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Obamacare: Why Bioethics Matters
Wednesday, January 6, 2010, 2:19 PM
Wesley J. Smith

Yesterday, I posted about a bioethics article that advocated dropping human intrinsic dignity as a fundamental premise to be applied in bioethical analyses.  This meme is profoundly dangerous to the medically vulnerable.  Moreover and alas, human unexceptionalism is the mainstream view in the field, in the field, evidenced by the popularity of personhood theory within the movement and the “human undignified” article being published in Bioethics, a notable professional journal. (I have often said, if you want to see what is going to go wrong in the coming years, read the professional journals.)

This matters because of the wide influence wielded by bioethics in medical ethics, law, media reporting and analysis, public policy, and indeed, through those vehicles, upon the views of general society.  Here’s how I put it in Culture of Death (citations omitted):

It is important to note that bioethics is not a synonym for medical ethics and does not restrict its scope to the behavior of doctors in their professional lives vis-à-vis their patients.  Rather, bioethics concerns itself with the relationship between medicine, health, and society, a far broader and more consequential matter.  Moreover, many bioethicists presume an overarching moral expertise that is breathtaking in its ambition and hubris.  Many view themselves, quite literally, as the forgers of “the framework for moral judgment and decision making” who will create “the moral principles” that determine how “we are to live and act,” a “wisdom” they perceive as “specially appropriate to the medical sciences and medical arts.” Indeed, some claim that “bioethics goes beyond the codes of ethics of the various professional practices concerned.  It implies new thinking on changes in society, or even global equilibria.” (My emphasis.)  Not bad for a school of thought that has only existed for about 30 years…

Once bioethics moved away from ivory tower rumination and to actively influence public policy and medical protocols, by definition the field became goal oriented.  Indeed, University of Southern California Professor of Law and Medicine, Alexander M. Capron, notes that from its inception, “bioethical analysis has been linked to action.” If dialogue is linked to action, at the very least, that implies an intended direction if not a desired destination.  Even bioethics historian Albert R. Jonsen, a bioethicist himself, calls bioethics a “social movement.”  Has there been any social movement that was not predicated, at least to some degree, in ideology?  Moreover, the bioethics pioneer, Daniel Callahan, co-founder of the bioethics think tank, The Hastings Center, has admitted that “the final factor of great importance” in bioethics gaining societal respect, was the “emergence ideologically of a form of bioethics that dovetailed nicely with the reigning political liberalism of the educated classes in America.” Thus, mainstream bioethics is explicitly ideological, reflecting the values and beliefs of the cultural elite.

If Obamacare passes, the field will grow, if anything, even more powerful.  The proposed law will establish scores of bureaucracies and advisory boards.  The people who will serve on these boards, testify in front of them, and otherwise exert powerful sway over our centralized medical delivery system will be bioethicists.  That is too much–and too dangerous– power to be wielded by denizens in a field that generally rejects human exceptionalism and its corollary, the sanctity/equality of human life.


Obamacare: Less Healthcare For More People
Tuesday, December 29, 2009, 11:11 AM
Wesley J. Smith

Over the Christmas holiday lull, I saw one commenter support Obamacare on the purely utilitarian grounds that the government should do that which benefits the most people.  I almost spit out my eggnog.  Obamacare will actually harm most people to benefit the minority by reducing the level of medical care we now receive so that the minority can get greater access.  I am not saying that is wrong–protecting minorities is usually a very worthy endeavor. But that statement just wasn’t true. For better or worse, the point of Obamacare is to provide less health care for more people, not better health care or more affordable health care.

None other than the liberal columnist Bob Herbert sees it and complains that union members will be hurt by that agenda in today’s New York Times.  He writes against taxing so-called “Cadillac” insurance policies–most of which are enjoyed by union members, and reveals an important truth.  From his column:

The bill that passed the Senate with such fanfare on Christmas Eve would impose a confiscatory 40 percent excise tax on so-called Cadillac health plans, which are popularly viewed as over-the-top plans held only by the very wealthy. In fact, it’s a tax that in a few years will hammer millions of middle-class policyholders, forcing them to scale back their access to medical care. Which is exactly what the tax is designed to do.

Precisely. And that “cost cutting” agenda is the law’s primarily thrust–which is why the expensive for whom to care will find themselves rationed out.

Moreover, since another primary purpose of the bill is to grant the government greater power over all our lives to promote the cultural agendas of the Left, Obamacare exacerbates the cuts to come by expanding the meaning of health care to encompass non medical things, like paying counselors visit the homes of families with small children. When the health care financing system pays for non health care services, it will mean, by definition, there will be less money to pay for the delivery of true medicine.


Obamacare: Opponents Have Not Yet Begun to Fight
Thursday, December 24, 2009, 11:59 AM
Wesley J. Smith

In one of the most morally corrupt and cynical acts of recent political history, the Senate has passed Obamacare.  More fighting ahead with a required blending with the even worse House version.  But I predict ultimate passage.  That ends it, right?  Not on a bet.

Obamacare supporters badly lost the political debate.  They had the numbers in the Congress to stuff us like a Christmas goose, but the struggle against it–and on behalf of a reform that won’t kill the patient–will continue.  Michael Barone, one of the nation’s best judges of the political landscape, agrees. From his column:

A health care bill like the Senate’s is unlikely to settle all health care issues, either, though the ensuing political struggles will stop somewhere short of civil war. “We aren’t done talking about health care,” writes Atlantic blogger (and Obama voter) Megan McArdle. “We haven’t even really started. Our budget problems are as big as ever, and we just used up both political capital, and some of our stock of tax increases and spending cuts, to pay for something else.”

The Senate bill contains provisions that are likely to be revisited. Its language channeling federal and consumer dollars to abortion coverage is opposed, according to Quinnipiac, by a 72 percent to 23 percent margin. Its provision establishing an Independent Medicare Advisory Board and stating that it cannot be abolished except by a two-thirds vote of the Senate is of dubious constitutionality, and even if upheld in a court of law may not pass muster in the court of public opinion. Since when has Congress passed laws that cannot be repealed?

Iowa’s leftist Senator, Tom Harkin, called this boondoggle merely a “starter house” from which the Dems will build a “mansion,” meaning total government control of health care.  But that is not where America wants to go.  Far more of us want to bulldoze this hopeless mess down to the foundation –and hopefully, as soon as it becomes law, that process can begin.

Barone agrees:

The Democrats’ health care bills are an attempt to settle a fundamental issue by partisan maneuver and cash-for-cloture. As Stephen Douglas learned [in passing the disastrous Kansas-Nebraska Act], such tactics can work for a while, but the country — and the Democratic Party — can end up paying a heavy price.

Expect lawsuits–surely forcing everyone to buy health insurance is beyond the government’s constitutional power.  Expect political guerilla insurgency.  Expect ongoing efforts to resist, defang, and defund.  Expect this to be a huge issue in the 2010 elections.

No, this isn’t bad sportsmanship: When you impose politically unpopular legislation on an unwilling country–and in a way that breaks all bonds of comity–don’t expect the issue to just go away.


Obamacare: The Danger of “Evidence” Based Medicine
Wednesday, December 23, 2009, 12:49 PM
Wesley J. Smith

Don’t let the headline fool you: I am not against evidence based medicine when it is used as a guide for doctors to provide optimal individualized care.  But I am against using EBM as a method of establishing categories for health care rationing–whether of “what” or “who”–as I believe we are destined for under Obamacare.  One reason is that–like global warming computer models–it all depends on what evidence is included or excluded in creating the studies. That means the evidence could well be cooked.

This point was acknowledge in the New York Times, of all places, in a recent article on end of life care.  From the story:

The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life. “If you come into this hospital, we’re not going to let you die,” said Dr. David T. Feinberg, the hospital system’s chief executive. Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not. That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Perhaps not so remarkable. I don’t know if it is true in this case, but the scientific study has become a method of ideological advocacy, and in such reports, the deck gets stacked.  In other words, sometimes the authors of such studies know what they don’t want to know because they have a result in mind rather than dispassionate analysis.

The Times gives an example:

Take the case of Salah Putrus, who at age 71 had a long history of heart failure. After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant. Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said his physician there, Dr. Tamara Horwich. Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.” They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection. His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant. Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

And here’s where Obamacare comes in:

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government…That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing. “There’s a real risk of doing harm here — real harm,” he said.

This is a very good article, illustrating that the outcome of “studies” depends on its design, and indeed, they may mislead more than they edify.  That point aside, this is a prime example of why it would be wrong to begin treating patients as members of a category instead of as an individual.  Statistics provide general guidance. But they are no substitute for personalized care.


Obamacare: Stifling Future Freedom
Tuesday, December 22, 2009, 11:27 AM
Wesley J. Smith

The Senate Obamacare bill seeks to stifle freedom by preventing further legislation that might change the terms of what it seeks to impose on our country.  From a blog over at the Weekly Standard:

Senator Jim DeMint (R-S.C.) pointed out some rather astounding language in the Senate health care bill during floor remarks tonight. First, he noted that there are a number of changes to Senate rules in the bill–and it’s supposed to take a 2/3 vote to change the rules. And then he pointed out that the Reid bill declares on page 1020 that the Independent Medicare Advisory Board cannot be repealed by future Congresses:

“There’s one provision that I found particularly troubling and it’s under section c, titled “limitations on changes to this subsection., and I quote — ‘it shall not be in order in the senate or the house of representatives to consider any bill, resolution, amendment, or conference report that would repeal or otherwise change this subsection.’ This is not legislation. it’s not law. This is a rule change. it’s a pretty big deal. We will be passing a new law and at the same time creating a senate rule that makes it out of order to amend or even repeal the law.”

Can you imagine the arrogance?  Passing a law that prevents future Congresses from passing a law?  I doubt that passes constitutional muster, but the totalitarian impulses of these people are a sight to behold. As I have been saying repeatedly–and it pains me as a man formerly of that political persuasion–the Left isn’t about freedom anymore, it is about the exercise of sheer raw power.


Obamacare: Rhode Island Senator Accuses Opponents Being Racists
Monday, December 21, 2009, 11:41 AM
Wesley J. Smith

The picture at the right is of Secondhand Smoke–at least if one listens to Rhode Island Senator Whitehouse. He claims opponents of Obamacare are nothing but a bunch of racists and right wing fanatics who wish President Obama didn’t even exist. From the story quoting the senator:

“They are desperate to break this president. They have ardent supporters who are nearly hysterical at the very election of President Barack Obama. The birthers, the fanatics, the people running around in right-wing militia and Aryan support groups, it is unbearable to them that President Barack Obama should exist.

I guess that means the clear majority of country is overwhelmingly fanatic and rascist since about 60% of us oppose the bill.  Oh, when will the hate stop?  When will it stop?


Obamacare: The Dems Have 60 Votes, No Public Option, Abortion Opt Out
Saturday, December 19, 2009, 11:43 AM
Wesley J. Smith

Senator Ben Nelson got as much lucre for Nebraska as he could, and with Joe Lieberman, killed the public option.  He also appears to have obtained an abortion compromise that would allow states to opt out of abortion coverage, which would result in huge swaths of the USA free from non therapeutic abortion insurance if the bill passes in current form.  From the story:

Under the new abortion provisions, states can opt out of allowing plans to cover abortion in insurance exchanges the bill would set up to serve individuals who don’t have employer coverage. Plus, enrollees in plans that do cover abortion procedures would pay for the coverage with separate checks – one for abortion, one for rest of health-care services….

Instead of a public option, the final product would allow private firms for the first time to offer national insurance policies to all Americans, outside the jurisdiction of state regulations. Those plans would be negotiated through the Office of Personnel Management, the same agency that handles health coverage for federal workers and members of Congress.

Starting immediately, insurers would be prohibited from denying children coverage for pre-existing conditions. A complete ban on the practice would take effect in 2014, when the legislation seeks to create a network of state-based insurance exchanges, or marketplaces, where people who lack access to affordable coverage through an insurer can purchase policies… And all insurance companies would be required to spend at least 80 cents of every dollary they collect in premiums on delivering care to their customers.

I still oppose the bill because of the rationing boards, cuts in Medicare funding, etc., and I am not happy with the Feds grabbing power in this area.  Also, very careful scrutiny will be required of the mischief to be done by the regulatory bureaucrats. 

But I must say, given the way things looked last July, this is a tremendous victory against full government takeover of health care in what appeared then to be a hopeless cause.  Moreover, the attempt to shove this down the nation’s throat without any regard for the will of the people has really hurt the political Left.  So, while the deal’s not done, and bad stuff will probably be put back in during the conference between the House and Senate–but no further bad things taken out–things could have been much worse. 

Questions: Will the pro life Democrats vote for less than Stupack total ban on abortion coverage?  If not, the bill won’t pass. If so, it will. Will left wing Democrats just play along after seeing the dramatic changes moderates secured in exchange for their support?  Maybe not.  The Left stopping the bill in its tracks may be the next surprise twist in this ongoing poliltical saga.


Obamacare: At the End of the Trail There Will Be No Public Option
Wednesday, December 16, 2009, 1:36 AM
Wesley J. Smith

In my recent predictions for 2010, I prognosticated that Obamacare will pass without the public option.  Today, Senator Lieberman said he will vote for the bill because the PO is out.  That could be the magic 60th vote, although abortion remains a potential impediment.  But what about the House? Representative Steny Hoyer, the #2 honcho, said the House too could vote the bill through without a public option. From the story:

Majority Leader Steny Hoyer said Tuesday the House can pass a healthcare bill without a public option. “My opinion now is that it is yes,” Hoyer (D-Md.) said at his weekly press conference in response to a direct question. Hoyer, who supports a public option, said “the guts” of the healthcare bill still provide insurance coverage to 30 million people who now do not have affordable, quality healthcare. “Reid does not have the votes for a public option so in a world of alternatives you gotta focus on what you can get,” Hoyer said.

That’s good news, but it’s not, because the darn thing will pass, meaning we will still be on road to rationing. Still, that won’t take place for years and bad laws can be fixed.  Moreover, given the political ground faced by Obamacare opponents, I am not sure what else could have been achieved.  If things turn out as they look to, at least opponents can take comfort in the fact that they clearly won the political battle–breaking the back of what seemed an unstoppable juggernaut only 6 months ago–and may have positioned matters for even greater success in the coming years.


Obamacare: Reid Makes a Mess
Sunday, December 13, 2009, 9:43 PM
Wesley J. Smith

The entire Obamacare saga has been the most dishonest, reckless, and foolish bit of legislating I think I have ever witnessed.  It is a mess,  and it seems quite obvious that our leaders don’t care that it is a mess.  The problem–and particularly, Harry Reid’ s part in it–was summarized quite nicely over at Commentary by Jennifer Rubin. From her blog entry:

Sen. Harry Reid threw a long bomb in an act of desperation. Recognizing that there was no deal on the public option, Reid resuscitated an old liberal gambit — expanding Medicare…At week’s end, a flurry of objections and criticism — from senators, the Medicare actuary, editorial pages, previously supportive business groups, doctors, and hospitals — together with shockingly negative polling on ObamaCare suggest that we may have finally reached a point when “doing nothing” (at least for a while) makes immense political sense for lawmakers…

In a sense, Reid clarified what many suspected was going on. The Democrats had ceased trying to craft a workable bill and had decided to pass something, anything, and fix it later. By choosing an approach so obviously hare-brained, however, Reid deprived his party of the pretense that they were engaged in serious lawmaking.

I still think it will pass in some form. But it will be a mess in desperate need of cleaning–and there will be a political price to pay.


Obamacare: The Potential For Stifling Medical Advancement and Innovation
Saturday, December 12, 2009, 1:02 PM
Wesley J. Smith

There is much to complain about with the US health care system. But there is no question it is the driving force in the world behind the continual advancement of medical knowledge and skill.  But that innovative energy could well be dissipated by the cost/control/ rationing boards that Obamacare would impose on both private and public insurance policies alike.

I thought about this when reading a story in today’s paper about how two breast cancer drugs extend the life of terminally ill patients for five or six months.  From the story:

Some women with very advanced breast cancer may have a new treatment option. A combination of two drugs that more precisely target tumors significantly extended the lives of women who had stopped responding to other medicines, doctors reported Friday. It was the first big test of combining Herceptin and Tykerb. In a study of 300 patients, women receiving both drugs lived nearly five months longer than those given Tykerb alone. Doctors hope for an even bigger benefit in women with less advanced disease and were elated at this much improvement for very sick women who were facing certain death.

The headlines calls this test “good news,” and it is.  But this is the very kind of medical advance that would be stifled by rationing–both in the delivery at the clinic and in the development.

Why is that?  Today, once a treatment is approved by the FDA, insurance companies can’t refuse it.  Imagine, the outcry if, for example, Aetna or Humana refused to extend the life of colon cancer patients by paying for a chemotherapy that gives another 9 months of life.  There would be hell to pay!  The lawyers would pour out of the woodwork. The government regulators would bring them to heel!  That’s because the burden of proof would be on the insurance company to demonstrate why it won’t provide the treatment–and woe betide the PR spokesman who invoked quality of life!

Yet, should the government refuse coverage based on quality of life, the denigrating judgment would be likely to hold because the entire burden of proof would shifted. And the system would be clearly be predicated on quality of life.  Most bioethicists, the very people who would be appointed to and advise the cost/benefit/best practices boards, reject the equality/sanctity of life ethic and embrace viewing medical delivery through a distorting quality of life prism.  In the UK, for example, the rationing board NICE uses a “quality adjusted life year” (QALY) measuring stick, in which a treatment providing life for five years could be worth only one QALY year.

Once rationing were imposed, rather than being on the side of the patient, regulators would be on the side of the bureaucrats, and the lawyers would have far less chance of prevailing.  That is because in a rationed system medicine becomes societal rather than individually oriented.  And indeed, as just one example, when Ontario, Canada restricted a colon cancer treatment that extends life for nine months, there was some public disquiet, but no redress for those patients told their lives weren’t worth the money to pay for it.  Ditto, the Barbara Wagner case in Oregon, in which a Medicaid bureaucrat refused life-extending chemotherapy, but offered assisted suicide. (Wagner eventually got the treatment free from the drug company.)

Should such a system be imposed on the USA, it would not only victimize the very sick, it would also sap most of the energy out of innovation.  It often takes billions to bring a drug to market.  If some of treatments derived therefom might not be covered even if they work, they won’t be developed.  Thus Obamacare would eventually both stifle the delivery of efficacious medicine and its innovation.  That would not only be disastrous for us, but for the world that looks to the USA for these kind of advances.

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