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Richard Fogoros, M.D.  
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Healthcare Reform: Then (1994) And Now (2009)

May 20, 2009 - 5 comments
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healthcare reform

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healthcare

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reform



DrRich has been around long enough to remember the sequence of events that accompanied the collapse of healthcare reform under the Clintons in 1993 - 1994.  (Heck, he has been around long enough to remember Nixon’s plans for healthcare reform, which drowned in Watergate.) When President Clinton was inaugurated, everyone agreed that the American healthcare system was in a state of crisis (e.g., spending levels could not be sustained, there were too many uninsured, there was too much waste and inefficiency, etc., etc.), and that the time for fundamental reform had finally arrived. We had a fresh, dynamic, young President with new ideas and with a solid majority in both houses of Congress, and he was armed with polls showing that the people were in favor of fundamental reform.

Accordingly, when Mrs. Clinton put together her working groups to devise a reform plan, she initially had the enthusiastic participation of numerous interest groups within the healthcare industry - notably including the insurance companies, physician groups, and drug and medical device companies.

But when she finally produced her plan - a disturbingly heavy tome filled with frightening details - everybody was horrified with at least some of the stuff they found there. Most of the big interest groups turned on her - most notably, the insurance industry, which then launched the famous Harry and Louise commercials to scare the people about government healthcare. The people, now duly scared, called their congresspersons, who (despite the Democrat majority) ended up sending Mrs. Clinton’s healthcare reform to a crushing and humiliating defeat. And the Republicans were able to capitalize on the “near miss” of the Clinton’s brazen attempt at socialism, and in 1994 ushered in 12 years of a Republican majority in both houses of Congress.

Obviously, for those Republicans and other observers who abhor Mr. Obama’s plans for healthcare reform, it is relatively easy to see parallels between what happened in the early 1990s, and what appears to be shaping up now. Those parallels, and the subsequent ignominious defeat of the Clinton plan, are the only things keeping these sorry individuals from donning sackcloth, heaping ashes upon their heads, and engaging in public self-flagellation.

So, perhaps, for such outsiders the spectacle of the major private healthcare interests this week throwing in with the Obama administration will be seen as one more sign from the gods that the parallels of 1994 are falling into place.

But they are wrong.

There are at least three important differences between the enthusiastic participation of private interests in Mrs. Clinton’s working groups on healthcare reform, and the action taken this week by representatives of insurers, doctors, drug companies, hospitals, and medical device manufacturers to pledge their undying support for President Obama’s efforts at healthcare reform.

First, in 1993 the private interests were powerful and confident. They participated in the process because they felt they could control it. It turned out they were wrong, of course - the only one who has been able to out-maneuver the Clintons is Mr. Obama - and the plan Mrs. Clinton finally produced (despite all the “input” from diverse private interests) really was a blueprint for a full government takeover of healthcare, all spelled out and wrapped with a bow.  But because the private interests were powerful and confident in those days, once they figured out what the Clintons actually had in mind they were able to scuttle healthcare reform entirely.

In contrast, today the private interests have come to the table not out of strength, but out of weakness. They come not as partners in negotiation, but as vanquished foes. They come to Obama as the Carthaginians came to the Romans after the second Punic war, suing for peace, begging for terms, offering massive tribute (in this case, $2 trillion) in exchange for being permitted to eke out a meager survival, at the edge of the desert. (DrRich wonders whether the insurance companies and their friends remember the third Punic war.  Surely they must know that somewhere in Congress is another Cato the Elder, ending every speech with the words, “The insurance industry must be destroyed,” and that at some point their remaining, puny base of operation will be completely sacked, and their mission statements sown with salt.)

Second, whereas Mrs. Clinton was a major policy wonk who reveled in providing a fully-fleshed-out and exquisitely detailed set of plans for healthcare reform - thus giving her foes sufficient ammunition not only to defeat her reform plan, but also to banish the Democratic Party to the wilderness for three election cycles - Mr. Obama is not. His reform plan will be bare-bones - merely an outline, more-or-less a statement of principles. There will be nothing to attack, since there will be no details, and little will be spelled out. (Implementing the plan will be left to unelected bureaucrats and regulators, who are always happy to produce prodigious amounts of undecipherable and self-contradictory detail.) This time, at least prior to its actual implementation, critics of the reform plan will be left trying to attack a phantom.

And third, this time there is no Plan B.

In 1994, once the private interests had scuttled the Clinton healthcare plan, they immediately offered an alternative. They came to us and they said: “Citizens!  We have just now dodged a bullet! Thanks to us insurance companies, doctors, drug companies and other patriots, the frightening socialist machinations of the Clintons have been defeated, and the Evil Ones have been reduced to embracing our agenda of tax reform and welfare reform as if it were their own.  But where does this leave our healthcare system? We stand now between Scylla and Charybdis, between the spectre of socialized healthcare on one hand, and the continued profligacy of traditional fee-for-service on the other, and we cannot survive either.

“But here,” they continued, “is a third way. A painless way, an American way, based on the principles of managed care, open markets, and free enterprise. Let healthcare become a business, like any other business, and let the natural efficiencies of the marketplace find ways to cut costs and improve quality, and with minimal government intervention.”

And thus we were launched into an era of managed care run by HMOs and other similar creatures of the insurance industry. And over the past 15 years, while managed care has utterly failed to produce any of the things it promised, it has not been for a lack of trying. They indeed have tried numerous things to control spending, from the reasonable-sounding to the absurd to the frankly murderous, and despite all their strenuous efforts the healthcare system remains a morass of confusion, waste, and inefficiency, and its costs are many times what they were in 1994.

To say it another way, the private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do.

And that’s why they have now fully abandoned their old allies, the Republicans (who are off somewhere - one knows not where - muttering to each other about the efficiencies of the marketplace, and wondering why nobody is listening to them). The last thing the insurance industry wants to hear today is that the burden of figuring out how to control healthcare costs belongs to them. They’ve tried everything they know and have failed, and they are desperately seeking terms for surrender.

So there is no Plan B this time. As of this week, the private interests have formally and publicly admitted they don’t have a clue. They’re throwing in with President Obama, despite the fact that they have no leverage with him whatsoever, not because they believe in his reform plans (which have not even been described in their most skeletal form), but because there is no place else for them to go.

And so, the last obstruction to healthcare reform has been removed. The path - the only path - is clear. If we fail to get comprehensive healthcare reform now, it can only be for one reason. It can only be because Mr. Obama and the Democrats, looking down that wide open road, will be unable to avoid seeing where it leads, and will decide that they do not want to be the administration or the party that finally has to begin saying the “R” word in public.

To turn away from healthcare reform now, when the way seems so clear, would be a crushing blow to them, and would likely not be politically survivable. But to go on will likely force them to begin speaking a truth - that rationing is unavoidable - whose name is more taboo than ever was the name of Yahweh. And every high priest of the ruling class knows that even hinting about healthcare rationing is political suicide.

But still, there it is. There is no Plan B.

Talk about Sylla and Charybdis.

*This blog post was originally published at the Covert Rationing Blog. (http://covertrationingblog.com/)*

Why Does America Love Dr. House?

Apr 19, 2009 - 55 comments
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house

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ethics

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medical ethics

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dr house

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doctor house



DrRich thanks the Cockroach Catcher (http://cockroachcatcher.blogspot.com/2009/03/house-md-95-vs-5.html) (his favorite retired child psychologist) for pointing him to an article (by Mark Wicclair, a bioethicist) and an accompanying editorial (by Deborah Kirklin, a primary care physician) in the peer-reviewed medical journal, Medical Humanities, which deconstruct the television show “House MD.”

A TV show may at first glance seem a strange subject for a medical journal, but this is, after all, a journal whose subject is the “softer” side of medical science. (DrRich hopes his friend the Cockroach Catcher will take no offense at this characterization, and directs him, in the way of an apology, to the recent swipes DrRich has taken at his own cardiology colleagues for their recent sorry efforts at “hard” medical science.)  Besides, the Medical Humanities authors use the premise and the popularity of “House MD” to ask important questions about medical ethics, and the consequent expectations of our society.

DrRich does not watch many television shows, and in particular and out of general principles he avoids medical shows. But he has seen commercials for House, and has heard plenty about it from friends, so he has the gist of it. The editorial by Dr. Kirklin summarizes:

    “[House] is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary.”

Given such a premise, the great popularity of “House MD” raises an obvious question.  Dr. Kirklin:

    “… why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House?”

Indeed. While it has not always been the case, maintaining the autonomy of the individual patient has become the primary principle of medical ethics. And medical paternalism, whereby the physician knows best and should rightly make the important medical decisions for his or her patient, is a thing of the past.

It has been formally agreed, all over the world, that patients have a nearly absolute right to determine their own medical destiny. In particular, unless the patient is incapacitated, the doctor must (after taking every step necessary to inform the patient of all the available options, and the potential risks and benefits of each one) defer to the final decision of the patient - even if the doctor strongly disagrees with that decision. Hence, the kind of behavior which is the modus operandi of Dr. House should be universally castigated.

So, the question is: Given that House extravagantly violates his patients’ autonomy whenever he finds an opportunity to do so, joyfully proclaiming his great contempt for their individual rights, then why is his story so popular? And what does that popularity say about us?

To DrRich, the answer seems quite apparent.

The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics, of course, is entirely consistent with the Enlightenment ideal of individual rights. This ideal first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this ideal culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy - or to put it in more familiar terms, individual freedom - is the foundational principle of our culture, and it is one that is perpetually worth fighting and dying to defend.

So the idea that the autonomy of the individual ought rightly to predominate when it comes to making medical decisions is simply a natural extension of the prime American ideal. Of course, most think, this ought to be the governing principle of medical ethics.

But unfortunately, it’s not that easy. There’s another principle of medical ethics that has an even longer history than that of autonomy - the principle of beneficence. Beneficence dictates that the physician must always act to maximize the benefit - and minimize the harm - to the patient. Beneficence recognizes that the physician is the holder of great and special knowledge that is not easily duplicated, and therefore has a special obligation to use that knowledge - always and without exception - to do what he knows is best for the patient. Dr. House is a proponent of the principle of beneficence (though he is caustic and abrasive about expressing it).  DrRich believes House is popular at least partly because the benefits that can accrue to a patient through the principle of beneficence - that is, through medical paternalism - are plain for all to see.

Obviously the principles of beneficence and of individual autonomy will sometimes be in conflict.  When two worthwhile and legitimate ethical principles are found to be in conflict, that is called an ethical dilemma. Ethical dilemmas are often resolved either by consensus or by force. In our case, this dilemma has been resolved (for now) by consensus. The world community has deemed individual autonomy to predominate over beneficence in making medical decisions.

DrRich’s point here is that Dr. House (the champion of beneficence) is not absolutely wrong. Indeed, he espouses a time-honored precept of medical ethics, which until quite recently was THE precept of medical ethics. There is much to be said for beneficence. Making the “right” medical decision often requires having deep and sophisticated knowledge about the options, knowledge which is often beyond the reach of many patients. And even sophisticated patients who are well and truly medically literate will often become lost when they are ill, distraught and afraid, and their capacity to make difficult decisions is diminished. Perhaps, some (like House) would say that their autonomy ought not be their chief concern at such times. Indeed, one could argue that in a perfect world, where the doctor indeed has nearly perfect knowledge and a nearly perfect appreciation of what is best for the patient, beneficence should take precedence over autonomy.

It is instructive to consider how and why autonomy came to be declared, by universal consensus, the predominant principle of medical ethics. It happened after World War II, as a direct result of the Nuremberg Tribunal. During that Tribunal the trials against Nazi doctors revealed heinous behavior - generally involving medical “research” on Jewish prisoners - that exceeded all bounds of civilized activity. It became evident that under some circumstances (circumstances which under the Nazis were extreme but which were by no means unique in human history) individual patients could not rely on the beneficence of society, or the beneficence of the government, or the beneficence of their own doctors to protect them from abuse at the hands of authority. Thusly was the ethical precept which asks patients ultimately to rely on the beneficence of others starkly revealed to be wholly inadequate. The precept of individual autonomy, therefore, won by default.

Subsequently, the Nuremberg Code formally declared individual autonomy to be the predominant precept in medical ethics, and beneficence, while also important, to be of secondary concern. Where a conflict occurs, the patient’s autonomy is to win out. It is important to note that this declaration was not a positive statement about how honoring the autonomy of the individual represents the peak of human ethical behavior, but rather, it was a negative statement. Under duress, the Nuremberg Code admitted, societies (and their agents) often behave very badly, and ultimately only the individual himself can be relied upon to at least attempt to protect his or her own best interests.

DrRich will take this one step further. When our founders made individual autonomy the organizing principle of a new nation, they were also making a negative statement. From their observation of human history (and anyone who doubts that our founders were intimately familiar with the great breadth of human history should re-read the Federalist Papers), they found that individuals could not rely on any earthly authority to protect them, their life and limb, or their individual prerogatives. Mankind had tried every variety of authority - kings, clergy, heroes and philosophers - and individuals were eventually trampled under by them all. For this reason our founders declared individual liberty to be the bedrock of our new culture - because everything else had been tried, and had failed. In the spirit of the enlightenment they agreed to try something new.

There is an inherent problem with relying on individual autonomy as the chief ethical principle of medicine, namely, autonomous patients not infrequently make very bad decisions for themselves, and then have to pay the consequences. The same occurs when we rely on individual autonomy as the chief operating principle of our civil life. The capacity of individuals to fend for themselves - to succeed in a competitive culture - is not equal, and so the outcomes are decidedly unequal. Autonomous individuals often fail - either because of inherent personal limitations, bad decisions, or bad luck.

So whether we’re talking about medicine or society at large, despite our foundational principles we will always have the tendency to return to a posture of dependence - of relying on the beneficence of some authority, in the hope of achieving more overall security or fairness - at the sacrifice of our individual autonomy. In DrRich’s estimation the popularity of “House MD” is entirely consistent with this tendency. (Indeed, the writers almost have to make Dr. House as unattractive a person as he is, just to temper our enthusiasm for an authority figure who always knows what is best for us and acts on that knowledge, come hell or high water.)

Those of us who defend the principle of individual autonomy - and the economic system of capitalism that flows from it - all too often forget where it came from, and DrRich believes this is why it can be so difficult to defend it. We - and our founders - did not adopt it as the peak of all human thought, but for the very practical reason that ceding ultimate authority to any other entity, sooner or later, guarantees tyranny. This was true in 1776, and after observing the numerous experiments in socialism we have seen around the world over the past century, is even more true today.

Individual autonomy will always be a very imperfect organizing principle, both for healthcare and for society at large. Making it an acceptable principle takes perpetual hard work, to find ways of smoothing out the stark inequities, without ceding too much corrupting power to some central authority. This is the great American experiment.

Those of us who have the privilege of being Americans today, of all days, find ourselves greatly challenged. But earlier generations of Americans faced challenges that were every bit as difficult. If we continually remind ourselves what’s at stake, and that while our system is not perfect or even perfectable, it remains far better than any other system that has ever been tried, and that we can continue to improve on it without ceding our destiny - medical or civil - to a corruptible central authority, then perhaps we can keep that great American experiment going, and eventually hand it off intact to yet another generation, to face yet another generation’s challenges.

*This blog post was originally published at the Covert Rationing Blog. (http://covertrationingblog.com/)*