Health care and incarnation

Sometimes things that come to us from different directions come together to help us see things more clearly.

Joe Gibbs’ and Jon Holmlund’s most recent posts look at different aspects of how we provide health care in our society. Joe expressed the need for a theologically grounded understanding of the need to provide health care for those who currently are unable to afford it. Jon discussed the need to have reasonable expectations in the treatment of cancer. These two ideas address two of the significant things that are broken in our current way of providing healthcare in the US. Both of them contribute to why we have a very expensive system that does not meet the basic needs of the most needy.

Today in chapel I listened to Skye Jethani give a very thoughtful talk about how we as Christians should interact with those with other religious beliefs. He suggested that in our increasingly multicultural world we should not retreat into isolation to protect ourselves from contamination. Nor should we hide our Christianity as we try to work with others for the common good which in turn benefits us. His recommendation was that we model how we engage those who are unlike us after Jesus’ incarnation. Jesus came to earth revealing God to mankind and intentionally engaging us to express his sacrificial love. Since love is willing what is best for another person, our faith should motivate us to engage those who are not like us to do what is best for them without hiding who we are.

As I reflected on what I had read and heard I realized they all fit together. As Christians we should be engaging not only those who are unlike us in faith, but all who are in need as we model Jesus’ incarnation. That leads us to seek out what is best for those who are not provided for in our current system of health care as Joe was saying. It means Christian physicians should help patients with cancer and others throughout our society better understand that what is best for them may not always be more treatment, but wise care with an understanding of our mortality and the hope we have beyond that. As we address the needs of the poor and the sometimes unrealistic expectations we have as a society about medicine with a focus on what is ultimately best for everyone we will begin to have the perspective needed to address our broken health care system.

Can the Church have a distinctive take on health care insurance reform?

The Supreme Court has finished hearing the case for and against various provisions of the Obama health care plan. All that remains now is to wait for the decision, which will be handed down sometime in June.

There is much to be opposed to in any scheme of health care insurance reform. If we are waiting for a perfect plan before we will declare our support, then we will never support any reform plan. However, I believe the problem of how to justly provide health care to all is an opportunity for the Church to counter the perception of alignment with partisan political agendas and show instead its alignment with an agenda that transcends political or personal preferences.

The doctrine of God’s love, of the self-giving agape which God demonstrates toward us and enables us to show to others, should surely influence our attitude towards health care reform. One expression in Scripture of what our attitude should be is found in Philippians, where Paul writes, “Each of you should look not only to your own interests, but also to the interests of others. Your attitude should be the same as that of Christ Jesus . . .” (Philippians 2:4-5) Much of our resistance to reform comes from considering only our own interests, to the neglect of the interests of others: placing our own desire for limitless choice over the interests of those who have virtually no choices; putting our desire to keep more of our income out of the hands of the tax collector over the interests of those with much more meager incomes who would benefit from the care increased taxes might provide; placing our general principled distrust of government higher in importance than the real good limited government intervention might be able to accomplish in this particular situation. As Christians, we can be concerned not first of all with our own rights and interests, but with those of others, and can willingly insist not on a right to maximum health care but only to a level that is socially equitable and affordable.

As Christians, we have a unique opportunity at this time in history to be a singular witness to Christ by approaching health care and its reform from a theological standpoint rather than the standpoint of a political party agenda or our own rights and interests. By overcoming the tendencies that naturally make us resistant to health care reform, we will show that we are conformed to something other than our culture or our own private interests. By making clear that the followers of Christ are advocates for those unable to afford care, even when it may be disadvantageous to ourselves, we will take our place among the ranks of our Christian forebears who, as they started the first hospitals and hospices in Europe, were at the forefront of health care reform in their day.

The real reason the Patient Protection and Affordable Care Act should be repealed (and it’s not the one the politicians give)

 

First, the bad news: Between 1980 and 2009, annual real per capita health expenditures grew by 4.1%. In the same period, per capita GDP (adjusted for inflation) grew by 1.8%.  In other words, health care costs grew faster than the money to pay for them. The inevitable endpoint, if such trends continue, is eloquently demonstrated in the graph from this 2005 study from the Robert Graham Center (a center for the study of health care policy), which projected that an annual US family health insurance premium would equal the average family’s annual income by the year 2025.

Now, the good news: A study in this week’s Annals of Family Medicine updated the projection, taking into account the passage of the Patient Protection and Affordable Care Act (PPACA) and the recent slowing of health insurance and wage increases. The new calculations push the date when the family’s premium will equal the family paycheck all the way back to 2033!

The PPACA got a lot of people hopping mad, and in an election year, it has become a huge political hot potato. Many feel it went too far, and therefore should be repealed. However, if the studies mentioned above are even close to accurate, the thing should be repealed, not because it went too far, but because it didn’t go far enough. It provided cosmetic surgery when what the patient needed was a heart transplant.

Many Christian voices have joined the chorus attempting to shout down the PPACA. However, this seems to me to be fiddling while Rome burns, because with or without the PPACA, our health care system is becoming unsustainable, and people — real people, like you and me, and disproportionately the poorer among us — are suffering physically, financially, emotionally, and yes, spiritually, because of the ruin they face from health care costs. And without radical change, more and more will join their ranks.

A large portion of Jesus’ recorded ministry involved healing the sick. The main difference between the sheep and the goats in the Matthew 25 parable is how each treated “the least of these.” It is those “least” that will suffer the most as health care costs become increasingly untenable. Therefore, as Christians, we should be at the forefront of efforts to ethically control healthcare costs and provide some level of basic, dignified healthcare to all. These efforts may or may not entail greater government involvement in health care. The recent controversies over contraceptive coverage show what can happen when the responsibility for health care reform is left solely to the government. But either way, it would reflect well on Jesus Christ if his followers took the lead in ensuring that compassionate health care is within the reach of all people. This will require radical change, as well as self-sacrifice; but who is in a better position to lead the way than the followers of the One who changes lives radically because of his self-sacrifice? The PPACA cannot deliver this; if the PPACA is repealed, it should not because it went too far, but because it didn’t go far enough.

Eight is Enough

 

In response to a family’s having eight babies by IVF and gestational surrogacy:

“In this society, if you have money, you can have miracles!”

“Having children is now a luxurious game for the rich!”

“This completely topples the traditional meaning of parents.”

“From the sound of it, they just tried to have some kind of baby machine.”

“Gestational surrogacy is the business of renting out organs.”

“Why did they have to hire so many people to have babies for them? Did they think they had the right to bear children just because they were rich? Secondly, what respect to life did they show? Multiple pregnancies are super risky.”

These are reactions from the public, press, and government officials to a wealthy couple having two sets of triplets and one set of twins via IVF and two surrogates in China, where there has been an official one-child-per-family policy since 1978. Last month a southern Chinese newspaper broke the story of this family, and you can sense the angry reaction of their society in the quotes above.

(There is apparently a large surrogacy industry in China, despite a 2001 ban on Chinese hospitals doing the procedures. The manager of one surrogacy agency reports being overwhelmed with applications from aspiring surrogate mothers, most of whom are having emergencies and “need a large sum of money.”)

In the uproar, we can see erupting some of the tensions surrounding these technologies that are still somewhat under the surface in our own society: What about the divide between those who can and can’t afford reproductive technology? What does it mean to be a parent, especially where surrogacy is involved? Is surrogacy the commodification of women, the reduction of woman to womb?

There is a lot of worrying that China will catch up and surpass western economy and culture. It seems that in some areas they have already caught up with us: pushing the envelope of societal norms with the use of reproductive technologies, and the commodification of women in the process. In another area they are still far behind us: they have not yet lost the ability to be uncomfortable, shocked, even a little disgusted at the ethical implications of these technologies for families and society.

 

(Sources: Here and Here)

Part 3: Caution, Compassion and Wisdom in Policy

“We should measure welfare’s success by how many people leave welfare, not by how many are added. The so-called war is not over and welfare programs are just not working.”

Last week I made the claim that we should be careful how we choose to assist those in need. This was based on four “principles” that I derived from an anecdote from my life:  Just because you think what you are doing is helping somebody, does not mean it is; Helping people requires an effort on both parts; People you help will take more than you give them and they may not stop taking; and, Temporary solutions may offer no long-term resolve.

The purpose of this week’s blog is that you do not think of me as a heartless beast. I recognize that people have needs they cannot meet. I also realize that not everyone has been given the opportunities I have. However, supporting the needs of the needy must be done with caution, compassion and wisdom. As I stated last week, our good intentions are not good enough for the societal implications.

There are now at least 77 federally funded programs for poor and low-income Americans, and their need has not gone away. These programs range from giving food aid to those in need to giving medical care to children–all of which are ‘goods’ in and of themselves. LBJ’s declaration of war on poverty produced these programs (partnered with FDR’s programs in the 30’s), which offered some temporary resolve for the basic needs of the “others” of American society.  (I think that counts as a declared war that will see no end…) But just as in all ethical deliberation, we must look at the consequences of the action, and then assess the value of the act.

While the mid-90s reform of Welfare has offered some progress and growth, the reality is partakers are not being weaned off the system. It is a benevolent service that creates a co-dependecy and not necessarily to the fault of the recipients. For a quick look into what Welfare offers those who partake, go here. Additionally, “Researchers at the Dartmouth Atlas Project and elsewhere estimate that about 30 percent of Medicare spending does nothing to make patients healthier or happier… and Medicare grew at an average annual rate of 9.3 percent over the past decade!”

Above Welfare and Medicare, Medicaid costs have grown substantially. “Spending jumped from $118 billion in 2000 to $275 billion by 2010. And even before the 2010 Health Act was passed, spending on the program was expected to double in cost to $487 billion by 2020.The 2010 law will boost Medicaid’s cost by about $100 billion a year by 2020.”

The heart of my concern is that there is a frightful similarity in the way my college roommates chose to help a homeless man and the way our society is helping those in need, without cautious consideration for the consequences on the individuals who are receiving these so-called benefits and, ultimately, on the society in which we live.

 

 

How private enhancement decisions led to a public health crisis

 

The proponents of using medical techniques not just for treating disease and dysfunction, but also for enhancing normal form or function, often appeal to privacy. Since most public and private insurance schemes do not pay for enhancement technologies, people who desire such “treatments” pay out of their own pockets; so, the argument goes, if they’re not hurting anybody, and they’re paying for it themselves, what’s the problem?

One of the more popular enhancement technologies worldwide is the cosmetic surgical procedure of breast augmentation. In the last few weeks a crisis of sorts has erupted around a particular brand of silicone breast implant, manufactured by the now-defunct French company Poly Implant Prothese (PIP) and exported all over Europe and South America. It turns out that the silicone used in PIP’s implants was not medical-grade, but industrial-grade, made to be used in mattresses; this may make the implants more prone to rupture. Rupture can lead to increases in inflammation and scar tissue formation.

About 300,000 of PIP breast implants are thought to have been used worldwide. This week, France and Venezuela took the step of offering to pay for the removal (but not the replacement) of all PIP implants. “We have to remove all these implants,” said Dr Laurent Lantieri, a French plastic surgeon “We’re facing a health crisis …” France will pay for ultrasounds every six months for those women who opt not to have the surgery.

Two things to note: first, removal of an implant is not like taking out a splinter. It is a major surgery, under general anesthesia, with all of the attendant risks — and expenses — of surgery. Second, other than those women who had implants inserted after breast cancer surgery, all of the women involved paid for their augmentation themselves. But now the state — that is, the citizens of France and Venezuela — will be paying for the corrective surgeries.

All techniques and technologies carry unintended and unforeseeable consequences. Even with the best planning and forecasting, all techniques will surprise us in some way. Medical techniques, because they work directly on the human body, have the potential and power to do very great unintended harm. The silicone breast implant crisis is an example of how choices made in private can have significant unforeseen consequences and costs for the public. The argument that using medicine for enhancement is merely an individual and private decision is simply not valid. How many more individuals will be hurt, and how much more will society pay, as enhancement techniques — and their unforeseen consequences — proliferate?

A Lament For the Loss of Community

This guest post is authored by LL French, a current student at TIU.

Community is dead. Cause of death: uncertain. But definitely dead, gone, passed, slipped on a banana peel, deceased, dead!

For Millennials like me, we’ve never lived in a world where neighbors help each other. After all, isn’t that the job of the government? Welfare? Food stamps? Medicaid? (Please note the heavy tone of sarcasm in my voice right now.)

Let me explain the reason behind my cynical rant on community. Today my little bioethics-obsessed mind ran across a CNN news article. In the story, Baby Pierce, a four-month-old with rare Heterotaxy Syndrome, needed heart surgery. Demanding the best care for her infant son, Pierce’s mother insisted on sending her baby to a top Boston hospital for his care.

Problem: Medicaid wouldn’t pay to send him to Boston when another “capable” hospital existed in Indiana.

Solution: fundraising on Facebook and donations from mothers of children with heart problems!

Now for the quote that convinced me that community was dead – in the words of Pierce’s mother: “I think it is sad that a bunch of moms and strangers who don’t even know me or my child have stepped up to the plate more than… the government, and insurance, and Medicaid.” This statement troubles me. She thinks “it is sad” for strangers to help? Isn’t that the very essence of community? Isn’t community, by definition, any group of people that come together to encourage, support, and protect you?

Should Medicaid have helped the young mother? I’ll leave that question to more capable minds. What I am shocked by is the assumption that strangers shouldn’t help! I fear we now live in a world where we rely on the government too much. We rely on the government to be the Good Samaritan that we once were. I mourn the loss of a traditional community where generosity to those in need was normative. Indeed, I fear bioethics and health care in general has much to lose if community dies.

Yes, I exaggerate. There is hope. Community is not dead, but perhaps transformed? Yes, we don’t live in a world where neighbors help each other. Instead, we live in a world where random people on Facebook can form a community to save a baby! Our traditional sense of community has been replaced by Facebook, Twitter, and texting, etc. As a natural cynic, I doubt Facebook’s power to bring people together in community, but Baby Pierce gives me hope that people can come together to form a new kind of community – but only if we are intentional in our pursuit of community and we lose this silly notion that strangers shouldn’t help each other.

See more on Baby Pierce

Infinite demand and the drawing of lines

 

Many of the problems with health-care financing in our country come about as a result of difficulty with line-drawing. I’m not talking about geometry, but about making hard decisions.

This difficulty with line-drawing is not new. In 1971, while Congress was debating national health insurance (!), a man named Shep Glazer testified in dramatic fashion before the House Ways and Means Committee about funding for renal dialysis — while hooked up to a dialysis machine. “Gentlemen,” he said, “what should I do? End it all and die? . . . If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up?” After thirty minutes of debate in the Senate and ten minutes in a House-Senate conference committee, Congress voted to extend Medicare coverage to any and all who need dialysis. The uncharacteristically short amount of time spent considering this action, one that should have raised some very hard questions about things like the just distribution of limited resources, suggests that the hard questions were ignored in favor of doing something that feels on the surface very good — paying for everybody’s dialysis — but that has far-reaching, unexamined consequences.

An excellent article in the Chicago Tribune last week described a recent iteration of the old problem. Through medical advances, increasing numbers of our oldest citizens are being made healthier by procedures that were once reserved only for younger people: it is not unusual for people in their 90s to have hip replacements or a 102-year-old to have a heart valve replacement. Now, these are good things! These people are living more fruitful lives through medical procedures. But they are living under a system, Medicare, that does not consider price, but only benefit to the patient, in making decisions about what medical procedures it will cover. And as the proportion of the population receiving Medicare expands, and as expensive medical techniques proliferate, the demand for such procedures will be virtually infinite. Unfortunately ,the resources to pay for them will be all-too finite.

At some point we have to go beyond emotional appeals, beyond doing the thing that feels the best but which bankrupts the country (covering everything for everybody at any cost). At some point we have to draw lines, to make hard decisions about who will get what — and who won’t.

What is the most ethical, most just way to make this decision? The Tribune article mentions one solution put forth by Daniel Callahan and Sherwin Nuland: set a cutoff age (they suggest 80) beyond which people will not be covered for anything beyond “good basic health care.”

Callahan said, “If you want to save all lives, you’re in trouble. And if you want to save all lives at any cost, you’re really in trouble. . . We need to stop thinking of medicine as an all-out war against death, because death always wins.”

Callahan’s perspective in that last statement is a good corrective to distorted expectations of medicine. I don’t agree with how and where he draws the line on providing medical care; but if it gets the discussion going, it’s at least a place from which to start.

Musings from a nursing home

 

It has been five months today since my sister had the first of many brain surgeries for a burst aneurysm. I was visiting her yesterday, and the visit prompted the following random bioethical thoughts.

Health-care payment reform – My sister is in a nursing home, and until recently had been receiving various therapies. Earlier this month her insurance ran out, and suddenly — without notice — now she receives none.

This situation is not surprising, given the claptrap patchwork of healthcare payment that passes for a system in our country. The health-care payment reform debate has been so politicized — that is, it has become a tool of political power that each party wields as a weapon against its opponent — that rational, ethical discourse on the subject seems to have been left in the dust. There is a more ethical way to deliver health care; however, as long as we leave it up to lobbyists, interest groups, and two political parties that seem more intent on power than government, we will see increasing numbers of people left in the medical and political dust.

Human dignity – By some standards, my sister might be thought of as having lost her human dignity. Before June 11th she was an energetic, triathlon-running, blog-posting woman; now we are excited if she can manage a hand-squeeze or a groan. By some estimations, she might be said to have a “life not worth living.” According to some bioethicists, she doesn’t have what it takes to be treated with the respect due to human persons. I’m sure glad they haven’t been taking care of her these last five months.

The search for a cure – Putting aside for the purpose of argument all of the insurmountable hurdles that have to be overcome, imagine for a moment that the fondest dreams of certain researchers reach fruition, and that embryonic stem-cell therapy for brain trauma becomes a reality. Imagine (you have to imagine, because it is all imaginary at this time, never mind the rhetoric to the contrary): What if my sister could walk and talk and laugh again, if only we were willing to sacrifice an embryo, “a glob of cells smaller than the period at the end of a sentence,” maybe an embryo leftover from IVF in fertility-clinic-freezer limbo somewhere?

Much of the Church has taken a stand against embryonic stem-cell research, as is right. But it’s easy to oppose something that has no forseeable hope of becoming reality. What would happen if the unthinkable became possible? Would the Church still stand against it? If cures for your daughter’s diabetes, your son’s leukemia, your wife’s brain tumor, your mother’s Alzheimer’s, were an embryo away? Would we be like the liberal bioethicists and find justifications for what we now rightly oppose? Or would we continue to respect all humans, no matter what size or developmental stage, even to our own hurt?

The procurement of organs for transplantation: China vs. the WMA

Can a convict sentenced to death give truly free and informed consent to the harvesting of his or her organs after execution?

There is great difficulty obtaining organs for transplant in China. Much of this is blamed on cultural factors, although suspicion of corruption in the medical profession is also a significant reason. Whatever the reasons, between 2003 and 2009 there were only 130 voluntary organ donations in all of China. Yet in 2006, there were 11,000 organ transplants performed.

So where are all of these organs that are not voluntary donations coming from? Answer: executed prisoners. To its credit, China does try to make sure that prisoners give informed consent. According to Bing-Yo Shi MD and Li-Ping Chen PhD, writing in Wednesday’s JAMA, “If a sentenced convict [in China] would like to donate his organs, the convict and his family must submit an official application and sign an informed consent statement with a lawyer present. Before execution, the convict is asked to confirm his organ donation again, and if consent is reneged, organ procurement is explicitly prohibited.”

However, the World Medical Association (WMA) in its Statement on Human Organ Donation and Transplantation explicitly states that “Because prisoners and other individuals in custody are not in a position to give consent freely and can be subject to coercion, their organs must not be used for transplantation except for members of their immediate family.” (Section F par. 4) In a 2005 resolution the WMA addressed China specifically, stating unequivocally that “The WMA demands that China immediately cease the practice of using prisoners as organ donors.”

In a society such as China’s with such strong biases against organ donation, what are we to make of this large number of sentenced convicts apparently consenting to donation? Are they simply the most altruistic segment of the Chinese population? In the absence of another explanation, one must wonder whether the fact of imminent execution itself is somehow a form of coercion, an external constraint on behavior. In the absence of another explanation, one must wonder whether China or the WMA is right:

Can a convict sentenced to death give truly free and informed consent to the harvesting of his or her organs after execution?

 

(Information for this post came from the letters, “Organ Transplantation and Regulation in China,” and its reply, published on pages 1863-4 of the November 2nd issue of JAMA: The Journal of the American Medical Association, which were in response to the article “Regulation of Organ Transplantation in China: Difficult Exploration and Slow Advance,” by Shi and Chen, published on pages 434-5 of the July 27th issue.)