Covid-19, Economics and Bioethics

Bioethics, in its essence, is multi-disciplinary. It involves medicine, philosophy, theology, political science, and supernumerary other scholarly fields. And, of course and, perhaps, unfortunately, economics. Bioethics is blessed, and plagued, by its confluence of academic influences, and operates within their inevitable, intersecting, conflicting, uncomfortable gray areas. The Covid-19 pandemic speaks to the bioethical implications that go beyond who gets ventilators and when do we get a vaccine to even more elemental questions. Can we survive the economic paralysis that comes from a quarantine designed to arrest or slow the spread of the novel coronavirus in the United States? Was it “worth it” to force a government shutdown of many industries in an effort to keep our population as safe as possible….and, perhaps, forestall further economic devastation…and, even if so, what is our endgame?

I write this as a veterinarian, a bioethicist, a small business owner, a father of three high schoolers suddenly thrust into “e-learning,” and the son and son-in-law of octogenarians. If those seem conflicting interests, then they are indeed representative of just what a mess this pandemic finds our society. We aren’t unique but, in so many ways American, have managed to find ourselves the world leaders in Covid-19 deaths, infections, tests and are the economic “canary-in-the coal-mine” for the industrial world.

The Atlantic, hardly a shill for the Trump administration or its apologists, has a sober assessment, two months into the general national “quarantine” zeitgeist that has been our reality in most of America. The complex effects of the coronavirus on our economics are described in this piece, one that also looks at what those economic effects have on other nations and, yes, the mental and physical health of our own citizens. It isn’t pretty. Macroeconomics is a bioethics issue.

Americans have now been forced to face, and decide between, our competing ethics of safety (a biggie in contemporary society), personal liberty (autonomy, in ethical lingo, another biggie) and self-sacrifice for a greater civic good (mostly read about in vintage World War II texts, but bringing on a new significance). And it seems we can’t begin to reconcile them, so we just retreat into support of one of the first two, claiming the third as its moral anchor. As we are seeing, this is no way to orchestrate a response to a pandemic that has left (as of this writing) over 80,000 Americans dead and an economy that currently can only be measured by the Great Depression levels of unemployed, but really should only begin to be assessed the way we do tornado damage…when the sun comes up and the clouds lift.

There are no numbers to encourage us. Yet, reports tell us that there are available hospital beds and ventilators, and that the navy ships brought in to our urban “hot spots” to offer more space were (thankfully) never needed. We succeeded in “flattening the curve,” that goal that was always our fundamental one when we paralyzed our economy and society many weeks ago. So what is the goal now? Is it avoiding a new wave that will create a curve that needs flattening again? Is it a quick or gradual reversal of the paralysis of the economy that lets us eat out, shop in malls, have gatherings with friends, play sports and see marching bands perform, and worship in community again? Governors have played a primary role here, perhaps an illustration of the wisdom of federalism to some, the limitations of the same when dealing with a pandemic across fifty free borders to others. It is inescapably political in an election year…do you want to see people die or go bankrupt? That is our apparent binary choice, and our political polarization has already entrenched the position of each side.

I reinforce to my clients who are making decisions for my patients, their pets, as well as to my own children, should they be listening, that every decision we make has consequences, and virtually none makes everyone a winner. The Atlantic article mentions the profound economic devastation that comes to our health if we enter an economic abyss. Some of that is already realized. That bioethical decisions are inextricably economic should be painfully obvious to all. It has always been the “elephant in the room,” sometimes at a micro- and others at a macro-level. We have viewed economics as, at best, a stern taskmaster who wants to ruin a good thing and, at worst, the archenemy of bioethics. In the West at least, we have been blessed by wealth to make high-level bioethical decisions. The challenge of who gets dialysis was answered by “everyone,” because we found a way to pay for it without creating economic devastation. When that wealth erodes, we are on a different playing field. Covid-19 shows us what happens when a bioethical decision runs headlong into economics. Again, it isn’t pretty.

Fundamentally, we need to decide what human dignity and human flourishing look like in a modern society. Justice for all, and with particular attention paid to those at the margins, always dictate this. The margins we face in Covid-19 are, of course, the elderly, the immune-compromised, the chronically ill. But they are also those who struggle in good times to make financial ends meet and who are suddenly out of work weeks after the highest level of employment in recent history. Some are facing mental health and addiction crises. Global poverty, and its accompanying hunger and death, will rise. Whether one out of five or one out of ten, whether in North America or sub-Saharan Africa, we have a group of people at the margins. The number will inevitably widen as the storm damage is fully assessed. To fail to account for them in our public health decisions is inept and insensitive. To ignore the power of a disease caused by a novel virus for which no nation in the world has yet achieved “herd immunity” is no better.

Be careful how strongly you support either position. Those who lead, ultimately, are successful when they disappoint those who follow them equally. This is not a Solomonic baby-splitting, but the hard work of public policy and personal behavior. We will give up (and already have given up, to a great extent) some things that are excruciatingly painful losses. Our Western obsession with safety, with the quest for immortality that cannot be realized, for choosing death on our own terms and in our own time, has come under attack. Now we can be safer, but lose our prosperity, or remain wealthy but sacrifice many more thousands of our own. We can’t have both. Our public health decisions must recognize that national and global economics are bioethical, human flourishing, epidemiological decisions that cannot be ignored. A cavalier approach to loss of human life is ghastly, and an economy that fails means a health care system that fails.

The Bioethics in Routine Office Visits

I saw two patients last week on the same morning for identical tests whose divergent stories generated an interesting debate amongst my staff regarding healthcare rights and the cost of providing the same.

For some background pertinent to this discussion, I perform a diagnostic test in my office called an Electromyogram (EMG) which quantifies the electrical function of muscles and nerves, and is used by my surgical colleagues to assist in their decision whether or not to operate. Depending on the diagnostic question, the test can take anywhere from 30 minutes up to 2 hours to perform, interpret and generate a report, the average encounter lasting about 45 minutes. Currently, we are reimbursed via rates we negotiate with the various insurance carriers, all of which are fixed at a rate that is some percentage of Medicare reimbursement rates (generally ranging from 80% of Medicare for most state Medicaid products to 125% of Medicare for some private insurance products). Without getting into the minutia of medical cost accounting, there are real costs to our group related to my performance of the test on any given patient such that, below a certain reimbursement level, we actually lose money. Further, if a patient cancels his or her test at the last minute and I am not able to move another patient into the cancelled appointment time, no revenue is generated for that appointment.

The first patient showed up for her test and had a state Medicaid insurance plan such that she paid nothing for her insurance plan. She was not even required to pay an office “co-pay” so she had no “out-of-pocket” costs for her medical care. When my nurse explained the EMG test, including the need to use rubbing alcohol on her skin in areas where I would be inserting an electrical needle, she declined the test. When asked why, she indicated she had just spent $120 on a “spray-on-tan” the day before and did not want to cause streaking of the tan. In our region, the going rate for this type of tan is $60 per application and she required two such applications to achieve her desired result. She was rescheduled and later did complete the test and our practice was eventually reimbursed at the contract rate of 80% of the standard Medicare reimbursement rate.

The second patient was a single mother of two who worked two jobs, making just enough to fail to qualify for the state Medicaid insurance just described, but not enough to afford the cost of insurance through the PPACA exchange in our state. She determined that her monthly insurance premium and $5000 deductible was more than she could afford. She requested our “self-pay rate”, which I further reduced to 95% of our Medicare rate after hearing her situation.

Most of my staff were disgusted with the behavior of the first patient and admired the behavior of the second. A few wanted me to further reduce the charges to the second. I pointed out that if I saw only patients like the first or second patient, I would have to lay-off 30% of my current staff, this after salary reductions all around. Others noted the first patient’s behavior was very rational from the standpoint of her personal cost accounting. A $120 spray-on-tan has financial priority over a $0 EMG test, despite the fact that the subsequent test did reveal a finding that caused my partner to correctly modify his treatment plan (i.e. the test turned out to be medically beneficial to her health).

The two isolated cases presented here are an insufficient basis upon which to form healthcare policy. In both of these cases, the EMG test results caused a better surgical decision to be made for each patient, so in that sense, both tests were medically necessary. In both cases my frugal office manager argues that we lost money. The cases did generate very good questions by our staff such as: How much should a necessary test cost a patient? How much should our practice get reimbursed for performing a necessary test? Essentially, who should pay for necessary healthcare? Is healthcare a right such that someone is obligated to provide the necessary service? What makes a service necessary? Should everyone have some (financial) skin in the game? Unfortunately, we generated several more great questions but no consensus answers.

Except for one: The only consensus opinion that my staff formed after considering these two examples was that one’s co-pay should approach the local cost of a spray-on-tan, but just a single application not a double.