From Coercion to Christmas

The recent wave of stories of sexual abuse and harassment led my residents (I teach family medicine residents) and me to a discussion of sexual ethical violations in medicine. The annals of disciplinary actions by state medical boards are filled with penalties inflicted upon physicians who have entered into sexual relationships with patients.

Why is it that in the patient-physician relationship, sexual intimacy between two (often) consenting adults is proscribed, and has been since Hippocrates prohibited it in his oath? Why, even in our sexually permissive age in which anything goes, is this still taboo?

The issue with physicians and patients — as with most of the accusations making headlines recently — is power. The patient-physician relationship is radically asymmetric with regards to power. The patient is vulnerable; the physician is not. The patient reveals dark secrets, and uncovers his or her body for examination; the physician does not. One person in the room is exposed, figuratively, and literally, and it ain’t the doctor.

It is this asymmetry, this difference in power, that makes it so difficult for an intimate relationship to be truly consenting; there is a very real danger that the less-powerful party will act from some sense of coercion, even if the coercion is unrecognized and unacknowledged. When a relationship as intimate and personal as a sexual relationship is coerced, even subtly, the potential for harm to the weaker partner is so great that the ancients, in their wisdom, forbade it, and we moderns have seen fit to respect that prohibition.

Of course it is not just patient-physician relationships that are asymmetric and thus liable to abuse. Whenever one person exploits their position of superior power over another the potential for abuse exists, such as when a person with great political power personally attacks those in positions of less power on social media. We call such abuse of power “bullying.” We rightly condemn such abuses.

This got me to thinking about the most asymmetric relationship possible: the relationship between God and people, the Creator and the created. While there is no sense in which God could be said to abuse his power, he seems remarkably restrained in his exercise thereof. We read of times when he shows up in dazzling displays — think of the children of Israel leaving Egypt, or God speaking to Job out of the whirlwind — but more often than not he is veiled: a still small voice, a dream, a soft but persistent voice in the night that keeps calling our name.

And when God gives us the clearest revelation of who he is, he eschews any semblance of powerful exhibition, and comes as a baby. When he grow up and displays his power, it is veiled in love: he heals, he saves a wedding celebration from disgrace, but often with admonition, “Don’t tell anyone.” Even his greatest display of power — his Resurrection — was carried out in such a way that many of those nearest to him had a hard time understanding or believing it.

God is powerful, no doubt. But he rarely uses his power to overwhelm or coerce us. He seems to prefer self-giving love as his means of persuasion. We are told that someday he will come in a full demonstration of his power and glory. But for now, as we celebrate at Christmas, he comes to us as a baby. He comes to be with us, as one of us, so that he can lead us from where we are to God. Or, as an old Christian named Athanasius said, “He became as we are, that he might make us what he is.”

I’m on call for our obstetrical service this holiday. I’m going to try to let each baby I see be a reminder of how God deals with us: power that clothes itself in self-giving love.

Racial inequalities in cancer survival

Three studies published in a supplemental issue of the journal Cancer this month come to disturbing conclusions: in the United States, the survival rates for colon, breast, and ovarian cancer are lower for black people than for white people.

The news isn’t all bad: overall cancer survival rates are going up. The three studies mentioned here draw from two larger studies of worldwide cancer survival, the CONCORD study, published in 2008, and the CONCORD-2 study, published in 2015. Between CONCORD and CONCORD-2, cancer survival increased across all groups. But in both studies, the survival of black people in the United States lagged behind that for white people by about 10%.

Now there are certainly many reasons for the difference. Black people may be getting diagnosed with cancer at later stages, when survival is lower. There may be differences between the two groups, like genetic factors or the presence of other illnesses, that cause the cancers to be more aggressive in blacks. Mistrust of the health care system is more common among black patients, so they may be less likely to access care or access it early enough.

But other reasons include socio-economic status and access to health care; those who can’t access medical care because they can’t afford it or because it is not available nearby are less likely to receive necessary screening and treatment. And most troubling is the “consistent finding that black women do not receive guidelines-based treatment compared with white women, even when treated within the same hospital.”

The situation is too complex for simplistic answers; one can’t say from these studies that doctors are individually practicing blatant racism, and there is after all such a thing as systemic racism. But the medical profession should take such findings seriously, and seek every available avenue of education and self-monitoring to ensure that of all the places people encounter racism, the health care system is not one of them. And Christians especially, who believe that God created all people with equal dignity because all of us are created in His image, should work towards a health care system where the value — or length — of one’s life does not vary based solely on the color of one’s skin.

The unbefriended and their doctors

There is a rapidly growing class of uniquely vulnerable patients showing up on our hospital doorsteps. Referred to as the unbefriended, or more prosaically as the unrepresented, these are patients who have no capacity to make medical decisions themselves, have no advance directives, and have no family or friends or anybody else on the face of the earth to speak for them. It is as if they dropped out of the sky, and we cannot find anyone with enough of a human connection to them to help us know what they think or desire.

There is great tragedy in reaching a point in life where there is seemingly nobody who knows you or cares about you. The tragedy is often felt keenly by those who provide medical care to such patients. If a patient cannot make decisions for themselves, and if they have no advance directive, and if there is nobody who knows them to make surrogate judgments regarding their care, we default to the “best interest” standard for making decisions: What course of action is in the best interest of this patient? Which leads to the next question, Who decides what is in the patient’s best interest? One can defer to the courts and pursue legal guardianship. However, in my state at least, such a process is neither timely nor inexpensive, and the chances are slim that a public guardian with an already impossible caseload will take the time to get to know the particulars of a patient’s condition in order to make a reasoned decision.

If not a legal guardian, then it is the care team that must decide: in particular, the burden falls to the attending physician. In any situation, it can be difficult to do things to patients without their explicit consent. In situations where withdrawing life-sustaining treatment is on the table, it becomes especially difficult. Even in cases where it is clear that withdrawing life-sustaining treatment is in the patient’s best interest — when the burdens of treatments far outweigh any potential benefit, when the treatments don’t actually treat anything — a thoughtful, well-meaning physician might torture herself with doubts: Are we doing this because the patient is seen as a burden to the system? Are we taking a step down a slippery slope?

Nobody should feel as though they have to make such a decision alone. Other care team members can contribute to the decision-making process, of course. Ethics committees can help to support the physician on an ad hoc basis. But the scope of this problem will only grow as the population ages. In order to protect these extremely vulnerable patients, resources should be made available to provide easily-accessible, compassionate, wise third-party decision-makers who will protect both patient and physician. In a few places accommodations have been made on an individual hospital or county-wide basis. However it is done, action should be taken to ensure that these, perhaps some of the most vulnerable patients outside of the womb, are treated within the medical milieu as people with worth and dignity, and that those taking care of them are not carrying momentous decision-making burdens alone.

Ethical Health Care Reform

Recently I heard a Christian TV personality refer to Obamacare as “iniquitous.” This started me thinking, What would make a health care funding reform scheme “iniquitous”? Or, although the words aren’t synonymous, what would make such a scheme unethical? What should go into ethical health care reform?

The answers to these questions are legion and conflicting. There are some who see government intervention as inherently wrong; for them, the free market is the key to ethical health care reform. There are others who distrust the free market, and consider some degree of governmental control to be the only ethical option. Some see personal mandates to buy insurance as unethical; others understand the mandates as ethical solidarity with our neighbor. Some ardently believe justice means everyone gets exactly the coverage or treatment they pay for; others just as ardently believe justice means everyone gets the same coverage and treatment.

What is ethical health care reform? There are many possible answers. I am not sure that Obamacare is any more or less ethical than the versions of Trumpcare that have been put forward. I am not sophisticated or smart enough to pontificate about the free market or theories of justice.

One thing I am certain of, however: Whether the system relies on markets or government regulations, whether there are more or fewer mandates or taxes, whether everyone gets the same coverage or not, one final measure of whether or not a health care system is ethical is how it treats those who are the poorest and most disadvantaged among us. If those who are least able to provide for themselves are not provided for and granted access to the system, then it is an unethical system.

Health care disparities: a pro-life issue

This month’s Health Affairs carries an article examining the correlation between one’s income and one’s perceptions about one’s own health and health care. Worldwide, those with the lowest incomes feel that their health is worse than those with the highest incomes do. They also are more likely than those with higher incomes to skip necessary treatment because they can’t afford it, and are more concerned that if they become seriously ill, they won’t get the best treatment their country has to offer. Perhaps not unsurprisingly, the United States has one of the greatest disparities between those with the lowest and highest incomes. But at least Americans are also the most aware of this disparity: 67% of US respondents, the highest number of any in the world, agree that “many” people in the US do not have access to the health care that they need. This is a good thing: awareness of a problem is the first step towards fixing it.

But what if we are aware of the problem, yet don’t really think it’s a problem? Only 54% of us in the US think it’s unfair that people with higher incomes can afford better health care than those with lower incomes. What if we see unfairness, but don’t recognize it as unfair?

In his post to this blog on June 6th, Mark McQuain asked what our number one bioethical issues are. As a physician who is privileged to care for a wide diversity of patients — from higher-ups in large corporations to those struggling to support a family by working two jobs and driving Uber — I see daily the very real differences between those who are granted full access to all our health care system has to offer, and those who get only the scraps from the health-care table: differences not just between healthy and sick but between life and death. The ones on the lower end are disproportionately the poor, the widows and single mothers, the aliens among us. I am pro-life; since access to health care can be a life-and-death issue, it is part of my pro-life identity to advocate for access to health care for all. The disconnect between recognizing inequity in access to health care and recognizing that we should try to do something about it is deeply disturbing to me. At this time and place, the injustice (and the recognition that it is injustice) in the inequity of access to health care based on income is the number one bioethical issue on my list.

Undermining the USPSTF: The most important stakeholders are the patients

A strange “health care” drama plays out daily in our clinics and hospitals. A healthy person has a medical test done (even though he or she is healthy): a blood test, a chest x-ray or mammogram, maybe an ultrasound of some body part. The test comes back abnormal. The patient (for she has now gone from being a healthy person to being a patient) is struck with worry, and undergoes a further round of testing to determine whether the initial, “screening” test was accurate. This more invasive, risky definitive testing causes the patient pain, complications, infections, further procedures to fix the complications. But the testing shows that the original screening test was wrong, and the patient is relieved of their worry and overcome with a sense of gratitude: “Yes, the follow-up surgery was painful, but at least it’s not cancer.” However, notice what caused the worry in the first place: not some symptom that they were experiencing, but a test that was performed on a healthy person. What a marvelous bit of sorcery: we take a happy patient, create unnecessary worry, then win their undying gratitude by performing risk-laden procedures on them to remove their worry!

There is something very intuitive about the concept that detecting a disease (especially cancer) early leads to better outcomes, that screening tests are inherently good. Yet when one studies the actual outcomes of implementing mass screening programs in a population of people who have no signs or symptoms of a particular disease, one finds to one’s surprise that, not infrequently, more people are harmed by our screening test than are helped (See: PSA testing, carotid ultrasounds, annual stress tests, etc). This harm may take many forms: worry, invasive procedures with all the risk they bring, radiation exposure, disfiguring treatments, stroke, even death. Yet there is no shortage of promoters of various tests that capitalize on our intuition that “More testing is better.”

In steps the United States Preventive Services Task Force (or USPSTF), a group of experts in preventive medicine and primary care (since it is mostly primary care providers who order screening tests). Their task is to examine the scientific evidence of the potential risks and harms of preventive strategies like screening tests, and to make recommendations based solely on that evidence. They strive to use the best scientific data available to benefit the most people possible. Even when their recommendations are unpopular (because they go against our intuition that more screening is better), they have a large effect on what tests are performed — and what tests insurance will pay for.

This week the USPSTF recommended against screening for thyroid cancer in people without symptoms. The data show that screening has found lots of thyroid cancer that never would have been found otherwise. The data also show that screening has not produced a reduction in death from thyroid cancer or an increase in quality of life. What it has produced is an increase in harms, such as injuries to vital nerves from the increase in thyroid surgery. Who knew?

Now there is legislation pending in Congress proposing that “stakeholders” — that is, specialists and industry representatives — be included in the membership of the USPSTF. This is a very bad idea. Consider: What do specialists like thyroid surgeons (who are not experts in screening for thyroid cancer; rather, their livelihood is tied to operating for it) or drug and device manufacturers (who sell the tests and ultrasound machines used to screen for thyroid cancer) add to the USPSTF’s process?  The main thing “stakeholders” (that is, people with a financial interest in seeing the test done) add is a conflict of interest. Whatever difference such “stakeholders” make would be tilted to the advantage of the few who stand to profit from the screening, and to the detriment of the many in the population who would be harmed from the screening. The USPSTF’s work must not be transformed from a transparent procedure that seeks to minimize harm into a get-rich-quick scheme.

How to make Nazi doctors

Most people who go into medicine have as at least part of their motivation the desire to help other people. I’m sure this was as true in 1930’s Germany as anywhere else. So how did a cadre of Nazi doctors come not only to commit crimes against humanity, but also to defend the moral correctness of their conduct when placed on trial for those crimes? The answer is complex, but one way was through the teaching of medical ethics.

An article in the April 18th Annals of Internal Medicine tells a cautionary tale for teachers and learners of bioethics. Entitled “Lectures on Inhumanity: Teaching Medical Ethics in German Medical Schools Under Nazism,” the article details how the Nazi party developed a curriculum for teaching ethics in medical schools that “was intended to explicitly create a ‘new type of physician’ . . . trained to internalize and then implement the Nazi biomedical vision . . . shifting the focus of ethical concern and medical care away from the individual patient and toward the general welfare of society or the people.” The curriculum included lectures in racial hygiene, the science of heredity, population policy, military medicine, and the history of medicine. Only long-standing members of the Nazi party were appointed lecturers. The lecturer at Berlin University, Rudolf Ramm, wrote the ethics textbook used in the curriculum, which emphasized physician paternalism in practicing their moral obligation to rid society of certain groups, and asserted that every (Aryan) person in Germany had a moral duty to stay healthy.

The article’s authors write, “The Nazis neither ignored nor abandoned medical ethics. Instead, they implemented their own version of it in order to substantiate their health policies and secure physicians’ allegiance. . .  an ethic that turned away from the individual and instead emphasized the well-being of the community. . . [They] reinterpreted the Hippocratic Oath for their purposes . . . [drawing] an analogy between the German people and a sick patient . . . so that the Hippocratic Oath seemed to fit with Nazi medical ethics: Exterminating Jewish persons, disabled persons, or patients with hereditary diseases was acceptable in order to heal the organism of the German people.”

The article’s authors draw the conclusion that “we should not rely on the existence of ‘eternal’ or ‘universal’ values in medicine because it is not the medical profession alone that determines the medical ethos but also the moral climate in society, the system of government, and its political goals.” However, this seems to me backwards; it is precisely because society, government, and politics are so fickle that it is vitally important that the practitioners of this art cling tenaciously to the universal values stated so simply and starkly in the Hippocratic Oath: I will not kill, whether in the womb or out of it. I will protect patient privacy.  I will treat everyone with the same regard, regardless of their status. Real Hippocratism should have been a resistance movement against Nazism; it should be again now against the forces that are threatening to deform the medical ethos. If we do not hold fast to these values and teach subsequent generations of doctors to do the same, we will find — we are finding — that we are playing variations on a Nazi theme: for the eugenic ideals inherent in Nazism, the idea that it is morally acceptable to kill some (unborn) people to benefit others, and the belief that there are lives which are not worth living, ideas which have “laid the groundwork for medico-ethical transgressions in the past, remain in play across time.”

But at least we don’t have socialized medicine

I just read T. R. Teid’s 2009 book The Healing of America. It’s a timely read in light of the bar brawl over health care that’s brewing in the U.S. legislature this week. Of particular interest are his snapshots of the health care systems of the UK, France, Germany, Japan, Taiwan, Canada, and Switzerland, systems about which I held many cherished misconceptions. All of these countries provide universal health care coverage for their citizens, but they do so in very different ways. Some countries are single-payer systems; in other countries, costs are paid by multiple (not-for-profit!) insurance companies, and employers and workers share the cost of insurance premiums. In some countries patients must pay a co-pay, in others they never see a bill. In some countries people have long waits for specialist care, in other countries they get in the same day. Despite the differences, there are some very important similarities. First and foremost, everybody in the country is covered and has access to health care. Everybody can see any doctor; none are “out-of-network.” By almost every population health measure from childhood mortality to life expectancy, these countries far surpass the United States. And they do so at a cost that is a fraction what the United States spends for health care.

The attitudes expressed by representatives of the various countries are revealing. In France, one doctor says, “It would be stupid to say that everybody is equal . . . But when we get sick–then, everybody is equal.” The founder of Germany’s system, Otto von Bismarck, called it “applied Christianity,” and said, “A rich society must care for the poor.” Japan has an individual mandate; everyone must sign up with a health insurance plan. As one Japanese doctor said, “It’s considered an element of personal responsibility, that you insure yourself against health care costs. And who can be against personal responsibility?” The report that helped launch Canada’s Medicare system reads, “Economic growth is not the sole aim of our society. The value of a human life must be decided without regard to . . . economic considerations. We must take into account the human and spiritual aspects involved.”

Reid reiterates several times that he believes that societies have a moral obligation to make health care universal. But in this country, there is another mindset, another ethic, that stands in opposition to that view: the view that at best government has no business getting involved in health care, and at worst that government is evil and must be prevented from extending its nefarious reach into health care. Adherents to this ethic often use the term “Socialized Medicine” in a pejorative sense to refer to any health care system that has more government involvement than their own. According to this ethic, the spectre of Socialized Medicine covers a multitude of sins, as in:

  • In our system millions of people don’t have access to health care. But at least we don’t have Socialized Medicine.
  • Untold numbers of people are afraid to leave jobs they dislike because of health insurance concerns. But at least we don’t have Socialized Medicine.
  • Despite paying way more than any other country for health care, our country has worse health outcomes. But at least we don’t have Socialized Medicine.
  • Many people can’t go see their doctors that they have seen for decades because they are suddenly not “in network.” But at least we don’t have Socialized Medicine.
  • Our for-profit health insurance companies have the highest administrative costs in the world, which is a large part of the reason we pay so much more for such lower quality. But at least we don’t have Socialized Medicine.
  • Thousands of people — uninsured and insured — face financial ruin every year because of medical costs. But at least we don’t have Socialized Medicine.
  • Thousands of people die each year in our country because of diseases that could have been treated had they had access to health care. But at least we don’t have Socialized Medicine.

If we really think Socialized Medicine is so evil, then we had best scrap that purest form of Socialized Medicine which is in our midst: the VA system. While we’re at it, we really ought to dismantle Medicare as well. But if we’re not willing to take those simple steps — if Socialized Medicine is after all not quite so evil in these instances — then we should be willing to debate different forms of financing health care on their own merits, and not merely dismiss any discussion with a nebulous term that we fondly imagine carries such moral weight that it lays to rest all other urgent ethical questions about our own system.

A Conflict of Interest is NOT an Ambiguity

Oregon Senate Bill 494 has been described as a “euthanasia bill” that is “intentionally ambiguous,” and as a piece of legislation that would “allow the starving and dehydrating of patients who suffer from dementia or mental illness.”

What has received less press is the composition of the 13-member committee who would be perpetually in charge of advance directive forms in the state, with no oversight by the legislature. Who would those persons be? According to the bill, the 13-member “Advance Directive Rules Adoption Committee” would include

  • The Long Term Care Ombudsman or that individual’s designee
  • 12 members appointed by the Governor
    1. one representative of primary health care providers
    2. one who represents hospitals
    3. one clinical ethicist affiliated with a health care facility
    4. two health care providers with palliative care or hospice expertise
    5. one who represents persons with disabilities
    6. one who represents “consumers of health care services”
    7. one who represents “the long term care community”
    8. one who has expertise in “advising or assisting consumers with end-of-life decisions”
    9. three members from among those proposed by the Oregon State Bar:
      • an expert in elder law
      • an expert in estate planning
      • an expert in health law

Why is the State of Oregon so interested in making sure their appointees are in charge of advance directives?  Is it because the state is so concerned about the health of its citizens?  Hardly, when those citizens in the health care system are described not as patients, but consumers.  Stacking the committee with lawyers who are experts in estate planning and elder and health law seems to assure the state that they will get their pound of flesh.  The State is aware of this:  deceased consumers no longer need their money or their organs.  The conflict of interest inherent in this scheme is not ambiguous.

 

— D. Joy Riley, M.D., M.A., is executive director of The Tennessee Center for Bioethics & Culture.

Advance Care Planning and its Detractors

The default mode of our technologically advanced medicine is to use our technology. Nowhere is this more true than close to the end of life. And our technology is really impressive; with it, we can keep chests going up and down and hearts beating for a long, long time.

The troubling thing is that there are many people who would rather not have lots of machines keeping their bodies going, thank you, maybe you could just give me some oxygen and pain medicine and let me die at home with my family? But they never get a chance to talk about it with their doctors, mostly due to doctors’ lack of time or comfort in addressing such questions. And, unlike every other procedure in medicine, doctors don’t need your permission to do one of the most invasive procedures of all to you: CPR. Of course, CPR is generally performed on someone who is indisposed and unable to give their informed consent to the procedure. And CPR is often the first step on the technological path of ventilators, tubes, dialysis, medications to support the blood pressure, machines that keep the heart pumping, and all of those wonderful interventions that are life-saving when used appropriately and death-prolonging when used indiscriminately. Treatments that treat . . . nothing.

Ideally, doctors take time to discuss patient preferences about such treatments with patients and their families before the occasion to intervene arises; however, the factors noted above make such discussions rare. Those discussions are ideally an exploration of patient values and expectations from health care, and a translation of those values into appropriate medical interventions. They also identify people who are familiar with the patient and their values who can act as surrogate decision-makers should the patient not be able to make or express their own desires in a particular situation.

Because of the difficulties finding time for these important discussions, it was proposed as part of the Affordable Care Act (aka ACA, aka Obamacare) that Medicare reimburse doctors for the time they take to counsel patients and find out their preferences for end-of-life care. In an act of breathtaking rhetorical deception (aka lying), these discussions with patients, meant to elucidate their preferences for care, got labeled as “Death panels.” (I am not making this up.) The proposal was dropped from the ACA.

Then, in 2015, Medicare started reimbursing physicians for having The Conversation. But last month a Representative King introduced a bill in Congress, deceptively titled the “Protecting Life Until Natural Death Act,” which would revoke such payments.

Fortunately, the bill’s fate is “highly uncertain.” It should never see the light of Congressional day. It propagates the idiocy that lay behind the charges of “Death panels.” And rather than promoting “Natural Death,” it will lead to more people dying anything but a natural death; instead, they will be dying a technological death, hooked to lines and machines and drugs — things they would never have wanted or received had they only had a chance to talk it over with their doctor.