I have begun to argue that controlling health care costs will require that we make a greater distinction between medical “treatments” and “services.” Treatments involve diagnosing and treating actual disease (roughly stated), while services involve using medical means to fulfill lifestyle or personal desires (roughly stated). I believe that coverge should mostly be restricted to treatments, and that to better control costs, most services should not be paid for at all (understanding that there are some gray zones).

A story out of the UK helps illustrate my thinking. The NHS–already going broke–is expanding coverage for IUI insemination to lesbian couples and raising the age for free access to IVF to age 42. From the Telegraph story:

Same-sex couples will be given the same rights as heterosexual couples under guidance issued by the National Institute for Health and Clinical Excellence. The NHS will also extend the upper age limit for IVF by three years to 42, following advice that suggests many women in their late 30s and early 40s could conceive after treatment. The move will see thousands of women a year given the chance to become mothers without having to pay up to £8,000 to private clinics. Fertility experts also questioned whether health authorities could afford to widen eligibility criteria, when only a quarter currently fund three cycles of IVF for infertile couples, as recommended by Nice…

The new guidelines call on health authorities in England and Wales to fund fertility treatment known as intra-uterine insemination (IUI), using donor sperm, for people in same-sex relationships. If they fail to conceive after six cycles of IUI, they should be considered for in-vitro fertilisation (IVF), which is much more costly and involved. The move follows a relaxation in the law, made under Labour in 2008, to put same-sex parenting on an equal legal footing.

This is an example of why we will never control health care costs if we keep expanding coverage for services in an evaporating payment pool.  Frankly, it’s nuts.

In the lesbian example, there appears to be no indication that the women have to be unable to conceive through sexual relations, just that they are gay. I get it. But should society pay for the cost when it isn’t really a matter of disease or an inability to get pregnant?

Ditto a woman being unable to conceive as she gets older. That’s not illness, that’s nature. In such cases, shouldn’t the cost of IVF be on the woman and not the health payer?  (By the way, I think the same thing about Viagra unless impotence has a medical cause, such as prostate cancer. It is not a treatment to enable older men to rev their engines like the could when they were 18.)

Meanwhile, remember that NICE rations bonafide medical treatments needed to sustain life and diagnose disease based on quality of life. We can expect the same kind of topsy/turvy thing here if Obamacare sticks: Governments making coverage decisions as much on politics as the necessities of health.

The quest for male birth control, other than of the latex kind, has moved a step closer with the discovery of a gene involved in sperm production.  From The Independent story:

A contraceptive pill for men which works by preventing sperm development could result from the discovery of a new gene, scientists have said. The gene, which is active in the testes, controls the final stages of sperm development. Blocking it would result in temporary infertility, without permanently damaging a man’s sperm-making machinery, the researchers said…

When the gene is blocked, the testes continue to make sperm, but only ineffective, immature sperm are released, said Lee Smith of Edinburgh University. “The effects of such a drug would be reversible, because Katnal1 only affects sperm cells in the later stages of development, so it would not hinder the overall ability to produce sperm,” he said.

A couple of thoughts.  Many men are very sensitive about their virility and may be reluctant to mess with the plumbing. Beyond that, never forget that men are dogs.  Even if this comes to safe fruition, no woman should ever believe the line, “Don’t worry baby, I’m on the pill.”

German doctors were not forced by the Nazis to commit infanticide or eugenic murder between 1939-1945, nor to participate in death camp atrocities.  Now, the German Medical Association has issued an unequivocal apology.  From Art Caplan’s column:

Unanimously adopted by the delegates of the Physician’s Congress, the declaration says that contrary to popular belief doctors were not forced by political authorities to kill and experiment on prisoners but rather engaged in the Holocaust as leaders and enthusiastic Nazi supporters. The apology notes that “outstanding representatives of renowned academic medical and research institutions were involved” in organizing and carrying out the mass extermination of millions.

In the statement, the German doctors said they “remember the living and deceased victims and their descendants and ask them for forgiveness.” I don’t know if forgiveness will be forthcoming. But in the history of apologies for crimes and abuses carried out in the name of medicine this is the most important ever made. It does nothing to soften the horror of the Holocaust but it both ascribes responsibility where it belongs and ends any further efforts to deny or obfuscate what actually happened.

That doesn’t bring back the lives lost, but at least it does help set history straight.  And, of course, none of the current members of the association bear any personal responsibility–undoubtedly making the apology easier to make. But it does help us accept that all that evil did not arise from ”The Nazis,” which too often becomes a defense allowing us to rationalize our own anti humanism because we don’t goose step on parade.

The real potential for such evil arises when we reject human exceptionalism. That opens the door to rationalizing oppressing, exploiting, and killing those denigrated as the contemporary untermenchen.

There is a tendency in media and among the public to blame racism and other assorted bigotries on ignorance, stupidity, or “superstition” (religion). And sometimes that is true. But just as often, evil comes from the top, down–from those who are the smartest, most intelligent, and well educated. Eugenics is the classic example. Those pushing that pernicious anti human exceptionalist tripe were primarily professors, scientists, and hyper rich philanthropists.  The evil they caused–including contributing to Nazi racial hygiene theory–cannot be measured.

Yale Alumni Magazine has an article admitting as much.  From “God and White Men at Yale:”

On a sweltering Friday in June 1921, a 54-year-old Yale economics professor named Irving Fisher delivered a major speech at Cold Spring Harbor on Long Island. The pain of the recent war in Europe was still fresh, and Fisher was troubled by the quality of those who had died, and the damage to “the potential fatherhood of the race” by the loss of so many young men “medically selected for fighting but thereby prevented from breeding.” In light of these losses, the issue, it seemed to Fisher, was that graduates of leading universities were failing to do their reproductive duty: the families “of American men of science” averaged just 2.22 children, versus a national average of 4.66.

That is what is known as “positive eugenics,” that is, the duty of the supposed betters in society to procreate bounteously. The real evil–the beliefs that led to involuntary sterilization and refusing Jews entry into the USA seeking to escape Germany, came from “negative eugenics.” Fisher was virulent on this topic:

To prevent that, immigration from certain regions needed to be sharply curtailed, and birth control “extended from the white race to the colored” and to other “undesirable” ethnic and economic groups, ideally under the control of a eugenics committee established to “breed out the unfit and breed in the fit.” Otherwise, “the Nordic race … will vanish or lose its dominance.”

It was strong stuff, and from a seemingly impeccable source. Irving Fisher ’88, ’91PhD, a dapper, balding figure, with a white van dyke beard and rimless eyeglasses, was one of America’s best-known scholars. The New York Times ran long, flattering profiles about his work, and for years the Wall Street Journal published “Fisher’s Weekly Index,” for tracking market prices. The rich and powerful, including congressmen and presidents, sought his advice. And with good reason: even today, Fisher is widely regarded as the greatest economist America has produced…

But Fisher was also a leading voice of the eugenics movement, which aimed to improve human populations through carefully controlled breeding…Fisher didn’t merely lend his reputation to bigotry. He made eugenics a major focus of his life and regarded it as a natural outgrowth of his economics: “national vitality” depended on a productive citizenry, and it was clear to him that healthy living and careful breeding were the best ways to make the citizenry become more productive. To that end, he helped found the Race Betterment Society; was an active member of the Eugenics Research Association, a group of scholars in the field; and served as founding president of the American Eugenics Society, which organized research, lobbying, and propaganda for the movement.

His story isn’t an anomaly.  The high university has often been a powerful source of anti human exceptionalism darkness. Think of the Nobel Prize Winner in Physics, the racist William Shockley, who parlayed his justified fame from helping invent the transistor into a return of old fashioned eugenics advocacy.

On the contemporary scene, a lot of smarties push pernicious ideas. There is Nobel Laureate James Watson, for example, who was rejected in the public square for pushing racism and anti Semitism.  Alas, the same can’t be said for for the anti human exceptionalist, Peter Singer–whose advocacy, if accepted as policy, would lead to infanticide and using disabled living people as organ farms and research subjects.  He was brought from Australia to Princeton not in spite of these ideas–but because of them–and may now be the world’s most influential contemporary bioethicist/moral philosopher.  Think also Oxford’s Julian Salvulescu, who not only pushes his own neo eugenics, but also publishes the Journal of Medical Ethics, home of such notable anti humanism advocacy as the “post-birth abortion” article that recently caused such a fuss.

We don’t want to take this too far.  The benign Albert Einstein was certainly a source of morality and conscience. Contemporary smarties that promote human exceptionalist virtue include the University of Chicago’s Leon Kass, Princeton’s Robert George, and Stanford’s William Hurlbut.

Here’s the point: The history of eugenics teaches us that while we should not reject policy ideas and advocacy because they come out of the most elite universities, we should also not bow down before those who inhabit the ivory tower as if they are our betters. In other words, hyper intelligence and a plethora of post graduate degrees have little to do with virtue and moral ideas. Indeed, an argument could be made that too often, it is exactly the opposite.

HT: The Corner

Oh joy. Yet another movie that features the “love” that supposedly is euthanasia. From the Daily Beast story:

The plot couldn’t be simpler. Georges (Trintignant) and Anne (Emmanuelle Riva) are retired classical-music teachers who still relish each other’s company and the daily pleasures of meals and attending concerts. When Anne falls victim to a stroke, their world is turned upside down. Their middle-aged daughter, Eva (Isabelle Huppert), returns from London to Paris with her English husband but is appalled by her once vibrant and lucid mother’s sad transformation. At one point she remarks to her father, “She’s speaking gibberish … what’s next?” He replies that her condition “will go steadily downhill until it’s worse.” While there’s no facile sentimentalism in Haneke’s portrait of old age, the critics in attendance at Cannes, many of whom could not stomach his earlier films, are apparently responding to the purity of the love shared by a couple who appear totally devoted to each other.

Of course he does.  But this is hardly new among the arteests.  I guess these people haven’t seen Million Dollar Baby,  the Kevorkian hagiography You Don’t Know Jack, and a plethora of other films and television shows that positively depict euthanasia.  Then, there was the notorious old 1941 German euthanasia propaganda film, Ich Klage an (I Accuse)–that had a doctor kill his pianist wife at her request because she had MS and couldn’t play piano anymore–a POV that is now mainstream in Hollywood.  Indeed, it is very close to Million Dollar Baby’s denouement, in which the Clint Eastwood character kills his female boxer protege because she has become quadriplegic.

But here’s a story that deserves to be made into a movie. It is a true story.  It has drama.  Conflict.  Heart rending scenes of suffering and an assisted suicide.  There was even a book by the suicide assister, But What If She Wants to Die?

Here’s the plot: George Delury–I think he should be played by Robert DeNiro, no, we need to go more sensitive, Alan Alda–is married to Myrna Lebov. I think we should call Maryl Streep’s agent, or if we want her to be more vulnerable, Diane Keaton.  Myrna has progressive MS, and of course, wants to die rather than live with a serious disability. George is reluctant, but he finally agrees. After the death, he turns himself in and the assisted suicide movement adopts him as one of their own–which, of course, he is.

But here’s the plot twist: George planned to write a book about the assisted suicide, so he kept a diary on his computer that was discovered by the police. I like Jeff Daniels, so let’s cast him as the detective.  It turns out that Myrna’s suicide wasn’t her idea, it was George’s!  Imagine what the sensitive Alda could do with that moment, transforming in front of our very eyes from a loving, compassionate, and sensitive husband into a crass and selfish abandoner!

Worse, the diary reveals that George pushed Myrna into the suicide, repeatedly berating her for burdening him, telling her, “I have work to do, people to see, places to travel. But no one asks about my needs. I have fallen prey to the tyranny of a victim. You are sucking my life out of me like a vampire and nobody cares. In fact, it would appear that I am about to be cast in the role of villain because I no longer believe in you.”  Oscar time, baby!

It would make a great movie.  But Hollywood won’t touch it.  True story. Wrong message.

A very disturbing article in New York Magazine by Michael Wolff.  It tells the difficult story of his mother’s dementia, a course of physical and mental decline about which I am very familiar as my uncle died from the complications of that Alzheimer’s disease. But Wolff says that such patients have lost dignity, and indeed, he more than implies the proper approach to dealing with dementia is to kill them sooner rather than bear the emotional and financial expense of caring for them over the long term.  From, “A Life Worth Ending:”

It is peaceful and serene. Except for my mother’s disquiet. She stares in mute reprimand. Her bewilderment and resignation somehow don’t mitigate her anger. She often tries to talk—desperate guttural pleas. She strains for cognition and, shockingly, sometimes bursts forward, reaching it—“Nice suit,” she said to me, out of the blue, a few months ago—before falling back. That is the thing that you begin to terrifyingly appreciate: Dementia is not absence; it is not a nonstate; it actually could be a condition of more rather than less feeling, one that, with its lack of clarity and logic, must be a kind of constant nightmare. “Old age,” says one of Philip Roth’s protagonists, “isn’t a battle, it’s a massacre.” I’d add, it’s a holocaust. Circumstances have conspired to rob the human person–a mass of humanity–of all hope and dignity and comfort. When my mother’s diaper is changed she makes noises of harrowing despair–for a time, before she lost all language, you could if you concentrated make out what she was saying, repeated over and over and over again: “It’s a violation. It’s a violation. It’s a violation.”

Often, the people who really suffer in dementia cases are the loved ones.  I know we did.  It is very hard to see your formerly vibrant and interactive mother, father, uncle, spouse, so ill and vulnerable.  But they are not without dignity–unless we so define them.  Their hygiene needs do notreduce them to something less human. The family chose to accept some high end interventions–which no one forced on them.  But those are tough calls too, so no judgment there.  And here’s the call to killing:

I do not know how death panels ever got such a bad name. Perhaps they should have been called deliverance panels. What I would not do for a fair-minded body to whom I might plead for my mother’s end. The alternative is nuts: to look forward to paying trillions and to bankrupting the nation as well as our souls as we endure the suffering of our parents and our inability to help them get where they’re going. The single greatest pressure on health care is the disproportionate resources devoted to the elderly, to not just the old, but to the old old, and yet no one says what all old children of old parents know: This is not just wrongheaded but steals the life from everyone involved. And it seems all the more savage because there is such a simple fix: Give us the right to make provisions for when we want to go. Give families the ability to make a fair case of enough being enough, of the end’s, de facto, having come…My bet is that, even in America, even as screwed up as our health care is, we baby-boomers watching our parents’ long and agonizing deaths won’t do this to ourselves. We will surely, we must surely, find a better, cheaper, quicker, kinder way out.

Yes indeed, for Baby Boomers, it is always about us.

My uncle was helpless at the end, his condition made more difficult by serious glaucoma, added to the travails of dementia.  But he was not undignified.  Indeed, I would posit he had a greater claim on our love, commitment, and care than when he was a vigorous activist in the Teamster’s Union.  And the people who cared for him at a wonderful Baptist continuing care home could not have been more committed to their patients’ well being, cleanliness, and comfort.

We already have the right to refuse unwanted medical treatment. Before becoming incompetent, my uncle made it clear that he did not want heroic measures or antibiotics at the end, and as his surrogate, I made sure he did not receive them. But his was not a life worth ending, it was a life worth caring.  And that is precisely what my uncle received, individualized and loving attention until his time had come.

But there is an agenda afoot to get us to die sooner rather than later.  So the caring story does not seem to be one that big time media is much interested in telling.

The UK’s rationing board, the National Institute for Clinical Excellence (NICE) wants doctors to use more pain control. From the BBC story:

NICE wants doctors in England and Wales to make more use of morphine and other strong opioids – the only adequate pain relief source for many patients. The guidelines recommend doctors discuss patients’ concerns. These may include addiction, tolerance, side-effects and fears that treatment implies the final stage of life.

That’s nice, and why aren’t doctors doing that anyway?

But, I’m sorry: This is no way to run a railroad.  Doctors shouldn’t constantly have to look to central control to determine how to treat individual patients.  Unless we give Obamacare the boot, we will have our own NICE technocrats telling our doctors what to do–and more insidiously, what not to do–from the bowels of the DC bureaucracy.

Good ethics and good science are an unbeatable combination.  For example, I believe that in part due to President Bush’s keeping the focus on the value of human embryonic life, scientists looked for ways to get the hoped for benefits of embryonic stem cells, without destroying or cloning embryos. This led to the induced pluripotent stem cell breakthrough that takes normal cells, changes them to stem cells, and thence into other types of tissue. Now, an important IPSC study has shown that skin cells made into cardiac cells function well in the heart. From the FNN story:

In the first procedure of its kind, skin cells taken from patients suffering  from heart failure were “reprogrammed” and changed into heart muscle cells.  Not only were the transformed cells healthy, but they were also  transplanted into the hearts of rats and were able to integrate with the  existing heart tissue. Published in the European Heart Journal, the research examined the use of  human-induced pluripotent stem cells (hiPSCs) to treat damaged hearts.   HiPSCs are cells that are derived from other cells in a person’s body.

“We were able to show [in earlier studies] that you can take these hiPSCS  from healthy heart patients and coax them into bonafide heart cells,” lead  author Lior Gepstein, professor of medicine (cardiology) and physiology at the  Technion-Israel Institute of Technology and Rambam Medical Center in Haifa,  Israel, told FoxNews.com.  “The question we asked in this study was whether  you can do the same from an elderly individual that had suffered from advance heart failure.” Because hiPSCs are derived from the person in need of the stem cells, they could potentially help to bypass the painful process of rejection that many  transplant patients go through.  According to Gepstein, if this process is  perfected, it could lead to much more localized treatments…

And that could materially impact health care costs, if it works.

At this point, it is important to remember that any time you deal with pluripotent stem cells, tumors are a potential problem. And let us be clear: This isn’t near ready for the clinical setting, but rather, is an “important incremental step,” as a scientist quoted in the story notes.  But that’s how science progresses; step, by step, by step.

Also, note the story illustrates the pressing need for animal research. Those, like PETA who say it should be forbidden would prevent these and other innovative research potential treatments from actually being tested in living organisms, since it would be unethical to start studies in human beings. Simple fact of life: Computer programs and cell lines don’t take us all the way home.

The often media-scorned pro life movement has made major inroads among the American people, according to the latest Gallup Poll.  Those who identify themselves as “pro life” now outnumber those who see themselves as “pro choice,” with the latter category at its nadir (41%) since before the turn of the century.  From the poll:

The 41% of Americans who now identify themselves as “pro-choice” is down from 47% last July and is one percentage point below the previous record low in Gallup trends, recorded in May 2009. Fifty percent now call themselves “pro-life,” one point shy of the record high, also from May 2009.

Pro life self identity has grown among Republicans, Democrats, and Independents.

When you look at the poll, the pro life side has been the plurality/majority view for several years.  The question is why? Here’s my take:

• The pro life movement has science on their side. A fetus is a human being in the gestating stage. He or she isn’t a parasite nor a tissue mass.
• The pro choice side became too strident and absolutist–as in fighting the bans on partial birth abortion and insisting on making abortion available to minors without parental consent.
• Just as in the gay rights issue, familiarity breeds acceptance.  Many people know pro life activists and understand they are not the kind of uncaring people the media and pro choice activists like to paint.
•  America remains a generally religious nation. Not all pro lifers are religious, to be sure, but the power of faith as a motivator on this issue can’t be denied.

Saying one is pro life isn’t the same thing as saying abortion should be outlawed.  But it does show, I think, that those who work indefatigable to value the lives of the unborn are respectable and mainstream.  And that means the incremental approach activists have taken on this issue for decades is slowly working.

Good grief. A survey of physicians, conducted by Jackson Healthcare, finds that 26% of physicians are not taking new Medicare patients, and 51% refusing new Medicaid patients. And with the Independent Payment Advisory Board and other Obamacare monstrosities, expect things to get worse.

One could whistle past the graveyard and note, correctly, that this isn’t Gallup. But the trend in this regard is clear across the country. Like I have been saying–I wish it weren’t so, but reality bites–single payer health care leads to doctor shortages and rationing.  Time for a new approach.