Medicine Men of the Mind

This past week I made my yearly journey from Wisconsin to Arizona by automobile with my dog to visit my husband who winThis past week I made my yearly journey from Wisconsin to Arizona by automobile with my dog to visit my husband who winters there. In this yearly process, I have discovered the delight of audiobooks. This year, I explored the holdings of our local library in rural Wisconsin, but the only audiobook of substance that they had (the only non-Evanovich) was Ayn Rand’s Atlas Shrugged, an author of whom I had heard, but with whom I was not acquainted. It has been fearfully intriguing to ponder the ways in which her philosophical ideas have crept (or been smuggled) into our culture—not wholesale, but part and parcel.

While her political ideas are not too dissimilar from anti-socialist emails that are making the rounds these days (or so I’ve heard—emails about professors applying socialist paradigms to grades and failing the whole class because those students with ambition and ability ultimately refused to carry the weight of the non-ambitious in the class—“Atlas shrugging”), it is her ethical ideologies that are most disturbing. For Rand, the moral measure of man is his hedonistic happiness. Correspondingly, she also rejects any doctrine of altruism. Her ideal is a society ruled by Men of the Mind, where selfishness, or rational self-interest, is the primary virtue. Ironically, Rand’s appeal is to the ideal of rationalism and not the reality of fallen rationality in a fallen world. While Rand objects to hedonism, in reality she makes no distinction between rational and irrational happiness, and therefore hedonism is a reality in a society of fallen persons of differing rational capabilities.

Men of the Mind are persons who choose to think, and such thinking requires a state of fully focused awareness achieved by the volitional act of focusing one’s consciousness. One can choose to focus their mind to a fully active, purposefully directed awareness of reality—or one can become unfocussed and let oneself drift in a semiconscious daze, merely reacting to any chance stimulus of the immediate moment, and making random, irrational associations. Such an unfocused semi-conscious drift as Rand describes is alarmingly true of our culture today, as we have become fractionated and distracted by the barrage of stimulants that confront our senses, and, as a result, are losing our ability to “perceive.” There is no time for, or importance given to, the use of the mind for thoughtful reflection–just mindless reacting to external stimuli which we require to ever greater degrees.

In Atlas Shrugged Rand vividly depicts the “end” of a society ruled by the “Mystics” (persons who rule society on the basis of faith, altruism, or other non-rational ideologies which find their source and goal in God or society) as one ensconced in violence which is the means to the promotion of their ways. Yet she, fatefully does not portray what a society ruled by Men of the Mind would look like. She claims that objectivism and capitalism are the systems most beneficial to the poor but she does not portray what would happen to those who are unproductive or somehow rationally challenged in a society where there is no altruism. Does she not believe that they would then turn to violence to support themselves, taking from those who have what they need for their lives and happiness by force and justifying such actions as their only means of procuring their own survival and happiness? Would not the end be the same but with a different ruling class?

It seems that her rational perception has been blinded to the reality of evil inherent in mankind. And that blindness is easily coupled with her attitude toward the fact of original sin. Rand refers to the concept of “original sin” as an evil and a monstrous absurdity which she claims makes a mockery of nature, justice, reason, and morality.

Her perceiving is also blinded by failing to perceive the reality of our human interdependence as objectively evidenced in that fact of our birth and growth. In Atlas Shrugged there are no families, no marriages, no children. One can easily surmise the reason: marriages, families, and children require self-sacrifice, a cardinal vice in Rand’s philosophical world. Even romantic love is a matter of rational self-interest; hence, there is no room for agape love. But with no marriages and families, the society she envisions is an unstable collection of hedonistic individuals, subject to disintegration. And with no children that society has no future, unless, of course, they can continue to cull members from the wider world.

Medicine, too, has fallen prey to her ideologies, where Men of the Mind have taken over from Men of Compassion; where the data of our senses is replaced by data from machines; where there is no room for altruism; where personally defined “happiness” and self-fulfillment have become the goals and ends of “medical care”; where technology and innovation serve the desires of the wealthy, but not the basic needs of the poor; where Money, Productivity, and Efficiency have come to be the image and symbol of success—the gods of a profession that was. Medicine is no longer about caring, because caring belongs to subjectivity, and is unproductive and inefficient, to the Mystics of the Spirit or of Society (which Rand lumps together in one malevolent category). Such a system no longer serves the needs of the vulnerable and needy for whom it was intended. Is this indeed where we are headed?

On Efficiency in Medicine

“Efficiency” has become the be-all and end-all of our culture. In a world defined by technique, efficiency is an unassailable defense against opposing viewpoints: one has only to say, “Well, this way increases efficiency,” to silence all the naysayers and get everybody’s heads nodding in agreement.

So my attention was riveted when I heard a physician wiser than I say, “All the efficiencies of the last fifteen years have reduced the time between patient and physician.” It was an offhand remark, mentioned in passing.

I thought, Wait a minute. Efficiency is a good thing. But less time with my patients or my doctor doesn’t sound like necessarily a good thing.

I went to my old Webster’s Collegiate Dictionary, Tenth Edition. “Efficiency” means “effective operation as measured by a comparison of production with cost (as in energy, time, and money).” “Efficient” means “productive of a desired effects.”

So “Efficiency” doesn’t equal “Good,” or even “Better.” In fact, “Efficiency” by itself says nothing about an activity’s moral content. Whether something is morally right or wrong depends not just on the means but on the desired effects, the ends we wish to achieve. If  we are more concerned with increasing the efficiency of our projects than with the content or outcome of those projects, we are in danger of spending our time “committed to the quest for continually improved means to carelessly examined ends.”

“Efficiency” seems to have taken the driver’s seat in medicine. In my work as a physician I daily hear exhortations to increase efficiency, and new projects — no matter how onerous — justified by, “This will improve efficiency.” But is it possible that improving certain means (= increasing efficiency), without considering other means or the ends towards which those means tend, might actually be detrimental?

Returning to the physician’s statement above, we must ask, “What are the ends of medicine?” The answers are Legion, and depend largely upon whom one asks. To some, it may simply be “health.” To stakeholders and bean counters, it might revolve around profit and return on investment.

Several studies indicate that a good relationship with a trusted physician is very beneficial for health, particularly for those with chronic diseases. So a better relationship with a physician would be an efficient way to achieve the ends of health, and “Efficiency” might mean more time spent with patients building meaningful healing relationships.

But if one measures efficiency in medicine only in terms of “the amount the doctor bills for his services per hour,” then more time spent with individual patients actually decreases efficiency.

If we make out “Efficiency” to be an ultimate good, and if we define it as cost per unit of time, then we will have destroyed medicine and remade it into something barely recognizable as the vision of Hippocrates (and Jesus). I maintain that this process has already advanced far, that we are steadily improving the means to poorly examined ends, and that we must reexamine the ends of medicine before we consider redesigning the means.

End-of-Life for a Major Hospice?

San Diego Hospice may not make it.

That’s the news out here for an organization that is described as “iconic in the hospice world.”  Last November, a Medicare audit concluded that the government had been overcharged—a lot—by San Diego Hospice.  Apparently the problem was filing claims for people who weren’t quite sick enough—expected to die within 6 months—to require hospice care by the Medicare reimbursement rules.  And, sometimes, people get a bit better, so they outlive expectations and aren’t supposed to qualify for continued Medicare reimbursement, but the hospice continued to file claims.

The immediate repercussions have been catastrophic—a Chapter 11 bankruptcy filing, a 30% shortfall of operating expenses, layoffs of about a third of employees, with more likely on the way, and a reduction in inpatient hospice census from 1000 to 450, so the local paper reports.  The CEO says they may not “have a viable organization moving forward.”  How much does Medicare think it should be refunded?  Try a number north of a million dollars—perhaps well north of that.  At least, that is the worry.  Just how much money we are talking about may not be clear to S.D. Hospice—and if so, that may be part of the problem.

The publicly-available information is still incomplete.  I have not seen allegations or speculations about poor management or fraud, and I certainly am in no position to speculate on the details of the case.  My first reaction was to think that an organization pressured by tight reimbursement rules got out “over its skis,” as it were, trying to get paid as much as legitimately possible, and in the process made some mistakes.  I don’t know.

There will still be hospice service available in San Diego County.  Competitors are emerging.  But I hope this will not mean that medically-appropriate palliative care will get too squeezed by payment rules—indeed, at a time when the merits of good routine palliative care is being more prominently discussed, at least in the oncology publications I try to keep up with.  And I guess it means that even for non-profits, money matters, and “good business management” is not a dirty word.

A story to be followed…

The Profession that Was

Once upon a time in a land far away, there existed a profession called “medicine,” a profession governed by internally derived standards and values, a profession that relied on both scientific data and experiential knowledge and judgment, a profession that focused on providing excellence in the care of others…
Last week I received a call from “utilization review” concerning the “hospital status” of a woman on whom I had just performed a vaginal hysterectomy by means of morcellation due to its size. The call challenged my decision to admit her for post-operative recovery.
Over the past 25 years we have gradually reduced the length of stay for our post-surgical (hysterectomy) patients from 5-7 days to 1-2. But the current impetus–mandated by insurance reimbursements and led by the governmental agency of the CMS (Center for Medicare-Medicaid Services)—is to require that hysterectomies be performed as an “outpatient” procedure. This entails discharging the patient hours after removal of an intra-abdominal organ with significant collateral circulation. As a default practice, such a mandate is unreasonable and unacceptable. It fails to consider the many contingencies of the individual patient and procedure for which physician judgment is still required.
At the risk of being too graphic, when a vaginal hysterectomy is performed, a major organ is removed through a relatively small orifice, compromising visualization of the surgical field. Inadequately secured blood vessels can retract into the pelvic sidewalls, out of sight, creating a risk of significant post-operative intra-abdominal hemorrhage. Fortunately, such risks materialize infrequently, but the risk still exists and requires a reasonable period of post-operative monitoring and assessment for the safety of the patient. For such bleeding, if it occurs, is potentially disastrous, even more so if the patient is not in the facility.
Over the past decade these same agencies have also become obsessed with pain control for hospitalized patients, developing and utilizing “visual analogue scales” (smiley faces) in an attempt to quantify the subjective and unquantifiable, and insisting that post-surgical patients be “pain-free,” an unreasonable expectation to begin with. Yet now it is proposed that patients be sent home with anesthesia-induced and pain-induced nausea and vomiting that prohibits them from taking their prescribed oral analgesics which results in more pain, more nausea, and more vomiting—a vicious cycle. Moreover, the increased intra-abdominal pressure that occurs with valsalva increases the risk of post-operative hemorrhage. As concerned as the accrediting bodies have been about pain control for hospitalized patients, there is no concern about the adequacy of pain control for patients who are discharged–it seems that it is then no longer their responsibility. But while it may no longer be the “responsibility” of the regulating agency, the pain and care of these patients is still my responsibility and concern.
Over the past few years this has resulted in “insurance-company-mandated-hospital-anxiety-over-lack-of-payment” induced game-playing over hospital status, games characterized by dishonesty and semantics. But these new rules, regulations, and games place physicians in the untenable situation of being morally and legally responsible for patient care that is legislated by a nebulous outside authority, one that lacks knowledge of the particular patient and/or procedural contingencies. Furthermore, as professionals, our calling is to be advocates for our patients and their care. Yet if we advocate for patients by refusing to abide by unreasonable and unacceptable regulations, especially in rural America, the hospitals in which we provide that care are penalized through the withholding of reimbursement and imposition of fines that threaten them with insolvency. Such a situation violates and undermines the concept of professionalism, which by its very nature is governed by internally derived values and standards, not externally imposed regulations.
Medicine is not a game, especially not a zero-sum game. It is a profession defined by excellence in its practices. Or at least it was. How is it that these “authorities” have assumed the right to dictate patient care without assumption of the correlative responsibility for any adverse consequences? I fear that we, ourselves, by shifting our focus from care to compensation, have let the fox into the henhouse. That fox has destroyed the profession…and I fear it is here to stay.

Conscience, Data, and the Burden of Proof

Dr. Susan Haack’s recent posts on conscience, and the ongoing struggle over the HHS regulations on mandatory insurance coverage for contraception under the Affordable Care Act, demand more careful further reflections than will fit in a blog post, but I will dare to stick a toe in nonetheless.

In The Line Through the Heart: Natural Law as Fact, Theory, and Sign of Contradiction, J. Budziszewski argues (see pp 8-15, for example) that “deep conscience,” which is “rooted in the constitution” of all humans, is a cardinal indicator of the existence of a natural moral law.  Deep conscience “remembers” general moral norms (including, he argues, the Decalogue).  I’d take this to be Dr. Haack’s “antecedent” function of conscience.  Budziszewski then distinguishes three “modes” of conscience:  cautionary, accusatory, and (for lack of a single term) confession/reconciliation-seeking—the “consequent” functions Dr. Haack mentions.  He would certainly agree with Dr. Haack (as do I) that conscience points to a transcendent authority.

Presumably (me talking now, not Budziszewski), we form correct moral convictions by agreeing with deep conscience about moral truth.  However we arrive at those convictions, we can argue that they too have “antecedent” functions in that they are, if properly understood, sufficient to motivate ethical behavior.  (I just glossed over a major discussion in ethical philosophy that I ask the reader to accept for the sake of argument here.)  Convictions do not, however, produce a sense of guilt, accountability, or of a need for reconciliation.   Conscience does that.   Whether we recognize it or not, conscience is witnessing to our accountability before God.  People who deny God’s existence, however—and who may well also interpret “guilt” to mean a response to bad-faith intimidation by the organized church—can still coherently claim, it seems to me, to act out of conviction with accountability to the community, as long as the standard is some sort of community-recognized norm.  In a pluralistic society, one can appeal to positive law or what we can agree on; or, alternatively, one can appeal to the shared understanding of what it is to be an autonomous moral agent (as I take the German philosopher Jürgen Habermas to do).  Just don’t plead metaphysics.  But the appeal to convictions is not ripped from its community connections—it depends on them, just in a different, but critically different, way.

And that, of course, is the problem.  People like me are making a metaphysical argument (actually, I want to argue for a form of natural law) in a positive law world.  Some of the “positive lawyers” claim that their convictions are objective, not relativistic, because they are available to observation, as in the natural sciences, so we can agree on them, revising our understanding as we get new information.  We are left with a sort of “naturalist’s natural law.” I think that is irredeemably relativistic, in the end—if God is dead, nothing is out of the question.   I understand Budziszewski to agree.  He criticizes the “positive/natural lawyers,” if you will, of pursuing a “second-tablet project”—that is, isolating the “second [stone] tablet” of the Decalogue (Commandments 5-10) from the more explicitly God-directed first 4 commandments of the “first tablet.”

So what?  First, I would submit that the “conscience/convictions” argument doesn’t help all that much in cases like the HHS mandate.  The issue is how much room to give to particular metaphysical stances—the public/private square problem.  Pluralistic norms vs religious freedom is still the battle.  And it will not do to say that profit-seeking makes the moral application of metaphysical commitments illegitimate.  To put the fine point on it, Hobby Lobby’s owners ought to be accorded the same freedom of conscience as are the Catholic Church, or a church-run hospital, or Wheaton College (for example).  I worry, perhaps too much, that bioethicists in particular worship at the altar of non-profit status in ways that risk serious mistakes.

Second (and cf. the recent post by Dr. Joe Gibes), statements like “[The] lack of any substantial evidence for post-fertilization effects [of emergency contraceptives] may significantly weaken conscience claims, and may militate against refusals to dispense or to refer,” [Lewis and Sullivan, Ethics & Medicine 28:113-120, 2012] will not do.  Failure to prove is not disproof.  Absent definitive data, prohibition of emergency contraceptives may be weakened.  But without definitive data—which may not be accessible by ethical experiments—sufficient to free the conscience of concerns, conscience claims of someone with a reasonable doubt about what the data mean ought to be vigorously defended, even against a strong majority consensus.   We should not let a prevailing tide of naturalistic, “data-driven” ethics confuse our use of the data in service of true moral precepts.

Reminders of the Challenges to Informed Decision-Making

Two recent reports remind their readers how difficult it can be to ensure that a person making a decision or expressing a preference about his or her medical care is doing so with proper information.

First, in the journal IRB: Ethics and Human Research, Kim et.al. ask the question, “Research Participants’ ‘Irrational’ Expectations:  Common or Commonly Mismeasured?” (Article free to the public, registration required.)  They cite the oft-raised concern of “therapeutic misconception” in clinical research:  people who volunteer for certain clinical trials often misunderstand that the primary goal of the research may not be to demonstrate a treatment is effective, or they think that their enrollment has a better chance of benefitting them, or even a known chance, when that is not the case.   Or, they do not grasp fundamental features of the research, including (or, better, especially) random assignment.  In their study, Kim et.al. found what they suggest is evidence that people may understand randomization perfectly well, but not apply it to their situation or appreciate its meaning for them.  They studied people with Parkinson’s disease enrolling in a randomized trial of gene therapy vs. a sham procedure, and they found that while study subjects could readily demonstrate that they knew what randomization was, and what it meant for the likelihood of being assigned to one study arm or the other, when they were asked what group they thought they personally would be in, many professed ignorance or some level of certainty that they would be assigned to the arm they preferred—viz., the treatment arm.  The study suggests (and the authors say so) that this is perfectly understandable and reasonable human behavior, and that the discrepancy does not mean the subject has been misled or is not intelligent.  Put another way, researchers should not look down on people who appear to overestimate their likelihood of personal benefit, or conclude that such an overestimate necessarily implies a deficiency in the informed consent process.  It also can be read as a bit of fresh air for conscientious clinical researchers who worry that—or are besieged with accusations that—they are taking undue advantage of sick people who want to get better.

The second article, in the Journal of Clinical Oncology, comes from the “Video Images of Disease for Ethical Outcomes” consortium—“VIDEO” for short.  (Everything has to have a slick acronym.)  In this study (subscription required), investigators from four major cancer centers studied 150 people with advanced cancer and an expected survival of less than a year.  They asked the cancer patients whether they would want cardiopulmonary rescuscitation (CPR) performed if their heart stopped beating.  Everyone was read a scripted description of CPR with an estimate of its likelihood of success, then half the people were randomly assigned to also view a 3-minute video that showed simulated chest compressions on a mannequin, and images of an actual ventilated patient receiving medications, with the script also included via a narrator.  The underlying premise was that words alone are insufficient to give people an appreciation of what CPR entails.  People who saw the video were more likely to say “NO” to CPR.  (The study did not include whether anyone actually had CPR performed.)  Women, white people, and people who had higher health literacy (an uncommon trait in our society) were also more likely to say “NO.”  Three-fourths of the people who saw the video said afterward that they were “very comfortable” watching it.  The study authors describe steps they took to keep the video or narrative from being alarmist or unduly influencing, and state that pushing a patient one way or another is a real concern for decisions like whether to plan to do CPR at the end of life.  (I couldn’t help but wonder what would happen if people with operable cancers were shown videos of their proposed surgery before deciding to have it—would they be less likely to consent to a procedure with known benefits?)  But when it comes to informed consent issues in general, my impression is that audio-visual tools to aid the decision process are generally viewed as helpful, and we should anticipate greater use of them.  It seems to me that context and equipoise are critical—context, in that any decision-aid tool should be used in the setting of a relationship of open communication and trust between patient and physician, and equipoise in the sense that the physician must have the patient’s welfare and free choice clearly in view, without competition from subordinate goals (like cost-control, public or private).

More on “Shared Decision Making”

Back on November 27, I posted on shared decision making, or SDM for short, and opined that in broad brush, this seems like a mom-and-apple pie initiative, with the goal of encouraging better communication, informed by better data more clearly communicated, about an individual’s medical decisions.  Central to that effort is the desirability for tools—written, audiovisual, and the like—that support the decision by making complex medical matters accessible to the average person, who is likely not to be sophisticated about medical or scientific matters.

Now, in a recent “Perspectives” article in the New England Journal of Medicine, Emily Oshima Lee and Ezekiel Emanuel urge more formal efforts to develop, certify in some meaningful sense, and use these decision-support tools.  The discussion strikes me as similar to a long-standing parallel concern about how to develop better consent forms for human subject research.

The kicker is that the authors urge a strong active stance by government to mandate the use of such tools.  This would serve three goals:  “promote an ideal approach to physician-patient decision making, improve the quality of medical decisions, and reduce costs.”

Although the authors of the article seem clearly to endorse a strong physician-patient relationship, with clear communication and decisions aligned with the patient’s values, the assumption is that in the preponderance of cases involving aggressive or costly care, or difficult decisions, the cheaper course of action will also be the medically appropriate course and the one that patients will prefer.  That may often be the case (and they cite reports from groups like the Kaiser Foundation to that effect), but when the patient prefers the more costly approach, there could be a conflict, to say the least.

The government would approve the tools, and, in order to ensure not only their use but the chance to collect data about the effect of using them, would demand they be used in Medicare, on pain of reduced reimbursement along the scale currently imposed on hospitals if they have to re-admit too many patients too soon after discharging them.  The CMS, the agency that administers Medicare, has the legal authority to proceed, that authority having been granted in the Affordable Care Act.  All they have to do is write the regulations, and put them into effect after the legally required advance notice (with open comment period) to the public.  CMS would mandate the use of the tools, not specific decisions about care—at least, they would not necessarily mandate specific decisions, not initially in any event.

Over at his “Human Exceptionalism” blog, Wesley J. Smith worries that this constitutes “the bureaucrat looking over your doctor’s shoulder.”  On one level, I’m not so worried—in my experience, the government is generally an accurate source of summary medical information, as on the NIH websites, for example.  Further, I bet the authors would insist that they do not mean to override individual decisions by a patient and his or her doctor.  It’s an open question how much the decision-support tools that eventually are derived will be written to push decisions one way or another.  In its human subject protection rules, the government is quite concerned, from at least the Belmont Report since, to guard individual safety and choice, so I am loathe to jump to conclusions here.

 

On another level, the goals do not exactly align with what I understood SDM to entail when I wrote about it before.  I thought that we were talking about helping a patient understand choices and clarify his or her values in conversation with the doctor, to support as informed a choice as possible—realizing that fully informed consent remains an elusive goal.  I didn’t think cost control was part of the deal.  While it is important to control costs, and it’s important that doctors not practice ineffective medicine, especially when to do so is expensive, cost control per se seems to me outside the boundaries of what I’d consider SDM to entail.

Further, I think we encounter again the tacit assumption that “data” will usually underwrite unambiguous, general rules that apply to all, or nearly all, medical decisions of a given kind and that are unencumbered by scientific controversy.  Regular readers of my posts will recall that I am suspicious of that assumption.  Add to that an assumption that government officials are especially if not uniquely equipped to create the decision-support tools, analogous to the HHS’s recent suggestion that it develop a single, national informed consent form for use in all U.S. clinical trials, a suggestion that I understand is being questioned by significant parts of the clinical research community.

Were this approach to SDM being taken by the medical insurance industry, we’d rightly be concerned that profit maximization was the goal.  But if the government—which pays roughly half of all health care costs in the country, and whose lead on payments is often followed by the private sector—is driving the process, should we be more confident that it has the patient’s interests at heart?  When does the government move from being a facilitator to a driver of care?  And should we really care?

These questions may be moot.  This interpretation of SDM is empowered in law and is probably coming.  Perhaps it would be a development of a more privately-driven approach, as well.  It seems like large organizations and rule-making regimes (I choose this language rather than the ill-suited term “system”) are engulfing more physicians’ regulated participation through mechanisms like direct employment, large contracts, etc, so this all may be the tide of history at work.  But we—patients and physicians—may need to read the print—which hopefully will not be too fine—carefully.

Questions, no answers

 

John P. Geyman, Professor Emeritus of Family Medicine at the University of Washington School of Medicine, in an article that was not about health care reform, nevertheless asked a few excellent questions about health care reform. I quote him here, from the journal Family Medicine:

 

The political debate over health care is focused more on peripheral issues than more fundamental, still unanswered questions. These include:

• Who is our health care system for? (ie, patients versus corporate stakeholders on the supply side)

• Should our health care delivery system be driven by a for-profit business model based on ability to pay or by a not-for-profit service model based on medical need?

• What is the role of government in setting health policy and providing checks and balances to the health care market?

All excellent questions, but the first one is especially trenchant; on its answer depends what one believes about health care reform. Who is our health care system for? And that question depends on an even more fundamental, ethical question: Who should our heath care system be for?

 

 

(Family Medicine, Vol 45 #1, Jan 2013, p 41)

A Couple of Other Bioethics Blogs Worth Checking Out

“Merry Christmas to all, and to all a good night….”

I am mailing it in on the holiday.  To do so, I thought I’d encourage readers of this blog to check out at least two other bioethics blogs that may not always be linked in the usual places.

One is Wesley Smith’s “Human Exceptionalism” blog at National Review Online.  Posts are reasonably frequent (although none in December 2012), with an emphasis on human dignity concerns (end-of-life, distinguishing human and animal moral status), biotechnology and risks of commoditizing human life, and the implications of the Patient Protection and Affordable Care Act (aka “Obamacare”).  Conservative, both socially and politically, as I take conservatism generally to be understood in today’s America.

The other is the “Over 65 Blog” at the Hastings Center website.  Organized by Daniel Callahan and colleagues, this blog focuses on reflections by senior citizens on health care, health policy, and generational issues raised by those and by the aging of our population generally.  The five stated goals are “a stronger role for seniors, self-determination, more care/less technology, confronting the cost problem, and the economic and family needs of the over-65 generation.”  The general perspective is more progressive or at least center-left.  Last week brought a really interesting post from Alicia Munnell, a management professor at Boston College, refuting the idea that older people working longer will mean taking jobs from the young.

I think both are thoughtful and authoritative, and welcome respites from the talking-point fiascos of broadcast journalism.

The CIA gets involved in providing health care

Eight vaccination workers were killed in the last week during a drive to provide oral polio vaccine in Pakistan, one of only three countries in the world where the paralyzing disease is still endemic. While nobody has accepted blame, the Taliban have issued threats against the UN’s anti-polio efforts, claiming that the vaccination workers are in reality US spies.

Vaccination workers as spies? Come on! This is obviously another paranoid accusation by a group with a long history of paranoid and unbalanced positions.

However, while the suspicions about the polio workers are patently absurd and completely unfounded, the Taliban have unfortunately been given a precedent for such accusations. Last year, a Pakistani doctor was hired by the CIA to run a hepatitis B vaccination program. But the program was a cover: its real goal was to obtain DNA samples in an effort to locate Osama Bin Laden. The program did provide vaccine, but only to those in the neighborhoods that were areas of interest to the CIA.

This is a repugnant misuse and subversion of the goals and ends of medical practice. It was of course wrong for a physician to deceive his patients, and he must bear the blame for his own actions. And the Taliban are directly responsible for their own twisted beliefs and actions, and I am not excusing their atrocities. But at least part of the blame must be borne by a government agency that unethically and blatantly promoted the corruption of a physician’s calling, in the interest of finding a human target.

This is categorically wrong. There is no national security goal that can justify such actions. We have seen the perversion of medical practice for ostensibly good purposes before, and each time it has done harm, intended or unintended, to the lives and dignity of human beings. This instance is no different. As a direct or indirect result of actions backed or taken by the CIA, one doctor is in prison, eight vaccination workers are dead, and who knows how many children may contract a terrible disease for lack of a simple oral vaccine.