't have money for school supplies, but seem to have money for costly manicures and expensive clothes from the likes of Hollister and Abecrombie and Fitch. Everyone makes choices, but with political power pressing the requisite of health insurance, this changes the playing field.For example, in Texas we are supposed to have car insurance to drive. But 25% of us do not have that kind of financial responsibility. What happens is that the rest of the responsible driving population must pay higher premiums and be covered for uninsured drivers in order to make up the difference. I don't see anything changing just because this is medical insurance. In fact, given the political powers that drive hospitals, schools and police away from demanding an ID in return for services, I think this kind of program will be absolutely gutted by the fraudulent use of identities to recieve services. And before you deny this, consider the amount of fraud that was recently discovered in the social security system wherein dead people were receiving payments.

What this boil down to is do you want someone else, someone who doesn't know you, making life and death decisions? While this administration uses the crutch of technology to forge their program, remember that with more interconnectivity, there is also more of a chance for your private medical history to become public knowledge. HIPPA laws were developed to avoid the possibility of employers finding out employees secrets, but how many people do you know who seek drug dependency, psychiatric help or other possible services that could be viewed negatively, off the books and on their own dime? That would be impossible under this system. While the government likes to assume privacy will be kept, once it is in the system, your information is no longer your own.Currently there is no law that you must accept whatever your employer offers. Sometimes you can do better on your own and there is certainly more privacy under an independent plan. But not every family will make those choices. I know of very well to do families who don’t get health insurance at all. I guess they hope and pray they never have to go to the hospital. I also know people who believe they can simply skip out on medical bills. The sad thing is that all of these scenarios drive up the cost for everyone that does the responsible thing and gets insured. And what is worse, if we are forced into a program that presumes to make ethical decision for us through the withholding of care, then we really have to question who is playing God here.

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