Breaking News: Insurance Coverage Affects Access to Health Care!!

 

Okay, so maybe it’s not breaking news:  the type of insurance you have may affect whether or not you can get in to see a doctor.  In particular, if you have Medicaid-Chidren’s Health Insurance Program (CHIP) insurance (sometimes called “Public Aid”), you might have trouble finding a doctor who will see you.

In a study published in the June 16th New England Journal of Medicine, women posing as mothers of children with common health conditions called 273 pediatric specialist clinics throughout Cook County, Illinois.  They made two calls, one month apart, to each clinic, trying to get appointments for their purported children.  The calls were identical, except that one time the callers said they had Medicaid-CHIP insurance;  the other time, they said they had Blue Cross Blue Shield, a “good” private insurance.  The results are unsurprising but sobering:  66% of the callers reporting Medicaid-CHIP coverage were denied an appointment, compared with 11% of those reporting private insurance coverage.  For those Medicaid-CHIP patients who did get appointments, the average wait for the appointment was 42 days, compared to 20 days for the privately insured.

On the surface, one might attribute these inequalities to a bunch of bad, greedy doctors.  The reality, however, is more complex.  In Illinois, Medicaid-CHIP pays about 20 cents on the dollar (when it finally gets around to paying, which is sometimes six months after the fact).  Because of this, physicians may actually be spending more money than they take in for each Medicaid patient they see.  One can only  do that for so long and still keep the doors open and the lights on.  No, the inequalities do not merely stem from the behaviors of individual, money-hungry doctors;  the inequalities are built into a disastrously flawed system.

I am looking forward greatly to the upcoming CBHD conference examining the “Scandal” of Christian influence on bioethics.  Christians are perceived as being very concerned about issues like abortion, physician-assisted suicide, and embryonic stem cell research, which threaten human dignity by estimating a person’s worth based on their age, appearance, or utility to society.  But it seems that we are perceived as being less concerned about the structural, systemic factors built into our health care “system” which daily lead to insults to human dignity by estimating a person’s worth based on their pre-existing conditions, income, or occupation (i.e., their ability to get insurance).  I wonder, if we Christians really stood out in society because of our concern for the latter as well as for our concern for the former, whether we might not have a greater hearing and make a greater difference in all areas of bioethics.  (Remember Mother Theresa?)

Hope to see you at the Conference!

What Are Your Thoughts?

Blogging is unique because there is potential for open dialogue between writer and reader. To enjoy this unique quality I have decided to do something different than the norm. I would like to offer you an opportunity to respond to one question.

Feel free to use quotes from favorite authors, old papers (the ones you have buried in some deep corner of your thumbdrive), recent papers, or whatever. Try to keep it under 5 sentences… If you are not a fellow blogger on [email protected] please make note (briefly, I might add) of who you are.

Oh yeah, despite my track record, I intend to reply to all comments (if there are any)…

So, here it is:

In medical ethics, is it ever right to take away someone’s autonomy? Cases? Examples?

Cover-ups

Recently I have been reading the account of David’s life in first and second Samuel. Although he had a close relationship with God, David had his ethical failings. Much of his problems started with his adultery with Bathsheba which he tried to cover up when she became pregnant. His first cover-up attempt failed when he called her husband Uriah back from battle, but he refused to spend the night with his wife while his companions were at war. Next he tried to cover it up by having Uriah killed and taking Bathsheba as his wife. The consequences in David’s life and in his family were devastating.

Cover-ups have been a part of the fallen human response to errors and wrongdoing from the garden of Eden to Watergate.

One of the common ethical issues in medicine is how to deal with medical errors. For most of us our first response is to cover it up. Explaining to a patient that an error was made that has had or could have a bad effect is not an easy thing to do, but reading about David reminds us how bad a cover-up can be.

Should Alzheimer’s Patients Have The Right-To-Die?

Erik Parens and Josephine Johnston, two scholars from The Hastings Center, recently wrote an article titled: “As Tests to Predict Alzheimer’s Emerge, So May Debates Over the Right to Die (http://healthland.time.com/2011/06/08/as-tests-better-predict-alzheimers-patients-may-contemplate-their-right-to-die/#ixzz1Pvs2A0mc, June 8, 2011).” They noted that although the persona of Dr. Kevorkian (a.k.a., “Dr. Death”) was less than appealing, “Yet he forced us to confront questions that, much as we might want to, we cannot ignore.” For example, are some outcomes, such as the fate of Alzheimer’s patients, worse than allowing those patients the option to end their lives? If the answer is “yes,” then it may appear rather cruel to deny an Alzheimer patient the right to die. Consequently, the authors observe that “It is vitally important for us to explore all of the reasons against allowing or assisting Alzheimer’s patients to end their lives. And it is equally important to begin to explore the reasons on the other side.”

Furthermore, emerging procedures now make it possible to predict Alzheimer’s in an individual. This raises the stakes considerably because individuals who are currently in their right mind can state in advance a right-to-die preference rather than suffering from Alzheimer’s in the future. Parens and Johnston believe that, “Fear should not keep us from trying to imagine whether we can honor the truly informed requests of people who believe that the way of dying that fits best with their understanding of a good life, is to leave before Alzheimer’s fully takes hold.” Indeed, “we have an ethical obligation to face these questions, in solidarity with the millions of individuals and families who otherwise will have to face them alone.”

I do not think we need to be afraid to ask questions or seek solutions. However, I see a couple of problems, not only with the so-called right-to-die alternative, but also with making this option available to Alzheimer’s patients:

1) First, while it may be possible to predict Alzheimer’s in a person, it isn’t possible to foresee whether the individual will truly suffer from the disease. Currently I have a relative with Alzheimer’s. While some may feel pity for this individual, it is my observation that she is generally in a very positive, albeit diminished, state of mind. In reality, she seems downright giddy most of the time. But suppose she was diagnosed in advance with Alzheimer’s and requested the right to die before the disease took hold? In her current state, would the right-to-die continue to be her actual preference? Would she be locked into a decision that was made when she was in a coherent state of mind?

2) Secondly, it seems that we are facing the “perfect healthcare storm” with aging baby-boomers, a gloomy economy, concerns about healthcare allocation, and the lack of concrete moral direction in the field of medicine. According to the National Institute on Aging, “as many as 2.4 million to 5.1 million Americans have AD. Unless the disease can be effectively treated or prevented, the number of people with AD will increase significantly if current population trends continue. That’s because the risk of AD increases with age, and the U.S. population is aging. The number of people age 65 and older is expected to grow from 39 million in 2008 to 72 million in 2030, and the number of people with AD doubles for every 5-year interval beyond age 65. In the years to come, AD is expected to pose physical and emotional challenges for more and more families and other caregivers, in addition to those with the disease. The growing number of people with AD and the costs associated with the disease also will put a heavy economic burden on society.” http://www.nia.nih.gov/nia.nih.gov/Templates/ADEARCommon/ADEARCommonPage.aspx?NRMODE=Published&NRNODEGUID={2D13AE9A-D6EF-4546-9F02-66D3B3CC1453}&NRORIGINALURL=%2fAlzheimers%2f AlzheimersInformation%2f

It would be my fear that end-of-life decisions would be made for Alzheimer’s patients if it was deemed to be in their best interest.

On Same-Sex “Marriage” Legislation: Political Defections in New York State

 

Last week, The Wall Street Journal reported a shift in political support for same-sex “marriage” legislation in New York State.  Four state senators (three Democrats, one Republican) who had voted against the measure two years ago have now publicly declared their support, and with a few more Republican defections anticipated, politicians on both sides of the issue expect the measure to clear the senate and become law.

For this blog, I’d like to focus on the explanations the politicians offered the WSJ in support of their realignment on the issue.

First, there is republican Sen. Jim Alesi, whose reported rationale was that “Social justice should apply to all.” Few phrases appear more frequently in contemporary ethical discourse than “social justice,” and few are as malleable.  In its context, Alesi’s usage of the term reflects the view that social justice is to be construed as fairness manifesting in identical treatment under the law. More generally, the issue is, for Alesi, a moral one, and on that point we agree. In truth, each and every law (proposed or enacted) reflects a particular vision of what is right and good. Anyone who says “you cannot legislate morality” is either ignorant or dishonest for law by its very nature reflects moral vision—be it good or bad. So, in weighing legislative proposals,  one  ought to carefully consider the moral assumptions that undergird the competing positions. On the issue at hand, Alesi’s conception of  justice is certainly ripe for examination, and it begs the question “what is  justice?” Will justice truly be served if homosexual “marriage” is granted legal sanction?

Second, there is the response of Sen. Joseph Addabbo, who reportedly remarked “For me, my vote was about one thing: my people and my district.”  The WSJ reporter, Jacob Gershman,  interpreted Addabbo’s comment as indicative of the senator’s sensitivity to the views of his constituents, and he is probably right though other interpretations are possible.  Less ambiguous was the comment of Addabbo’s colleague, Sen. Shirley Huntley: “I did a survey. I can tell you the numbers had changed.” As presented, Huntley’s position rests on the notion that the legislator’s primary task is to deliver on the preferences of some critical mass of voters, presumably a perceived majority.  Legislating in this manner may be expedient  and facilitative of one’s efforts to remain in power, but is it right and proper? Does government exist merely to ratify and enact the impulse of the majority? To whom are legislators chiefly accountable?

Lastly and, perhaps, most forthright was the explanation of Sen. Carl Kruger, who proudly proclaimed, “We’re about to redefine what the American family is, and that’s a good thing.” Kruger is to be commended for his honest disclosure of intent, but what about his bold moral claim?  Is the social transformation Kruger has in mind truly a “good thing?” By what measure should we assess that claim?

I’ve asked several questions, and certainly there are more. Your thoughts?

First Day in the ICU

As I write this I am sitting in an ICU family waiting room.  I have often sat in rooms like this, comforting families and explaining to them what is happening to their loved one or discussing treatment options. Today, it is my family I am sitting with, and my family member in neurosurgery.  The ten of us are sitting in a circle.  The comfort of being together is inexpressible.  We sit and talk alternately of trivialities and of life and death.  One knits, another is on the laptop posting updates to Facebook, I am writing a blog entry.  The surgeon figured it would take three hours.  That was over four hours ago.

This was in none of our plans for the weekend.

***

The surgeon finally came out.  It was worse than he anticipated.  He was trying to be positive, but let slip words like “heroic measures” and “if she makes it.”

It is all very surreal.  Someone says, “I feel like I’m watching a movie.”  The whole gamut of emotions pours out, opposites juxtaposed incongruously:  shocked looks, tears, laughter at a suddenly resurrected old joke.  We pray.

***

The surgeon just came back out, a few minutes later.  A terse, hurried report this time:  the post-op CT scan shows swelling, and they need to do emergency surgery now to relieve it.  Silence, everybody together but alone with their own thoughts.  Someone passes out snacks.

***

I hate being a doctor and knowing what’s going on.  Or maybe I just hate what’s going on.  Is it more terrifying to hear cryptic references to “dilated pupils” and “midline shift” and have no idea what they mean, or to know exactly what they mean, and their implications, and get a queasy feeling of impending doom?

***

Some of us eat snacks.  Some read waiting room magazines.  Every once in a while an attempt at small talk, an attempt at normalcy.  Mostly quiet.  I’m glad we’re all together.

***

It’s been another hour, and no word.  That can’t be a good sign.

***

Hurry up and wait.  Another half hour has passed.  We’re a little more lively group now, laughing and kidding each other.  It’s hard to maintain that serious aspect through the long, anxious watch.

***

 

At last — the surgeon has come back.  He is guardedly optimistic.  He looks weary.  I walk out with him for a doctor-to-doctor talk out of everybody else’s earshot.  He is more frank about how he feels;  in some way, we can understand each other.  When I return to the group, the atmosphere is much more relaxed.  Not that the news is that great, but at least the uncertain waiting is over.  One round of waiting, that is;  everything depends now on how she will wake up, and how she does over the next couple of weeks.

***

 

The next moment of truth;  the nurse has just come out, and told us that in about ten minutes the family can come in to see her, two at a time.  Deep breaths:  we’re about to dive in, and God only knows what the water will feel like.

***

Psalm 121.   I lift up my eyes to the hills — where does my help come from?   My help comes from the LORD, the Maker of heaven and earth.   He will not let your foot slip — he who watches over you will not slumber;   indeed, he who watches over Israel will neither slumber nor sleep.   The LORD watches over you — the LORD is your shade at your right hand;   the sun will not harm you by day, nor the moon by night.   The LORD will keep you from all harm — he will watch over your life;   the LORD will watch over your coming and going both now and forevermore. (NIV)

***

Just back from visiting her room.  The ICU smell!  Intubated, sedated, tubes everywhere, the Darth-Vader hiss of the ventilator, monitors, drips, her head wrapped with a little blood seeping through the right side of the bandage . . . I talk to her as if she can hear, I kiss her on the side where she still has cranium.  I come back to the waiting room and I am trembling.

***

Exhaustion.  I was tired before this started;  I am almost numb and staring now.  If this were a novel, I would have to fight turning to the last page to find out how it ends.  It is a little like a novel, or a movie.  Sometimes I want life to have a plot.  Well, it does today:  suspense, unexpected turns, hope and despair and snatches from the jaws of death, heroic actions, a beautiful damsel in mortal peril.  God knew what he was doing when he made life full of more routine than plot.  I don’t think we could take too much of plot.

***

***

It is too easy as a busy physician to forget in the rush that all patients have stories, have families.  It is all too easy to objectify people, to think of them as their disease, to fall into thinking of “the asthmatic in room 39” instead of “Mr. Brown, who is a forester with a wife and three children and who has just been laid off and is here because his asthma is worse.”  Or to say, “The drunk is back” instead of “Mrs. Smith, who desperately wants to stop drinking but her daughter came over with a bottle and she couldn’t resist so she is back here looking for help and does she ever feel awful.”  It is a good reminder, this being on the other side of medical care.  I have cried (and laughed) a little bit more readily with my patients this last week.  I don’t think that’s a bad thing.

On Ending Aging

 

While we all may agree that the idea of avoiding aging or prolonging life has its appeal, very few people would attach themselves to the pursuits of Aubrey de Grey. He is a passionate man dedicated to the quest of ending the leading cause of death–aging.

At great length Grey has written and spoken about SENS; “to repair or obviate the accumulating damage and thereby indefinitely postpone the age at which it reaches pathogenic levels.”

Though my mentioning of him may seem strange, I was reminded of this beautifully bearded man when I came across an article about a study done on the horrible and rare genetic disease, progeria.

In this article, Dr. Francis Collins proposes the common assumption that “the aging of cells and of individuals was just a matter of everything running down,” is just not right.  “The same mechanism that causes children with progeria to age seven times the normal rate may play a role in normal aging as well.”

So, what does this mean?

In layman’s terms, Collins claims his study shows aging to be an active biological mechanism that is programed into cells not a passive wearing out of cells.

 

 

For those of you who know of Aubrey’s proposal, are there any conflicts between his views and this recent development?

Do you think this could be an initial step at accomplishing Aubrey’s ambitions?

Do you think that substantially extending the human life is even possible?

 

 

X-Men and Eugenics

By Heather Zeiger

For my inaugural post, I might as well come clean that I am a nerd. Part of my nerd-background is that I am a comic book fan, and am especially fond of Marvel’s X-Men. Therefore, I was pleased to watch X-Men: First Class, but don’t worry, I didn’t don the yellow and black uniform to the theaters. I did, however, walk away from this movie thinking on the two views of human nature represented in the main characters, Eric and Charles.

One of the elements that attracts me to the X-Men series is the complexity of the characters. Often the comic books would portray the mutants as dynamic, tortured, and complex. Much like fantasy/science fiction book genres, the mutants in X-Men live in a different world than our own, but one that we can certainly relate to. In this world, some people have a mutation that gives him or her special abilities, however the mutation usually has a cost. Perhaps that price is an odd appearance, as was the case with Hank (Beast) and Raven (Mystique), or unwieldy energetic powers, or in some of the cases in the comic books, inability to have physical contact. In the comic book world, the mutants would keep themselves in hiding because they feared being ostracized from society. Some mutants felt ashamed, some of them dealt with shame from their families. Some were bullied. Some were abandoned. Some ran away. The movie dealt with the hiding for fear of being ostracized. The two mutants with the most drastic physical features discussed wanting to be “normal” and what it means to be ashamed of their appearances.

Here people do not have mutant super powers, but, certainly, we have a concept of normal. And, as is often the case in sci-fi/fantasy, by putting the reader (or viewer) in a different world, we are able to evaluate ourselves. The mutants in X-men are gifted, but their gifts come at a price. I was always intrigued by the storylines in which the characters wrestled with their flaws including other people’s response to their “abnormality.”

X-Men: First Class dealt with this head on in Eric’s background as a persecuted Jew in a WWII concentration camp. In probably the darkest scenes of the movie, Eric, as a child, is torn from his mother and father as they are lead to separate areas of a concentration camp. When a scientist, later revealed as Sebastian Shaw, sees that Eric can move metal, he brings him in for questioning. Shaw has a line that should send chills down anyone’s spine who has read about eugenics and Nazi Germany: “The Nazi’s methods certainly do work.” If you see the movie, the context of this line, makes it all the darker. But it is true; the Nazi’s methods of de-humanization and blatant disregard for human life certainly did “work.”

Eric (Magneto) and Charles (Professor X) always had a complex relationship in the comic books. They are archenemies, and yet formerly friends. Both wanted to help mutants accept themselves and use their powers, but they eventually parted ways because Eric wanted to overpower humans while Charles wanted to work with them. The movie did not disappoint in developing these complex characters and their entangled relationship. Eric and Charles are two sides of the same coin; they are two different responses to human nature, each of their response based on their backgrounds: Eric as a Nazi science experiment and Charles as an aristocratic academic in England. Eric ends up becoming Magneto, a complex and perhaps sympathetic villain. Charles becomes Professor X who leads our heroes, the X-men. Eric’s past plays into his low view of human nature and certainty that society will de-humanize mutants, using them as instruments for personal gain. Charles, on the other hand, has a more positive view of human nature. He tends to see the good in people and the possibilities. As a point, Charles is a telepath while Eric can manipulate metal.

Throughout the movie, we get a much more obvious parallel between eugenics, Nazi Germany, and how mutants may be received in the real world. We see a range of responses to the mutants, but most importantly we also see how some would consider them less-than-human. And in case the normal movie-goer doesn’t get it, Eric’s character reminds us that these were the same kinds of sentiments said by the Nazis in regards to the Jews.

Fiction serves to hold a mirror up and show us ourselves and it serves to help us imagine an experience without having to live it. As a viewer, you root for the mutants and you hate those that would de-humanize them. And yet, how would we respond to the freakish, the abnormal, or even the less-than-beautiful?

Ethics and Atheists

Jim Spiegel, a colleague of mine at Taylor University, published a book last year titled The Making of an Atheist. In the book he contends that the rejection of God is a matter of will, not of intellect.  He suggests that immoral behavior leads to an inability to see the clear evidence for the existence of God.  Atheists choose to reject God for psychological reasons such as the lack of a loving human father and because they do not want a God to exist to whom they would be accountable for their immorality.

Not surprisingly, his book did not go over very well with the atheist community, but there is the seed of an idea there that suggests a way ethics can be used to draw those who reject God toward truth about God.  Many who reject God still believe that there are things that are intrinsically right and wrong.  While a desire not to be subject to ethical standards leads a person to atheism, the understanding that there are ethical standards is the first step toward God.

So the next time someone who does not believe in God disagrees with you on an ethical issue commend them for their belief that morality is something to be concerned about.  Taking morality seriously can be the first step toward the one who is the source of all that is good.

There is no “welcome mat”

Last week (June 7) I noted that some gains have been made by the pro-life movement after all.  But how should Christians view these advances?  Does it suggest that the “welcome mat” is out and the door is wide open to push for further pro-life legislation?  I don’t think so.  Although there have been some setbacks to the pro-choice movement, Christians shouldn’t expect pro-choicers to admit defeat.  In other words, we may be free to knock on the door, but don’t anticipate opponents to invite us in for tea and cookies.

Regardless of the response, I would like to offer the following thoughts about Christian engagement in the public square.  I define the public square as that realm where citizens from a plurality of perspectives convene to deliberate on matters (e.g., laws, policies) that concern national and local community life.  Like the apostle Paul, Christians can use the “marketplace” when possible to present truth (e.g., Acts 17, Paul in Athens).  But wasn’t Paul primarily concerned with preaching the gospel?  This is true, but my point is that Paul had an important message and he worked within the “system” to communicate that message.  So the question is, “What can be done to promote life human dignity within the current system?”  Although there is disagreement about strategies and the extent of engagement, Scripture clearly teaches or implies the following:

1) Scripture neither encourages nor forbids participation in the political arena.  Thus, a Christian is free to follow his or her calling if that calling includes active involvement in political matters.

2) Christians have a duty to be good citizens which includes submitting to governing authorities.

3) Christians have moral obligations that do not apply to the general public (e.g., observance of the sacraments, prayer, church discipline, etc.).

I realize that I could be accused of an argument from silence, but whereas Scripture gives guidelines on church government, it says very little about political involvement.  However, Scripture does not even remotely suggest:

*that Christians should impose onto the world the teachings of Scripture

*that Christians should have decision-making priority or the last word in the public arena

*that only Christians should be in positions of political or legal authority

*that Christians should attempt to establish a political theocracy