Immoral Medicine

The magician distracts the audience by doing meaningless but fascinating things with his right hand, while his left hand is doing the really meaningful activity unnoticed by the crowd.  The bigger the trick, the bigger the distraction required.

Democrats and President Obama should make David Copperfield proud.  With one hand they are distracting the American people with a nonstop barrage of bills and discussion:  What will happen to the budget? How many are really uninsured?  Is the Congressional Budget Office to be believed?  

And for the ultimate distraction, Mr. Obama paraded a group of “doctors” in borrowed white coats for a great visual effect wholly devoid of  substance.  For all we knew, these guys could have been a group of actuaries at a DC convention bussed in as props for the day. (More likely they were doctors of the government paid variety, like Rahm Emanuels’s physician brother Ezekiel, sheltered in research institutions and teaching hospitals where they don’t have to run their own small businesses.)
While this diversion is going on, the real issues are hidden from the public — the consequences of government funding of medical care on individual liberty and our moral compass.

Government pay medicine — under any name you give it — is immoral for patients/citizens, and for physicians.  No citizen would consider it moral to put a gun to his neighbor’s head and demand that he pay for his mother’s medical care — no matter how much she may need it.  It is no more moral when people use the government as intermediary.  For the physician, it is impossible to practice moral medicine in a government system, because ultimately at some level a physician will have to choose between doing the best for his patient or acquiescing to the requirements of the state.

The worst moral examples of course were the German doctors who were forced to cooperate in death camp selections.  At the other end of the spectrum the moral tightrope has already started here with Medicare.  Federal practice guidelines have slowly become mandates.  If you do not do what the government has deemed the optimum pathway for care, the hospital will not get paid.  In my case, for the most part, the guidelines can be followed, but the day is coming when I will have to choose.  

There is no question that the risk of DVT — deep venous thrombosis, and PE (pulmonary embolism) goes up after some hip fractures.  So, usually, Orthopaedic Surgeons prescribe a form of blood thinner to prevent this complication.  But thinning someone’s blood comes with its own risks of death and morbidity, and there are certainly people for whom the risk of anticoagulation is greater than the risk of thrombosis after the fracture. Without federal “guidelines” physicians used clinical judgment to cull out those people who would do well without the risk of anticoagulation, e.g. those who have a non-displaced fracture, who undergo minimally invasive pinning, and who are mobilized within hours of the fracture.  This is not uncommon in small hospitals where these patients can be treated promptly.  

But the government is telling us we must anticoagulate all patients — as if all patients and all circumstances were the same. Although there are recognized exceptions to the blood thinning protocol, judgment of relative risk by the surgeon is not one the government accepts.  So surgeons are in the position of doing what is best for their patient, or what is prescribed by the state wielding a financial mallet.

In between these two extremes is the Canadian physician who must prioritize patients in a system with too little resources.  Dr. Leo Kurisko is a radiologist who left Canada to practice in the US (as have 11% of practicing Canadian doctors).  At a recent medical meeting, he related the moral problem of practicing radiology in Canada.  Because the system is chronically short of functioning CT scanners, at his regional hospital there was a three month waiting list for a CT.  Dr. Kurisko would review the requests for testing, and would then triage which patients went to the front and which to the back of the queue.  After the scans were finally completed, he reviewed the studies and began to recognize patients with life threatening tumors whom he had prioritized to the back of the line.  Faced with this Canadian version of “death camp selection” he quit.  He has documented the evils of government medicine in a new book, Health Reform:  The End of the American Revolution?

Consider the Netherlands, where the number one reason for the death of children under the age of ten is murder by their doctor.  Oh, of course they do not call it that, but it is what it is.  Because the Netherlands pays for medical care, they choose whom to support.  And severely disabled children and the infirm elderly are not high on their priorities.  

The Dutch doctors practicing thus are the children and grandchildren of physicians who went to the death camps themselves rather than participate in the Nazi killing machine.  So how did this happen?  It happened through the moral incrementalism of becoming state doctors–of putting the good of the state above the good of the individual patient.  

Medicare has been an assault on freedom since its inception.  Americans who turn 65, may think they are still free but they are not.  You are not free to opt out unless you are willing to forgo your social security payment.  Even people who see Social Security as part of the problem are not willing to give up an entitlement they have paid into all their lives.  And once enrolled in Medicare, you cannot pay for services outside the system unless these services are not offered at all by Medicare, or unless you find that rare physician who runs a cash practice totally off the grid.  

Physicians who see any Medicare patients at all are not free to bill outside the Medicare system for services which they cannot afford to offer at Medicare rates.  For example, if an active 65 year old patient wants to have a special high tech knee implant that was designed for the more active younger patient, he cannot pay the difference between the regular implant and the latest development.  If Medicare offers “the service” at any level you cannot buy the service on the free market.  

In this way, rationing by diminishing the supply of specialists has already started by diminishing the options open to Medicare recipients.  Physicians are not that different from Starbucks — they are not going to pay you for the privilege of serving you.  

Although, for a while, Oncologists did just that.  In the last few years, as Medicare cut the reimbursement for some newer types of chemotherapy, Oncologists would suck up the cost because they wanted to do the best for their patients.  But now, as Medicare has ratcheted back payment even more, they have reverted to older drugs.  And because there is no free market, the patient cannot simply pay the difference to get the latest scientific breakthrough.  

So ignoring the smoke and magic mirror tricks, government payment for medicine must be rejected, not on practical financial grounds, but by people who value their freedom and their moral lives. As recognized by our founders, but ignored by the current crop of politicos, the most unhealthy immoral force in human history has been overly powerful central governments.  Charley Reese put it best when he said, “It is an eternal shame to give up one’s freedom for a filled bowl of oatmeal and the promise of security from liars”.