The VA Scandal- Stepping Back for a Broad View

The recent scandal involving the VA healthcare system is easy to criticize and difficult to decipher. It is one issue where there is a gratifying sense of unity among divergent political groups, and for this veteran, in that there is an odd sense of satisfaction.

I will measure out my observations carefully, in an attempt to avoid the obvious and already-announced conclusions. There is no merit (nor gain) in blaming the current administration for the VA’s troubles, for the nature of such organizations is such that problems take root early and are unswayed by short-term changes in political administrations. The VA healthcare system is a complex organization, as expected for its size, and within its sprawl are many areas of excellence as well as unsatisfactory performance. How can these coexist for so long?

My starting observation is that true understanding of the fundamental flaws of large organizations is not within easy reach—certainly not easily grasped by political pundits, editorialists, and even leaders within the organization itself. In my few years at a regional headquarters for a very large healthcare organization, I was prone to saying that I was “two levels removed from reality.” Pride kept me from admitting that it was probably more than that. There may be justifications for a change in leadership, but it is highly unlikely that Secretary Shinseki’s experience in the Army enables him to have a fundamental grasp of what truly keeps the VA healthcare system from doing what he wants it to do. Good luck finding someone who can understand it, put it into words, is able to make changes against huge inertia, and perseveres long enough in such an organization to see it through.

We might, as many have done, use that as an argument against creating large healthcare organizations. That appeals to many, but a practical view of our changing society, with its enlarging population, economic strains (producing pressures for economy of scale), and demands for (and technological enabling of) standardization mean that while we may cringe at centralization, we want what it produces. Think Walmart. Throughout our society we can expect more of the dynamics that produced the current state of affairs at the VA.

Therefore, a conversation that produces productive changes requires that we step back and recognize the broader realities of our society, and that what we say we want in one breath contradicts what we ask for in another. That is one critical step for the next one we will have to take, including in this area of healthcare for veterans: to actually decide what we can have, and admit what we can’t.

Ultrasound before Abortion: Consideration of Recent Research–Closing Comments

In my previous two posts (April 22 and April 29) I discussed an article in the January edition of Obstetrics & Gynecology entitled, “Relationship Between Ultrasound Viewing and Proceeding to Abortion.” The authors found that in Planned Parenthood clinics in LA, the voluntary viewing of ultrasounds by patients seeking abortions appeared to dissuade a very small percentage from continuing on to abortion. From their data the authors concluded that women should not be required to view ultrasounds prior to elective abortions. They state that, “…because fewer than half of women select this option, mandatory viewing “may have negative psychological and physical effects even on women who wish to view.”

Three points regarding the authors’ ethical calculus: First, their equation is incomplete; second, to weigh “effects” we must be more precise in what they are; third, they fail to describe the one group of people who ought to be doing this ethical calculation, but are not.

First, this article certainly does not weigh all the adverse psychological and physical consequences involved in the act of abortion, or even all the consequences—good or bad—of mandated ultrasounds. It is premature, therefore, on the basis of this study to argue that they are either harmful or beneficial psychologically or physically. The authors make no mention of the possibility that harm or benefit of one’s actions may proceed well into the future, or of the possibility that simply because there is “certainty” regarding abortion that the decisions are informed, or not coerced.

Second, the authors cite “negative psychological and physical effects,” but this is a most imprecise description—by design, I believe. What are these untold effects but modern society’s taboos of guilt and regret? These words must not be spoken of by those in favor of abortion because they would remind of us of right and wrong existing beyond personal choice. Guilt and regret, after all, do not spring de novo. They are born of some sense of wrongness, and point to values beyond simple autonomy. To hold to the thin reed of “choice”, however, one must disallow discussion beyond “psychological and physical effects.” But this blinds us to the existence of a greater morality than individual choice, and therefore to the reality of the human condition.

Finally, in this research the focus on whether or not women changed their mind after viewing their ultrasound or even desired to view it at all fails to acknowledge that there is one group of moral agents whose decision-making is central to the issue of abortion, including to the decisions of the women themselves: physicians. As Justice Blackmun stated in Roe v. Wade’s majority opinion, “the abortion decision in all its aspects is inherently, and primarily, a medical decision, and basic responsibility for it must rest with the physician.” A reading of the subsequent opinion will show that this medical decision-making is ultimately a moral endeavor. But where is the physician in this article’s abortion process? Where is the seeking of each patient’s story, fears, concerns, goals, needs, and so on, that are all necessary for rendering a proper “medical” (but truly moral) decision? In pro-abortion arguments, no allowances whatsoever of physician judgment are allowed to eke into the discussion, yet the Supreme Court justified the legality of abortion on its active (and determinative) role in each decision to abort.

This “medical” decision is supposed to have a certain inherent moral authority, or imprimatur, born of the professional judgment and obligations of physicians. If such individualized contemplation regarding each procedure of abortion is not modeled by those medical professionals whose careers ostensibly carry the moral credentials stemming from caring for others, then there is no surprise when a woman in crisis does not reach a moral epiphany that directs her to the exit. It is sad that our society, which once had a physician profession that was firmly and universally dedicated to the well-being of the unborn, now senses some need to get moral awareness awakened by some other means. The problem, then, wasn’t that the women viewing the ultrasounds failed to change their minds, it’s that the physicians performing them didn’t.

 

Ultrasound before Abortion: Consideration of Recent Research, part 2

Last week I began a discussion about an article in the January edition of Obstetrics & Gynecology entitled, “Relationship Between Ultrasound Viewing and Proceeding to Abortion.” The authors found that in Planned Parenthood clinics in LA, the voluntary viewing of ultrasounds by patients seeking abortions appeared to dissuade a very small percentage from continuing on to abortion. Overall there appeared to be 0.6% absolute risk reduction (99.0% of those who did not view the ultrasound, and 98.4% of those who did, proceeded to abortion).

This is a small reduction indeed. If we calculate the “number needed to treat,” or NNT (we might use the term “number needed to scan” in this setting), we find that it took 151 ultrasounds to cause one woman to change her mind. But how should we interpret these results? That is, how should we assign a value to raw numbers?

If one considers that an ultrasound could be a “screening” test to find that cohort of patients who would change their minds about abortion, and that the outcome is a saved human life, then the numbers become quite appealing. In other words, if the number needed to treat (or scan) to save one life is 151, then scanning is an outstanding intervention. In contrast, nine times as many women aged 50 to 59 years must be screened for breast cancer with mammograms to achieve the same number of lives saved.  One could try to calculate in the relative risks to women’s lives from abortion vs. term pregnancy, but these numbers are quite small compared to the relative risk to the fetus’s life from abortion vs. term pregnancy.

Is not one human life gained worth the time, effort, and cost of 151 ultrasounds? As a physician I perform or order countless tests, including many as part of standard prenatal screening, with much slimmer hopes of benefit. And, with succeeding generations of lives produced from each fetus saved, the NNT drops dramatically. For those opposed to abortion, the statistics seem to provide little hope for a significant change of minds that they would hope for. But whenever I observe the dramatic miracle of a single birth I see an outcome grand enough to justify the effort.

It is a fundamental flaw of the research to impose a moral equivalency on all outcomes. It is not simply a matter of weighing 150 choices in one direction for every one choice in another—it is the weighing one human life gained vs. all other outcomes. Isn’t the saving of lives what we’re here for? Or do physicians direct their lives’ work toward simply accumulating “choices” satisfied?

Next post will discuss the ethical conclusions made by the authors, who raised concerns about risks of viewing the ultrasound itself.

Ultrasound before Abortion: Consideration of Recent Research

In the January edition of Obstetrics & Gynecology was an article entitled, “Relationship Between Ultrasound Viewing and Proceeding to Abortion” by Gatter et al that has already received publicity. There is no doubt that this article will be oft-cited for many years, so it merits discussion.

The authors performed a retrospective review of one year’s worth of records at Planned Parenthood clinics in Los Angeles, finding that in that particular practice setting the voluntary viewing of ultrasound (after being asked, “Do you want to see your ultrasound picture on the screen as the clinician performs the examination?” or a similar question) did very little to dissuade women who were seeking an abortion from going through with it. They found that, “Most women presenting for abortion care in our sample had high decision certainty, and ultrasound viewing had no effect on their abortion decision.” Even among those who had “medium or low decision certainty” about having an abortion, 95.2% of those who viewed the ultrasound proceeded to abortion, compared to 98.7% who had not. Overall the difference was even smaller: 98.4% compared to 99.0%.

We can all probably agree on one conclusion— that this particular article certainly does not provide data to support the notion that viewing ultrasounds of pregnancies causes women seeking abortions to change their minds in significant numbers. But it is, unlike what the authors might nudge us toward believing, too early to write off the merits of offering and performing ultrasounds for these patients.

But what critiques can we make? I can think of a few, which I will enter over the coming weeks.

First, the reader must note that the ultrasounds were done in Planned Parenthood clinics in Los Angeles. The article did not attend to any details of what the “viewing” of the ultrasound entailed; the authors did not indicate that there was any attempt to “script” that process. I would propose that in the setting of a clinic dedicated to providing abortions, the discussion surrounding the ultrasound may bear little resemblance to the detailed explanation of fetal anatomy that a happily expectant couple may get from her obstetrician. Features like the brain, spine, heartbeat, limbs, fingers and toes, spontaneous movements as well as reactions to the pressure of the ultrasound are all part of what I discuss with my patients. For the woman seeking abortion, the physician performing it seems unlikely to attend to these details. I propose that not all ultrasound experiences are alike.

The article later raises concerns about mandated ultrasound viewing (arguing against it). It is a contentious notion already; to suggest that the viewing of an ultrasound ought to contain specific content and discussion would make it only more so. But would not true informed consent require it? And for the purposes of research, would not a dismissal of the impact of ultrasound’s effects on a woman’s decision require a more descriptive effort of what happens inside the exam room?

This is a reflection on the method of the intervention; in coming blogs I will add more thoughts about interpretation of results, and the ethical conclusions made by the authors.