Who does the doctor serve? When we lived in a society with common values, the answer was easy–the patient. Today, not so easy.
Now, doctors sometimes are asked to take lives, not just save them. And there is a push within organized medicine to create a destructive dual mandate for physicians, to care for patients yes, but to also concomitantly look out for the interests of society–a prescription that could create a conflict of interest between doctor and patient. Ditto, granting a right to patients to force doctors’ complicity in procedures that the physician finds morally objectionable. Thus, creating proper ethical guidelines for doctors is not as simple as it might have once been.
As discussed in an earlier post, the American College of Physicians has published a new Ethics Manual that–all things considered–seems pretty good, at least from my perspective. Still, there are some reasons for concern. From the discussion, “Patients First and Stewardship of Resources” (No link):
This language needs clarifying. I like the parts I emphasized in italics, but not the clauses that I underlined.
First, a doctor should certainly respect a patients “values and preferences” in the context of carrying out medical treatment. If a patient doesn’t want chemotherapy for cancer, for example, the patient should be able to say no even if it will shorten life. But what if the patient wants a doctor to kill a fetus in an abortion or participate in life ending acts such as euthanasia or assisted suicide? Should doctors be forced to be complicit in actively terminating life? I say no. Thus, I would add a specific clause protecting medical conscience rights of doctors, subject to certain terms and conditions, (as I have written), such as notice to patients ahead of time. (The Manual does briefly discusses medical conscience in the context of reproductive issues. We’ll look at that in more detail in a subsequent post.)
As to the issue of husbanding resources: “Equitable availability” should be irrelevant in the context of an individual patient’s treatment and could become a wedge for creating the conflict of interest that I worry is coming with Obamacare and other policy shifts. In other words, Doctor A treating Patient A has no ethical obligation to hypothetical Patient C, D, and E, much less to society overall.
Thus, I would rewrite the last point to read, “In the context of physicians primary responsibility to the patient, the physician should practice effective and efficient health care, use health care resources responsibly, and do so in such a way that the individual medical needs of the patient are not compromised.” End of sentence. I think that would prevent cooperation with health care rationing or the imposition of Futile Care Theory based on financial considerations, while also informing doctors that they should not be profligate in the way they practice their art.
January 8th, 2012 | 10:10 am
“Who does the [physician] serve?”
The answer is often insurance corporations, as filtered through healthcare directors. Physicians also serve medicare – which is generally liked by patients and set up by the people.
Values complaints are utter nonsense within the economic vacuum the right-wing tries to create.
Obviously, only rich people should be served by physicians and life-saving medicine. Equity is really scary.
Just like the vile Rick Santorum said (video clips also available):
http://articles.latimes.com/2012/jan/06/news/la-pn-santorum-tangles-with-voters-over-gay-marriage-health-insurance-20120106
The question should have been, “Who SHOULD the physician be serving?”
Thank empathy we have “Obamacare” to guide us to the answer. Imagine playing a role saving the life of a poor person who is your fellow citizen…
January 8th, 2012 | 2:35 pm
The answer is often insurance corporations, as filtered through healthcare directors. Physicians also serve medicare – which is generally liked by patients and set up by the people.
Values complaints are utter nonsense within the economic vacuum the right-wing tries to create.
Your claim that physicians give a lower standard of care to patients because insurance companies, rather than patients, pay their bills, is not true. It is because America’s health care is the best in the world, with the highest standard of care and the highest survival rates on specific procedures, that is the reason people in states with socialized medicine fly here to get their work done.
You can honestly argue that American health care is a problem because it doesn’t cover everyone, but I don’t see how you can honestly argue that American health care is not good for those who have it.
And physicians fight medicare, which frequently expects them to work for less than market price. The physicians that accept medicare are often doing the equivalent of donating their time (is there such a thing as half-donating?)
Just because you’re on the left wing doesn’t mean you have to misrepresent the truth, even if the climax you are trying to build to is both unsupported and an ad hominem.
January 8th, 2012 | 3:38 pm
Yes, David! as you indicate: It appears that the Republicans believe that “only rich people should be served by physicians and life-saving
medicine.” — Except, of course, veterans and old people (who vote) are an inevitable problem for the lawmakers and the VA budget has always been a source for budget cuts when the war is over.
Obviously, on behalf of the private insurance companies and the AMA and the Drug Companies, certain powers want to destroy Obama care and Medicare and the “compromise” they demanded that was passed into law because they want to return to the status quo where millions of Americans are uninsured and millions more are underinsured.
They want to continue to treat health care as “product for profit” and not as a human right or a civil right that government has an obligation to protect under our Constitution’s promise of life, liberty, and the pursuit of happiness.
More and more, the only “value” that US law protects is the value of money and the profits of those on the top of the financial pyramids who have influenced the laws to protect their profits.
It’s obvious that the AMA lobbied NOT to be put under the 1991 Self Determination Ac t because this would ultimately have meant that physicians would have to seek “informed” consent for futile “end-of-life” outpatient treatments and “hopeful” research that would result in some patient self-rationing of outpatient care.
CAN’T do anything that would ration treatments and, therefore, profits! The social conscience of the state has to be seen as an evil influence and an enemy of the Capitalist State according to the Republican candidates — except, perhaps, Dr. Ron Paul??? who is always undercut because he tells embarassing truths.
The Republicans are implying that all of the problems of the Western “welfare states” are because of their “health care” systems that serve ALL of their citizens. Wall Street and Greed and the Bankers and the Insurance Companies, of course, had nothing to do with the current “world” recession and the problems in the so-called welfare States? –It’s just their lousy health-care systems that are causing their current problems????
Thanks to free speech and The University of Google, the masses may not remain stupid forever.
I voted for President Obama and I like both the white and the black part of him which has produced a remarkable human being. But, if the Democrats don’t do something about the under-the-radar passive euthanasia of old Medicare patients, I may have to right Ralph Nader’s name in on my ballot for a third time –if I live that long!
I agree with Wesley Smith’s editing but I agree with you, David, that the question should be “Who SHOULD the Physician be treating…?
January 8th, 2012 | 6:42 pm
I agree, Blake, that American Health Care is the best in the world “for those who can afford it.” —and, for those who can afford to buy the best insurance –and access the best doctors –but maybe not for the elderly on Medicare/Medicaid who think they have the best insurance and that their rights and choices to live or die are protected under the law.
We had Medicare and Tri-Care-for-Life was our secondary payer because my husband was retired Regular Army. This is excellent so-called full coverage but it didn’t prevent the hospital and the physician from cooperating to remove my husband’s “informed choice” for a life-extending procedure because the hospital and the physician knew that they wouldn’t be reimbursed for the procedure under Medicare’s reimbursement protocol.
Obviously, the Medicare authorities who adopted these reimbursement procedures thought that the threat of criminal prosecution for illegal and unauthorized DNR’s would protect elderly patients but, of course, it doesn’t because everyone knows that the law is not enforced.
Everyone knows that unauthorized DNRs most often go unnoticed in the hospital charts and that oral and unwitnessed DNRs placed by physicians and nurses will go unnoticed and unpunished because the elderly patient is dead and the matter is moot for the family.
Medicare’s reimbursement protocol, of course, is an attempt for the insurers to use a value-based purchasing program with new initiatives that reward providers who provide best-practice care and to penalize those who do not provide best-practice care. Best practice care is defined by the insurers with statistics, etc.. and codes that must be satisfied to earn reimbursement.
The inclusions of errors and omissions (some of which are malpractice) as bad practices that will not be rewarded or reimbursed by Medicare/Medicaid, and the private insurers means that many elderly patients face a very hostile environment in the hospitals when they become victims of errors or omissions and/or other reimbursement protocols that penalize the hospitals for not providing “best-practice” care.
The hospitals resort to illegal and secret DNRs in the charts of the elderly ill patients as a means of capping the unreimbursed costs of the care for the elderly that the hospital will incur as a penalty. .
The patient, of course, is not advised that the hospital/physician is being penalized and the hospital/physician doesn’t bill the patient for the unreimbursed costs for obvious reasons —the fear of a “legitimate” malpractice lawsuit or reputational damage.
Physicians and other suppliers complain loudly that Medicare doesn’t reimburse them sufficiently but, of course, the truth is that most of them can’t exist without the Medicare/Medicaid money. The Acute Care Hospitals can’t exist without the Medicare/Medicaid funds. They are penalized and punished by withholding of Medicare/Medicaid reimbursement.
Physicians even advertise on the Internet that they perform lots of unnecessary procedures because they are afraid of being sued but, of course, they really want the government to give them immunity from lawsuits and a blank check to provide any kind of treatment and care that they deem necesary and PROFITABLE. It pays to ADVERTISE and look how the medical profession advertises their “credence goods.”
January 9th, 2012 | 4:43 pm
Yes, David! as you indicate: It appears that the Republicans believe that “only rich people should be served by physicians and life-saving
medicine.”
Thank you for revealing yourself to be so maddened by your hatred of those who don’t share your beliefs, that I am spared any desire to read beyond your first sentence.
How irrational is this sentence I’ve just quoted? Do you seriously believe this stuff?
January 9th, 2012 | 6:20 pm
If you are talking to me, Blake, “yes” I do believe everything I write to be the truth.
I am sorry that we had to discover, through a cruel experience, that my husband’s rights were unimportant and could be easily violated under the hospital’s policy that appeared to encourage the physician to place an unauthorized DNR in the hospital chart.
The hospital/physician, both, wanted to cap the costs and keep my husband out of ICU. They knew that they would not be reimbursed for my husband’s care under Medicare’s Best-Practice Care reimbursement protocol as implemented under the CMS “Value-based Purchasing Program.”
I’m sure they felt no personal malice toward my husband or me, but they rationalized that he was going to die anyway and it was merely expedient for them that my husband die sooner rather than later in order to save money and resources for the hospital/physician.
The idea of HOSPICE and PALLIATIVE CARE is primarily for the purpose of encouraging the elderly to die much more cheaply in their own homes or in or in residential nursing homes or assisted care facilities —and NOT in the ICU’s of the nation’s acute care hospitals.
This is public policy that, when combined with reimbursement protocols, has unintended and traumatic consequences for innocent elderly citizens who don’t know that the hospital/physician, sometimes, are NOT being reimbursed for their care because of errors/ omissions and other reimbursement rules. The elderly don’t understand that they are in a “hostile” environment in which they are at risk.
This is not a Republican or a Democrat scandal but the illegal DNR and the influenced DNR, in fact, are prevalent in US Hospitals.
This does mean that the United States, the home of the free and the brave, IS often passively euthanizing its elderly citizens as a matter of fiscal expediencey.
Research this, Blake, and keep an open mind! This is an UNINTENDED consequence of an intended action to cut the costs of the treatment of the elderly to Medicare and the Private Insurers who replace and supplement Medicare, and to cut the costs of Medicaid.
February 7th, 2012 | 12:13 am
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February 8th, 2012 | 5:25 am
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