The Gift: a Parable for Our Time

Once upon a time lived a woman who loved to garden and care for creation. Her home was a cottage, handed down through the generations, which she had surrounded with the beauty and fragrance of flowers of every variety. While not wealthy, she was content and at peace surrounded by the splendor of creation.

One day, while digging in a far corner of her yard, she came upon a solid object in the soil. Carefully excavating it, she was surprised to discover what appeared to be a wooden chest. She lifted it from its earthen grave and set it upon the grass, beholding it for a while, pondering its origins and the reasons for its burial. The wood was weathered and worn, the brass fittings tarnished. Her hands gently stroked its surface and edges, probingly. After several moments of embracing the mystery, her fingers deftly released the latch. Lifting the lid, the sunlight reflected brilliantly off of a collection of glass bottles each filled with clear liquid. Again, as she pondered the significance of these bottles, her eyes caught sight of a yellowed envelope attached to the lid of the box. She opened the envelope. Inside was a small piece of paper on which was inscribed a simple message: “ A gift of healing.”

She pondered. She contemplated. She considered her own poor eyesight, wondering if it would help. She removed the top of one bottle, inhaled its fruity fragrance, and tipped the bottle to her lips, tasting its sweetness. Suddenly she noticed her vision blur. In panic she set down the bottle, removed her heavy-lensed glasses, and rubbed her eyes only to discover that her vision was crystal clear. Brimming with excitement, she was amazed and in awe of this “gift.” How could she best to use this remarkable gift? It took her only a moment to recall the crippled man who often inhabited a busy street corner of her town. Would it work for him as well? Hurriedly, she recapped the bottle, placed it carefully in her shoulder bag, washed her hands, and set out for town, filled with anticipatory joy.

As she neared the corner, there she saw him, huddled against a building, with a worn shawl draped over his shoulders. She approached him excitedly, pulled the bottle from her bag, along with a small cup, poured a small amount of the golden liquid into the cup and extended it to him. “Try this. It may help.” He reached out his withered and trembling hand to take the cup with a look of puzzled gratitude in his eyes. But as he did so, a figure in a black coat and hat stepped from the shadows, interposing himself between the reaching hand and the extended cup.

Facing the woman, the imposing figure said, “Excuse me. Do you have a license to distribute tonics?” “Well, no…I was hoping to help…” “Not without a license,” he retorted. She stared into his face, veiled in shadow, struggling to discern the meaning of the intrusion. But after a moment of silence that stretched into eternity, she withdrew the cup, returned the liquid to the bottle and headed home—disheartened but determined.

Weeks later, the license arrived in the mail. She quickly packed up her bottle and cup and returned to the corner. The man was there as usual. Again she poured some of the liquid into the cup and extended it to the man. As his hand reached out, the figure in the black coat and hat stepped from the shadows again. Quickly the woman produced the license to distribute tonics, but without looking at the license, the man in black demanded, “Is your tonic registered?” “No, but I have a license.” “That will not do. To be distributed the tonic must be registered.” Again, she slowly withdrew the cup, replaced the liquid, and turned for home, discouraged but resolute.

More weeks passed. The registration arrived in the mail. She placed the registration in her bag with the license and bottle of healing liquid and headed to town, her steps burdened but hopeful. Again she poured the liquid into a cup and extended it to the man. And again the figure stepped out. She pulled out the license and the registration, but he said, “Excuse me. This man is not enrolled in a healing program. He must be enrolled before he can receive your tonic.” She turned and headed for home, now disillusioned.

After many months of protocols and paperwork, the man was successfully enrolled in an appropriate program. With paperwork in hand she returned to the corner, her footsteps reflecting the apprehensive heaviness in her heart. Yet believing all was finally in order, she reached the man, pulled out the bottle, filled the cup and smiling with sad ambivalence, extended it to him once again. As his hand was haltingly extended, the figure interjected himself once again. She reached in her bag and produced the required documents. “I’m sorry, but this man has not undergone the steps required before administration of a tonic.” She stared at the figure, open-mouthed, disbelieving. All she wanted to do was share her gift. After a few moments of open-mouthed disbelief, she closed her mouth, replaced her documents and her tonic, turned and slowly returned home, dispirited, demoralized, without hope, deprived of joy.

Upon reaching home, she took the bottle out of the bag and placed it carefully back into the chest. Closing the chest, she picked it up and carried it to the backyard. Taking a shovel, she began slowly and deliberately to re-dig the hole in the corner of her backyard. With a heavy heart, she replaced the chest into the hole and slowly, sadly, shoveled dirt mixed with tears, back onto the chest. On top of the soil she then planted a single lily.

While on an errand a week later she passed sorrowfully by the corner. The man was no longer there. But lying abandoned beside the building was the worn and tattered shawl. In that moment, she realized that they both had been deprived of the benefit of her gift: he of the healing; she of the joy of giving.

We live in a world that has been richly and diversely gifted by God, a world in which receiving and giving are to reciprocally mark our lives. We were created to receive our many gifts from God’s hand, not solely for our own purposes, but in order to extend those gifts to others in love. The great reward of such giving is joy—the joy we receive in return for giving—but the act of giving also frees our hands to accept more of God’s gifts. Thus in God’s economy, the reciprocity of receiving and giving provide benefits to the recipients of His gifts and joy to the hearts, souls, and lives of those who give.

But we live in a world that is rapidly changing, a world in which it is believed that regulations are required for the protection of one against another. Giving and receiving along with sharing and caring have thus become highly regulated. But this world of overregulation has killed the joy of giving, of sharing our gifts, whatever they may be. Sadly, the process is causing many to take their gifts and leave, burying them. The result is an impoverished world, for it is a world divested of countless gifts and deprived the ensuing joy that sharing those gifts was intended to bring.

Uterine Transplantation Redux: Another Boundary Issue in Medicine

Speaking of boundaries…which I spoke about in my last blog
It was one and half years ago, in September of 2014 that the first baby was born following a successful uterine transplantation in Sweden. While the baby was apparently healthy, Dr. Mats Brannstrom, the pioneering physician in Sweden said, “The principal concern for me is if the baby will get enough nourishment from the placenta and if the blood flow is good enough.”

In November 2015, uterine transplantation hit the news again when the Cleveland Clinic announced plans to begin a clinical trial of “highly experimental” uterine transplantation using cadaveric organs—for reasons of “safety.” The experimental procedure is lauded by many as “open(ing) the door to an innovative and promising advancement within reproductive medicine.” Dr. Alan Lichtin, chairman of the Cleveland Clinic’s ethics board, further justified the procedure by noting that the committee’s initial impression was, “This is really pushing the envelope. But this is the way human progress occurs.” There it is again: the god of progress for which we will sacrifice not only lives, but all boundaries.

Uterine transplantation, in fact, pushes the envelope both medically and ethically It is the first transplant procedure involving a non-vital organ, and the first considered “ephemeral” because of its temporary nature—it is removed after one or two children have been produced to avoid the ongoing risks of immunosuppressive drugs.

The defining concern in uterine transplantation, however, is its motivation: this is not an issue of health, but of experience, one that is being dubiously linked to health care by labeling it a “quality of life” issue. It does not treat a disease but provides the opportunity for an experience—an attempt to give a woman, not a child to raise, (which can be accomplished by safer, less costly means), but the experience of pregnancy. Understood from that perspective and in that context, it is a very costly procedure that poses grave threats to a woman’s health and even greater threats to the life and health of any child born in such an experimental situation. Add to this the enormous financial costs associated with a minimum of 5 required surgical procedures and it becomes clear—even judging by the utilitarian standards that govern much of our society, much less the cardinal principles, if you will, of autonomy, beneficence, non-maleficence and justice–that the ends do not justify the means. Moreover, such procedures that in fact treat no health condition fly in the face of justice. In a country—and world—where so many lack even basic health care, this is an irresponsible use of our limited resources. But where reproduction is concerned, such arguments carry little weight.

Furthermore, within days of publishing the news that such trials would begin for women with uterine factor infertility, another boundary issue was raised: could uteri be transplanted into men? And of course the answer is “yes”—probably within 5-10 years. Men lack the “support systems”—vasculature, ligaments, hormones—to maintain a uterus and pregnancy, but none of these are believed to be impossible to create. The most insurmountable obstacle is felt to be economic. “We can’t even begin to guess how much a uterus transplant will cost if the surgery makes it out of the research phase, and chances are slim that insurance companies will pay for it.” But that comment is out of touch with the reality of our society: if Medicaid will pay for sex reassignment surgery for an inmate serving a life term, on what grounds could they deny uterine transplantation? In reality, it may be more likely that there will be insurance coverage for transgender uterine transplants than for treatment of uterine factor infertility in non-transgender women.

From the very beginning, humankind has disdained boundaries. Now being enslaved to technology we repeatedly demonstrate our inability to set moral or ethical boundaries for its use. Therefore transplanting uteri into novel subjects, like men, and upsetting all natural boundaries—because we can—is a given. It is as if we are sneering in the face of our Creator, while proclaiming our freedom from His patronizingly imposed boundaries and limitations on our lives. Have we no respect?

Medical Care and the Boundaries of Technology

In a recent post entitled “A View from the Other Side: Roboticized Care,” I recounted my recent encounters with the healthcare system from the perspective of a patient. Some of those observations deserve further reflection.

Technology is, indeed, a wonderful gift, benefiting mankind in innumerable ways. But technology has transgressed its boundaries largely because we have failed to set or enforce boundaries for it. From the time of the Garden humans have had a problem with boundaries, there transgressing the only boundary we were given: do not eat. Technology now offers us the opportunity to transgress another boundary, one that is actually part of our nature: the physical limitations of our embodiment–our boundedness to time, space, and skin. Despising our boundaries and our boundedness, we seek to transcend them through the machinations of technology. This, in truth, was the essence of Satan’s temptation of Jesus—to tempt Jesus to use his powers to escape the limitations of His human boundedness. But God chose a bounded and self-limiting way of relating to us.

But not only are we physically bounded, we are relationally bounded. By God’s design, we are not the wholly autonomous beings we have come to believe, but are social, relational, bounded beings, created by a relational, Trinitarian God for fellowship with Himself and others. It is through our relational interdependence that our lives acquire meaning and significance. Moreover, in this interdependence our choices and actions are limited by and reinforce the dignity of our fellow participants. To be truly human is, therefore, to live within the boundaries of our bounded, mortal, embodied life, while simultaneously being open to God and to our neighbor.

Which brings us to the issue of medicine. In medical care, it is “care” that is the crucial component–“medical” is a mere adjective describing the sphere in which that care occurs. To care for someone is to provide for his or her needs out of concern for that person. While it may be true that physical needs can be effectively addressed and provided for by technology, the emotional, psychological, and spiritual needs of those who are suffering requires the care and concern of flesh and blood persons who know experientially what it is like to live in mortal, perishable bodies–bodies that break down, bodies that die. Only the body that is receptive to disease and death is receptive to the suffering of the other.

Furthermore, for centuries we have known of the importance of human touch in caring and curing–even Augustine viewed sensation as the most basic form of knowledge–yet that element of medicine is being routinely eliminated as technology replaces physical diagnosis and fears of contamination reduce physical contact. Furthermore, any claim that “face robots” will positively impact “care” is based on a reductive presupposition that humans are nothing more than robots, and that robots can therefore be designed to perform any task, including “caring,” that humans can do, and not only better but more effectively and efficiently. But a mechanical entity cannot relate to or comfort one who is facing the limitations and vulnerability of their own embodiment, no matter how well programmed they may be. And the touch of cold, hard metal cannot replace that of living flesh and blood. For our bodies are the location of our personal presence, a presence that can be neither explained nor replicated by mechanical processes. In medicine, attempts to transgress the boundaries of our being by replacing humans with robots threaten the human element that is the essence of medical care.

Medical care has always consisted of two components: the art and the science–the human and the technological. Recognizing this we must not allow technology to surreptitiously replace the human component of medicine, but must strive to set and enforce boundaries for the technological component. Technology may be able to cure, but it cannot care. And care is crucial to healing. Moreover, our attempts to transcend the weaknesses and limitations of our human embodiment, to substitute technology and robots for human care may, in fact, leave us less than human as we become ever more roboticized–ever more like the machines we emulate rather than like Him who is our Exemplar.

A View from the Other Side: Roboticized Care

After years of disillusionment with regard to the bureaucratization of medicine and dissatisfaction with my increasing inability to care for patients appropriately (issues I wrote about frequently on this site), I retreated, retiring from the practice of medicine in 2014. Having lived a healthy life-style, I hoped to avoid contact with the system, an intention made more possible by the recent trend towards elimination of preventive care practices. Nevertheless, within months I found myself catapulted inextricably into the morass of modern day medicine, experiencing, full bore, the horrors of the system from the other side—from the “patient” perspective.

My first observation: in a system that has sought to improve safety through technological means, errors are prominent. Over the course of two hospitalizations, at least seven medical errors were intercepted and avoided, only because of medical knowledge that enabled me to appropriately question tests and procedures. While most of those errors would have been relatively inconsequential, primarily increasing fiscal costs, two of the errors were potentially dangerous. Moreover these errors occurred despite the use of EMR, instituted to eliminate such errors, since “to err is human.”

But just as alarming was the transmogrification of nursing. As I sat alone in my room and pondered the new role of nurses, I began to wonder what part of their “job description” a robot could not perform? Nursing aids appeared at the door with their self-contained wheeled “companion” to assess vital signs three times a day: they slapped a blood pressure cuff on my arm, put a pulse oximeter on my finger and a digital temperature probe in my mouth; and in 15-20 seconds were wheeling their companion out the door with a cursory look back, questioning, “Need anything?”

Nurses were no different: unless I requested additional pain medication I saw them twice a day for distribution of medications and their “nursing assessment.” They, too, appeared at my door with their “computer on wheels,” scanned the barcode on my wrist band, verified my name and birthdate, distributed the medications, performed their nursing assessment (not determined by the patient condition but by fulfillment of “meaningless use“ criteria) and wheeled their companion away, again with a perfunctory, “Need anything?”

Despite careful gloving and gelling in and out, there was little contact—physical or visual—outside the required interactions. No nurse ever appeared at my door just to check on me—to “care.” There was negligible conversation: no one ever took the time to find out for whom they were “caring.” There was no traditional “nursing care:” no bathing, no massaging, no changing of bed linens. There was a cute plastic triangle snapped into my wristband upon admission containing the words “fall risk”—a category into which all surgical patients are automatically placed–but no one instructed me to call before getting out of bed, nor did anyone assist me in ambulation during my stay.

Moreover, these changes are not relegated to nursing. In twelve encounters with physicians over the last 9 months, only once has a diagnostic hand been laid on me. Physicians and/or providers have listened to my chief complaint, ordered tests, referred me to a specialist, or scheduled me for procedure. They have demonstrated that they are little more than triage experts, a mechanized role easily replaced by robotic algorithmic protocols as well. Nor are these observations site specific: their embryonic development was observed in small hospitals in the rural mid-west as they scrambled to comply with increasing outside regulatory demands.

Sadly, there was little in a nine-month course of medical treatment that could not have been done by a robot. Medical personnel have become so task oriented that there is no longer time for care (a fact recently recognized by the AMA). Nursing has become so mechanized that robots may soon surreptitiously replace them—and no one will notice. Many physician roles will not be far behind. As another author put it, medicine has been “McDonaldized.” If so, it is only a matter of time before medicine follows suit with robotic nurses and interactive computer programs replacing their human counterparts.

While technological advances have wrought tremendous advantages in medical diagnostics and therapeutics, they have effected significant immaterial costs as well. Techology has transgressed its boundaries, threatening the human aspect that is the essence of medicine. Is that a price we are willing to pay? For unless we take seriously the course on which medicine is currently travelling and work to reverse the trajectory–restoring the caring human element to the profession–we will be left struggling to provide “evidence” that sanitizing gel will work on mechanical hands.

Where Have All the Heroes Gone…?

The response of the CDC earlier this week to the development of Ebola in a Dallas nurse illuminates another sad consequence of the rise of bureaucratic medicine. In their very disturbing response to this tragic incident, the CDC arrogantly announced—prior to any investigation and without adequate evidence–that the cause of the transmission of the Ebola virus to Nina Pham, the nurse involved in the care of Thomas Duncan, was a “breach in protocol.” Labelling it “unintentional” did little to soften the blow of their judgment.

The pages of medical history are filled with stories of heroic individuals who have sacrificed their lives in the provision of care to the sick and dying during times of plagues and epidemics. The fate of such caregivers has been viewed as a tragic end to the noble and heroic act of caring. But today, from our bureaucratic perspective, it is viewed as a “preventable error” with blame shifted from the bureaucracy toward the effected employee. Instead of honoring this nurse for her self-sacrificial care, the CDC portrayed her as a casualty resulting from careless compliance with their protocols, implicitly blaming her. This woman is no longer a hero who has risked her life for the care of another, but someone who, having done her job imperfectly, is suffering the consequences.

The presumption of the CDC is that their protocols are perfect and that by precisely following all protocols and procedures transmission of this virus will be prevented. Such a position assumes far too much. It assumes, first of all, that we have extensive and accurate knowledge of this organism and its virulent potentials; yet it appears that our knowledge is in fact inadequate—or even faulty–as we are daily bombarded by evidence contradicting what we were previously told. Second, it assumes the perfection of our protective procedures and protocols, which, if one checks the CDC website, do NOT include the use of impermeable Hazmat suits (as portrayed on television) or N95 head shields, but merely ordinary gowns, face masks, goggles, and gloves. This recommended protection provides less coverage than one has in the operating room, because it leaves one’s head, hair, and neck exposed to body fluids from projectile vomiting or explosive diarrhea. Alarmingly, the CDC’s recommendations for removal of the protective equipment is also contrary to that used by surgeons in the operating room for removing contaminated garments: the CDC’s protocol recommends removal of gloves FIRST, leaving ungloved hands vulnerable to contamination from removal of a body-fluid soaked gown; surgeons always remove gloves last. Third, it assumes that our equipment is flawless, that there are no holes or imperfections in our protective gear. How many times are surgical gloves donned only to find they have holes before they’ve been used? Finally, it assumes the impermeability of our protective gear to viral particles, and fails to acknowledge what we already know: that latex has pores that are small enough to adequately prevent bacterial penetration but are NOT small enough to perfectly prevent viral penetration: viral transmission is merely hampered, not prevented. Not surprisingly, this position is similar to the bureaucratic declaration that “safe sex” can be achieved through the use of condoms: condoms may prevent pregnancy and transmission of bacterial organisms but do not entirely prevent the transmission of viral particles and hence, are not entirely “safe.” And they break!

It is indeed vital that the CDC thoroughly investigate this incident, but by beginning with the assumption that their protocols and procedures are adequate, they are biasing their investigation and impeding the search for knowledge and truth. A more appropriate response would be to humbly acknowledge that we are fallen, fallible humans with imperfect procedures and flawed equipment, and then to look open-mindedly at the situation in an attempt to safeguard our caregivers and prevent the spread of this disease to the best of our corporate ability.

It is likely that the CDC has painted this picture with colors of blame in order to squelch fear-mongering among the population as well as to reassure health care providers that the protocols in place, when properly followed, provide adequate protection from this life-threatening disease. But in true utilitarian fashion, what they have essentially done is to throw this nurse “under the bus,” sacrificing her for the sake of the emotional reassurance of many others. From this perspective, there are no heroes. Therein lies the tragedy.

Population Health: the New Medicine

Below is a modified copy of my response to an informational article that was recently sent by the CEO of our hospital to our medical staff. Many suggested that I make this letter available publicly. Little do they know that I do so on a regular basis!

“I want to thank our CEO for forwarding this article to us while simultaneously pointing out its significance to any of you who might have merely glanced at it casually. For this article is illustrative of the subterfuge of changes taking place in medicine, changes that have created a paradigm shift in how we understand medicine—how we understand ourselves as physicians, ourselves as professionals, and the medical care we render.

Central to our understanding of medicine has been the physician-patient relationship, a relationship that has been considered sacred and inviolable, that has been determinative of our responsibilities, and has been a limiting factor in keeping governmental intrusion at bay. While responsible medical care has always provided for the good of the individual while keeping the good of the society in our peripheral vision, it was the care and needs of the patient before us that was our primary concern. But over the last decade, forces foisted upon us largely from outside of the profession have been driving a wedge into that relationship, with the apparent intent of severing it. Those forces have taken many forms: the EMR which forces us to turn our backs to the patient; the “medical home” which has been surreptitiously substituted for the relationship with “my doctor;” the increasing loss of the independent physician (who now, by virtue of her employed status, have a primary obligation to an employer rather the patient, and is now subject to the governmental regulations that dominate that employer); and now this deceptively subtle utilitarian shift in focus from “patient” to “population.”

A utilitarian ethic can be effectively summarized as “the greatest good for the greatest number,” but patients are neither numbers nor statistics, they are persons–idiosyncratic beings that possess histories and exist in contexts that are not reflected in mere “data.” Moreover, as I am fond of saying, flesh and bones do not fit into algorithm boxes without remainder. We have failed to realize or acknowledge that a profusion of data (not always readily accessible) is no substitute for personal knowledge that grows out of relationship.

What we are being expected to do is to shift our focus. But the human eye, not to mention human attention, was created to be able to focus on only one entity at a time (as evidenced by my road-hunting husband who often misses the game in front of him on the road as he is searching for it in the fields!). And this is not a zero-sum game: attending to the horizon—population health—detracts from our ability to focus on that which is before our eyes—the individual person.

Furthermore, such a shift involves is a category mistake: it is an attempt to substitute apples for oranges; it confuses the distinction between medical care and public health, which are separate entities–we received degrees in medicine, not public health. Furthermore, one has only to look at the effectiveness other governmental initiatives, well-intentioned as they may be—initiatives such as the “Food Pyramid,” “MyPlate,” etc.—in changing America’s dietary habits and impacting obesity to see what potential influence a “population health” initiative and focus will have on the health of our population.

A shift to population health will have disastrous consequences for many of our patients. Take for instance, L.B. who has probably made a significant contribution to my income over that past few years as I have seen her regularly for her chronic vulvodynia which I am unable to cure: often I do nothing more than listen which is at times, for her, therapeutic; but “therapeutic listening” is not quantifiable and does not compute in the system focused on population health. One of the principles of medical care, dating back to Hippocrates, has been “To cure sometimes, to treat often, to care always.” But in today’s outcome based management, “care” has been replaced by “cure,” because “care” can’t be quantified and measured. But how will L.B. and so many others like her be cared for in a system that is only interested in quantifiable, documentable changes, in measuring outcomes and cures?

So beware! Population health has a nice ring to it; it looks like a nice bandwagon onto which we should all be willing to jump. But it is taking a detour off the main road, onto a bureaucratized, industrialized one–a detour which appears smooth and streamlined and efficient, but one which will leave the persons we are called to care for lying in the dust…”

Creating a “New Race,” a New Problem…or Both?

In my last post I spoke about an ethical issue mentioned in passing in a book that examined reproductive medicine from the perspective of organizational theory: that in this age of evidence-based medicine some of the most vital decisions—who lives and who does not—are based primarily on subjective grounds. A second issue mentioned in the book that I found greatly disturbing was that the use of ICSI—intracytoplasmic sperm injection, a procedure now readily accepted and utilized in reproductive medicine–potentially creates a “new race” of persons.

As quoted in the book, from a professor and entrepreneur of a British infertility clinic, “…they [children born of ICSI] are of a different kind, another race than us.” How is that so? In normal fertilization, only the head of the sperm penetrates into the egg; the mitochondrial portion including the male mitochondrial DNA is left behind. Consequently the fertilized ovum contains only maternal mitochondria. But with ICSI, the entire sperm is introduced into the heart of the ovum, along with the male mitochondrial DNA and the potential for the incorporation of this material into the offspring. As this same professor is quoted as saying, “That does not mean it is dangerous but it is on the other hand not what happens during normal fertilization. So there is this little question mark and it is (sic) interesting to see what happens when these children are starting to reproduce.”

A little question mark indeed! Studies are inconclusive; beliefs vary. According to Australian researchers, “The elimination of sperm mitochondrial DNA is essential for the functional integrity of the offspring, as sperm mitochondrial DNA appears to harbour a large number of mitochondrial DNA defects.” This issue becomes particularly relevant given the recent surge of interest in mitochondrial disorders and the means of preventing them through the use of donor eggs. Many believe that the paternal mitochondrial DNA undergoes ubiquitin degradation, supported by studies that fail to demonstrate expected levels of paternal mitochondrial DNA in offspring, but the numbers studied have been small—six, to be exact! Other studies have documented its presence in embryos, and suggest that it is protected by the plasma membrane surrounding the mitochondrial sheath. Could it be that it becomes sequestered in certain tissues? There have been case reports of severe mitochondrial myopathy due to a mitochondrial defect that was paternal in origin.

To further complicate matters, ICSI has become a standard, and hence, unindicated, procedure. Once used only for male factor infertility for which it was of great benefit, it is now used commonly because it was found to “a little bit more effective.” Whereas male factor infertility affects only about 20% of infertile couples, ICSI is used in 60-89% of in-vitro cycles. As an anonymous clinician stated, “It will be interesting to learn if the boys have inherited this male factor because that has not been studied…We do not know what is happening to all these children.”

Interesting indeed! Such attitudes, which permeate this field, are cause for alarm. Economic interests and “freedom of choice” too often overrule patient safety; and expediency is allowed to trump prudence. Not surprisingly, most of these questions arose after ICSI became standard practice. But “cutting edge” technology is often a double-edged sword, cutting both ways. Are we iatrogenically creating long-term problems for short-term gains? Is a greater good for some going to prove to be a greater harm for many? Are we creating a new race, a new problem…or both?

Who Lives, Who Dies, Who Decides…

I just finished reading a very dry book on organizational theory as applied to reproductive medicine. The book was a Swedish observational study evaluating the sociomaterial aspects of that subspecialty, particularly Swedish IVF clinics. While the book did not directly address ethical issues in reproductive medicine, it did note some of them in passing. One that caught my eye was issue of the choice of the embryo to be placed into the womb. In Sweden (unlike the US), the standard is, and has been, single-embryo transfer, so one embryo must be chosen from the many created for the privilege of transfer to the womb. While genomics and metabalomics are factors in this highly regimented and scientifically technical field, the ultimate choice of embryo—of which living being gets the first shot at life—is made, not on the basis of scientific evidence or quantifiable parameters, but on “morphological analysis”—on vision and appearance—the subjective vision of the laboratory technicians as they evaluate the appearance or form of the embryo.

Some of the visual qualities considered include the number and size of the cells for the stage of growth, roundness, symmetry, degree of fragmentation (cellular garbage), multi-nucleation, and so forth. But ultimately it becomes a matter of which one appears to have the best form.

Disturbingly, there are times when none of the embryos “appears” to be optimal, but one is still chosen and placed into the womb; and some pregnancies do result from the use of these “sub-optimal” embryos. But no mention was made of any studies of the outcomes of such pregnancies—were the pregnancies ultimately successful? Were the babies who were born of such pregnancies healthy? Perhaps more significantly, when such “suboptimal” transfers are performed—suboptimal in the eyes of the beholder–the prospective parents are neither notified nor given the choice of not proceeding: consent is assumed. Should they be given “informed consent” on the basis of little or no “knowledge”?

The hubris involved in such actions is sobering. In our fallen world we are all suboptimal beings. But because we have ventured down this path—because we have sought to intervene in the hidden recesses of life—no doubt enabling some to have a child of their own who otherwise may not have had that opportunity—we place ourselves in the position of having to judge the worth of a life. A sociomaterial perspective—one in which the embryo is not a living being, but merely a conglomerate of organic human material—is no doubt helpful, enabling those involved in this business to justify their role as judge of which conglomerate should be given a chance at life and which should not.

In this medical age where we deceptively demand objective, concrete evidence to justify all that we do, we continually refuse to acknowledge that even the best of our “evidence” is corrupted with subjectivity from beginning to end. Despite our best efforts, subjectivity cannot be removed from human moral endeavors: it is inherent in anything and everything we touch. It is therefore ironic that in a cultural age in which we insist that people should not be judged on the basis of appearance (skin color, nationality, gender, dress) we rely solely on the basis of appearance for judging those worthy of a chance at continued life. It is even more ironic in this scientific age, that in this most vital of choices we judge solely on superficial appearances in the eye of the beholder—and believe ourselves capable and worthy of doing so.

A Vision of the “New Medicine”

I confess that at times I feel like a broken record, lamenting the same story repeatedly; but I’m watching as the bulldozer of progress plows under a profession near and dear to my heart, a loss that will impact all of us, for better or for worse. The power behind these changes is nebulous and pervasive—and impossible to obstruct or thwart. While there is no blueprint for what they intend to construct out of the rubble, occasionally one can catch a glimpse of their vision; and a number of recent articles have served as triggers.

For years I have watched as the specialty of obstetrics and gynecology has struggled to define and justify their role in medical care. First we were specialists; then we sought to increase our market share by designating ourselves “primary care for women.” That became especially important as the specialized obstetrical procedures that marked us as obstetricians were eliminated from our armamentarium—and routine deliveries, whether vaginal births or cesarean sections, could and are being handled by others—family physicians, midwives, and/or general surgeons. But then the reasons for routine visits also began to be eliminated: long-acting reversible contraceptives were promoted over oral contraceptives (which had been tied to routine visits), and pap smear frequency was diminished (from yearly to every 3-5 years).

In 2012, the American College of Obstetrics and Gynecology (ACOG) defined the “well-woman visit” as consisting of “vital signs, BMI (a calculation of doubtful meaning and significance), abdominal palpation (of questionable value given the obesity of the general population), and palpation of inguinal lymph nodes (which are only palpably enlarged when there exists and serious and symptomatic problem—for which it would no longer be a “well-woman” exam!)—all else in the physical exam they declared to be discretionary.

Now the American College of Physicians has pounded in the last nail in the coffin: they state in their new practice guidelines that there is no evidence to support routine pelvic exams–that they cause more harm than benefit. ACOG, seeing the writing on the wall, is circling its wagons, stating “lack of evidence does not mean lack of value.” Value: there is that nebulous, unquantifiable, qualitative concept raising its head again.

But is there evidence of benefit for ANY preventive exam beyond the unquantifiable—beyond the relational? Other than vital signs, is there any evidence that physical examination is superior to laboratory testing or imaging studies?

The Institute on Medicine has just reported on its 2-year study of Graduate Medical Education, concluding that the current physician training system, subsidized by Medicare funds, is not producing physicians prepared for the changing health care system. They recommend transition to a “performance-based system” of funding—whatever that entails. In light of the “evidence” above, eliminating training in the physical exam as well as history-taking would be one step toward diminishing the cost and length of graduate medical education.

Therein lies the vision for the future of health services (a more appropriate term than “medical care”): health encounters will consist of scheduled appointments for vital signs, laboratory testing and imaging studies with interpretation and intervention based solely on objective data; emergent health issues will then be routed to emergency or urgent care centers (something we have tried to eliminate over the last decade), but they will now be anachronistically referred to as one’s “medical home.” It will be a clean, streamlined, and highly efficient system, having eliminated all of the messy interpersonal confounders.

But since it is those “messy interpersonal encounters” that have provided personal and professional fulfillment, I can see that I’m getting out none too soon….

Following in the Errant Footsteps of the VA

The recent revelation of the crisis—and failure–of caregiving in the VA health system raises grave concerns for American health care in general and should motivate physician leaders to re-evaluate their approach to ethical health care.

Until recently, the VA health system was a recognized leader in health care quality, patient safety and ethics, outperforming most American hospitals in these areas. It had also established an award-winning program entitled “Integrated Ethics” designed to tackle “a recognized ethics quality gap.” This program addressed ethical issues on three levels of organizational activity in the VA system of health care: clinical decisions and actions, organizational systems and processes, and environmental and cultural factors. It was a program that was to “ensure that our systems and processes are designed to make it easy for people to do the right thing.” Yet despite this acclaimed and award-winning program, the “VA scandal” was a crisis of ethics. How does this happen?

Some have maintained that it was inadequate leadership: “the perceptions of leadership define the culture—not only what the leaders do themselves but also the behaviors they encourage, support, and don’t tolerate in others.” Others have pointed to a vast and rigid organization that valued documentation over action and reduced ethics to compliance and risk management. Still others have pointed to the focus on quantifiable performance measures that perceived ethics as an impediment to quality care, since “one cannot manage what one cannot measure.” Rob Nabors, President Obama’s deputy chief of staff, in his White House review of the Veterans Health Administration characterized the institutional culture as “corrosive” and concluded, “The VHA leadership structure is marked by a lack of responsiveness and an inability to effectively manage or communicate to employees or veterans.”

In reading through the VA documents on “Integrated Ethics” one notes the striking shift in ethical focus. “Leaders” are no longer physicians, but administrators. The locus of ethics as well as accountability is no longer the individual or the physician-patient relationship but the system. This, I would maintain, is the most lethal change, for once again, the physician-patient relationship, so crucial to medical care, has been severed and the physician is now tethered, instead, to the organization.

What should give us pause is the fact that our new government-leveraged health care system, the Affordable Care Act, is undoubtedly modeled on this once highly successful government-run VA system. Why would the government not use a system that has been highly successful one venue as a template for an even greater venue? And so the same processes that gave rise to the VA scandal are likely to be repeated on a greater level in the Affordable Care Act. The underlying fallacy is that systems and processes that are designed to optimize coding and maximize billing will be able to make it easy for “people to do the right thing.” Form-filling and box-checking cannot substitute for meaningful dialog. And metrics, no matter how good, cannot measure “care,” especially when those performance measures are tied to reimbursement dollars–for dollars dictate. In the end, one ends up serving “mammon”–and as we know, “one cannot serve both God—or ethics–or patients—and mammon.”

Organizational processes increasingly marginalize and eliminate ethical concerns because those concerns fail to accommodate themselves to the efficient and pragmatic processes of organizational health care systems–they don’t fit into “utilitarian boxes.” The implementation of processes has eliminated what really matters—the physician-patient relationship. And so as we follow in the footsteps of our big brother, the VA, and attempt to incorporate the same system processes into our even larger health care system, we may be faced with an even greater fall–unless we can take back the reigns and restore the relationships…