Even Many Doctors Want to Force Colleagues to Violate Hippocratic Oath
An op/ed in today's Baltimore Sun has two doctors insisting that physicians refer patients for abortions if they don't wish to do the deed themselves. (The term used is reproductive health, and so it isn't only abortion to which they refer--but it is part of what is meant by the but euphemism.) In complaining about the Bush conscience regulation, that protects health care workers from being discriminated against if they refuse to participate in health procedures they find morally offensive or that is against their religion, the doctors support the must-refer approach. From the column:
As health care providers, we are, at the very least, obligated to provide all patients with appropriate referrals--even if we do not participate in or agree with the care. Our personal morality does not enter into it. For example, we cannot refuse to treat a drug user for his drug-induced heart attack just because we are morally opposed to drug use. Nor can a doctor deny a blood transfusion to a woman who lost blood in a fight, even though he or she is opposed to violence. How, then, can we allow a receptionist, doctor, nurse or janitor to turn away a women seeking birth control at a clinic that provides such services just because the employee thinks premarital sex is wrong?I wish these kind of columns had the courage to argue the actual issues primarily involved rather than side matters that are either irrelevant or extremely rare. Be that as it may, forcing a doctor refer a patient to a provider that he or she knows will do the abortion or assist the suicide is to force the referring doctor to be complicit in those acts. Thus, while there certainly should be cooperation in transferring records from the original doctor to a replacement if a patient decides to go that route, no dissenting physicians should not be required ethically to participate directly or indirectly in acts that explicitly violate the Hippocratic Oath.
I don't think the Bush guidelines are the perfect answer, and as I have written, a lot more thought needs to go into who is covered and under what circumstances by the conscience issue. And as I have also written, I think a distinction needs to be made between elective and non elective procedures, as well as between offending procedures and patients.
But I do believe that if the culture of death prevails legally, we should not permit dissenting health care providers to be driven out of medicine or force facilities such as Catholic hospitals that follow contrary moral teaching to be forced to choose between violating their beliefs and closing their doors.
HT: Holy Terror
posted by Wesley J. Smith @ 12:55 PM
60 Comments
60 Comments:
Killing human beings in the unborn stage (or the born stage) is an unspeakable crime. Referring someone to someone else who commits crimes is itself a crime. This would constitute aiding and abetting a crime.
Forcing people who object to committing violent and lethal crimes against human beings (in this case abortion crimes) to commit those crimes is itself an awful crime. It is a crime against both the medical professional who is coerced and the unborn human beings whose life is destroyed.
It is morally obscene that "doctors" would argue that true doctors should be forced to commit crimes.
Whether it's crime or not, there's an obvious difference between refusing to treat a patient who is before one and needs immediate physical care and refusing to refer someone who wants abortion or birth control to someone who will do it. Is the doctor who refuses to do it the only source of referral in the world for the person? Why must s/he be "the" one to make the referral? The doctor I would trust in general would be the one who stuck to his/her guns re his/her own ethical principles regarding the sanctity of life, rather than the one who was willing to abandon them and the Hippocratic Oath along with them. Demanding that a doctor abandon his/her own principles is demanding that s/he do something harmful to her/himself, and no doctor has the right demand that anyone do that.
Ianthe: I think they want the dissenting doc to do the referral because they want everyone complicit.
What a stupid argument in the original piece. As if _anybody_ is arguing from the wrongness of premarital sex here. That is not the argument, of course. Good grief. People are so sloppy. They just think that by talking that way they can make pro-lifers look bad: "Um, you're the people who are opposed to abortion because you think premarital sex is wrong, right? Like, the woman should be punished with the pregnancy for the sex? Isn't that it?"
Sheesh.
Lydia: That wasn't sloppy. It was intentional misdirecton. Had they actually discussed the elephant in the living room, it would have made it harder for them to persuade.
Lydia: That wasn't sloppy. It was intentional misdirecton. Had they actually discussed the elephant in the living room, it would have made it harder for them to persuade.
Wesley: I think that's what they want too. My father used to say that there is no such thing as a virtuous person in a place inhabited by those who are not virtuous, because if a virtuous person walks into a place inhabited by those who are not virtuous, the latter will not allow the former to remain virtuous. I never fully understood that, but maybe it means that they consider the virtuous person a threat. If all are complicit, none can be blamed individually, or blow the whistle.
Wesley: I guess it also means that the virtuous person had better get out of there right quick. If enough did, they could start their own hospitals -- if the system would allow it. I remember a doctor newly arrived from Italy who wanted to speak up for me when I was the victim of medical malpractice and then told me that the doctor who had sponsored his coming here told him, "Mario, if you speak up against another doctor here, you will lose your license and they could put you to jail." That doctor was using methods he'd learned in Europe that helped me when ones standard and accepted here had failed (yes, there is a way to cure food allergies that cause anaphylactic reactions using sophisticated diagnostic equipment and i.v. vitamin C treatment, but not according to U.S. medicine); perhaps his sponsor was referring to that, and FDA reglations. But I still don't understand why doctors are afraid to speak out against one another. It's got to be for more reasons than professional courtesy.
Wesley: If the COD prevails legally, how will we be able not to permit doctors not to be driven out, etc.?
Wesley: If the COD prevails legally, how will we be able not to permit doctors not to be driven out, etc.?
The Hippocratic oath comes from a time when virtue was the paramount ideal. But this is a time when money is the paramount ideal and virtue is no longer taught.
Ianthe: Only if they have "choice" not to participate, as is currently the case in Oregon as an example.
Ianthe: On the other hand, your dad might have missed that sometimes the virtuous person casts such a lovely light that others follow.
I think perhaps unconsciously, we know when something is wrong and we do resent those who refuse to go along. I know I have been on both sides of that.
Wesley: I'm surprised that it's Oregon. Well they say that even a broken clock is right twice a day. But for how long? And how can it be prevented when everything else is stacked against it?
I agree about people knowing when something is wrong and resenting those who refuse to go along. I think that's what he probably meant, from the way he explained it to me. He knew that the virtuous person casts such a lovely light that others follow, and was that way himself. But real evil does seem to exist, and to prefer to accomplish its ends to allowing itself to be turned around.
You would do well to consider the facts and not take the Hippocratic Oath out of context. The Oath was written 2,500 years ago, give or take a century, and it's safe to say that the state of the medical profession and knowledge in general has progressed somewhat since then. So let's take a closer look at it. Does it trouble you that doctors no longer believe in Apollo, Asclepius, Hygieia, and Panacea --- the deities to whom the Oath requires them to swear? Do you seriously expect them to "take to witness all the gods, all the goddesses..."? With respect to abortion, the Oath only proscribes dispensing "a pessary to cause an abortion." It does not proscribe abortion per se. Granted it makes great headlines to say "doctors shouldn't be forced to violate the Hippocratic Oath" but the reality is that the Oath is an anachronism that few take seriously.
History Writer: Most patients take it seriously because they know its values protect them.
The Oath passed down the millenia and the parts about the ethical duty of a doctor to a patient and a society remained intact. Margaret Mead even wrote about it as a huge achievement
Today, to accomodate new moral views the Oath isn't taken seriously be some and/or what it was about is subjected to revisionism. But so what. Many still do take it seriously. The point is that health care professionals who continue to believe in the orthodox view of medical ethics should not be forced out by a tyranny of "choice." Nobody should be forced to choose between participating in killing (ending life) in the medical context or having to sell shoes. But your note proves my point: the culture of death brooks no dissent, eh what?
Ianthe: Oregon is wrong about assisted suicide and let doctors opt out becuase it was needed for passage of the measure.
If PAS grows in acceptance, we will see the opt outs removed--as has been tried in California.
Wesley: That is what is, in the current "health care" jargon, "concerning." How then do we not permit it?
While we're at it, why not throw out the Old Testament, too. I always did think that the Judeo-Christian ethos is what ended us up with the death culture, and that more real progress and human exceptionalism were displayed when gods were made in the image of man than when man arrogantly assumed that man is made in the image of God and that our own foibles could and should have an excuse which we invented ourselves. I'm fine with the pantheon, Apollo, and the rest of the deities named in the Hippocratic Oath, and the progress of civilization, and medicine along with it, did well as long as what they represent continued to be respected; without them, we've got the death culture and medicine that can do good but wants to be able to do harm with impunity, which is a net loss of progress. As for abortion, understanding, rather than purporting to write, history would yield the astounding revelation that that's how abortion was done at that time. But if it's old, it must have no standing and ought to have the plug pulled on it, right? As long as we're throwing out the Hippocratic Oath and the Old Testament, might as well throw out the Iliad, too; then wouldn't have to read about Thersites.
(Making gods in the image of man reflected a sense of self-worth that at the same time reflected the humility of the realization that we can't know what is beyond ourselves, with healthy skepticism, and the belief that we're good enough to deserve to live, which is the essence of the life culture; supposing that we are the image of God tries to validate us and assumes that there is something greater than us and this life, which opens the door to the notion of death as "better" than life. A useful crutch, perhaps, for those who were having a rough time back then, but my vote is with the sunlight guys who were glorying in life and actually creating things, like, oh, say, a certain approach to, and a codification of the ethics of, medicine, a science which has been around for millenia and developed techniques from way back, and all over the world, some of them superior to and more effective than what current U.S. medicine, which in its arrogance is ignorant of them, has to offer, while costing less and requiring more wisdom and skill. But why pay attention to the old stuff; how could our time possibly not be wiser than theirs in any respect.
Like "context" is irrelevant to that's how abortion was done in that time, and "progress" is independent of being based on anything. Sheesh, as we say in the context of our time.
Wesley: I don't believe that there can be such a thing as "new" moral views; that's the same relativistic approach which would ratify the death culture. Something is either moral, or it isn't; morality is by definition absolute in nature. A culture can consider certain things moral, and change around what it considers to be moral, but that doesn't change whether they moral or not, and if its values are not moral, that culture is not going to survive in the long run. The Hippocratic Oath may be under assault, but what's going on while it is proves the point.
It's a question begging-argument when the writer assumes that things like abortion and other things that people may find objectionable are considered health-care. It's not just a question of "I don't feel comfortable with this but this should be permitted," it's a question of "this should not be even considered because it isn't health care."
Bobby: That's right. It's one thing for a doctor to know how to perform an abortion which is absolutely necessary in order to save the mother's life, in which case it can be considered health care, and another for abortions that are a matter of choice to be considered health care. Similarly it's one thing for a doctor to know how to keep a patient comfortable as the patient is dying naturally, and another to assist in suicide. Those considerations are even apart from whether or not the doctor is comfortable doing an abortion or an assisted suicide. Part of the rationale of those who wanted abortion to be legalized (personally I don't believe it should even be a matter of law one way or the other) was to avoid the dangers of back-room abortions; people want what they want and they want others to give it to them, and as they wish, whether the others wish to or not; but just because it's legal doesn't mean that doctors have to do it, now, does it. There are enough doctors willing; why force the rest into compliance? Not every wants to have an abortion and every doctor should not have to provide this elective service. Someone's in an accident, a plastic surgeon may have to be called in, and to do what is needed. Someone wants a nose job or a chin tuck or a face lift, the same plastic surgeon is entitled to say I don't believe in changing someone's natural features; the person will be able to find a plastic surgeon willing to do it. If I were a doctor and someone brought me their child or teenager who wanted their ears pierced and for it to be done safely by a doctor, I'd refuse, because I don't believe in people piercing their ears or mutilating themselves in any other way; if the kid had an ear infection of course I'd treat it, and if the parent took umbrage and changed doctors, good riddance. Similarly if they wanted me to prescribe unnecessary pharmaceuticals. A doctor shouldn't be able to have a practice or work in a hospital because s/he has principles and adheres to them and does not wish to do anything other than give medical treatment? But this is the problem with current verbiage. It's not doctor, nurse, medicine now; it's "health care professional." The umbrella keeps getting wider in every respect.
In the distant past there existed many more ways to abort a fetus than simply using a pessary. Nearly every culture had its methods. Apparently the Greeks disliked the idea of pessaries, not of abortion, otherwise the Oath would have said plainly: "I will never perform an abortion." Some Supreme Court Justices have been criticized by the anti-choice crowd for reading things into the Constitution that aren't there in black and white (e.g., a right to privacy, such as that which forms the basis of Griswold v. Connecticut and Roe v. Wade). Yet here I see people trying to enlarge the interpretation of the Hippocratic Oath in much the same way. How can this be justified?
I've read it in the original Greek, and I have a pretty good understanding of what it said, what it meant, the context of the words chosen, etc. It's pretty arrogant to presume to read into it what it "otherwise" would have said, and to try to skate over it with "apparently" or to compare it with the writings of modern-day Supreme Court justices which, as a remindeder, are in a different style, time, and context.
As I've mentioned before, HW, you really do need to check in with your shrink. You're not exactly batting 1000 in your arguments here. Read up on Thersites in the waiting room.
Let us not engage in ad hominem. Thank you. Carry on.
Thank you, Wesley. She did seem to be getting carried away. I, too, have read the Hippocratic Oath in the original Greek. My undergraduate major was Classical Lit. It's always nice to meet people who've studied the classics. Perhaps lanthe came to Law the same way I did; through an appreciation of both pre-Socratic and classical philosophy. As I mentioned, one either believes that a writer said what he/she meant, or one doesn't (intentional satire and sarcasm excepted, naturally). I see nothing arrogant in taking someone's writings at face value and, as a result, concluding that if they had meant to say something else they would have said that instead. This is the point I was making with respect to the Constitution, and to law generally. When was the last time lanthe went into court and told the judge: "Your Honor, I know the statute says thus and so, but what it SHOULD say is ...." Why should it seem unreasonable or arrogant to believe that if Hippocrates had meant to say that no doctor should EVER perform an abortion, he would have said exactly that? Naturally I regret that my arguments don't "bat 1000" on lanthe's scale. But then neither do anyone else's. We are, after all, "imperfect, fallen humans."
Wesley, you write: "we should not permit dissenting health care providers to be driven out of medicine or force facilities such as Catholic hospitals that follow contrary moral teaching to be forced to choose between violating their beliefs and closing their doors."
I agree, and I appreciate your position philosophically, but as a practical matter where shall we draw a line? Or should we draw one at all? The practice of medicine certainly has profound ethical implications. But how about the corner pharmacy? The pharmacist is subordinate to the physician, in that he is forbidden to prescribe, and duty-bound to fill the physician's prescriptions with 100% accuracy. Does his position as a shopkeeper (albeit a highly specialized one) allow him to second-guess the physician on moral grounds? What if the drug prescribed is both legal and prescribed by the physician in his best professional judgment? How can he in good conscience NOT dispense it? Would you support his refusal to dispense a lawfully prescribed contraceptive simply because he doesn't personally believe in birth control? At what point might we suggest to him that his moral reservations might make it desirable for him to seek some other livelihood? And what of other professions? Should the local undertaker turn away a family because he doesn't believe in cremation? Should the bus driver pass up an obese passenger because he sincerely believes it would be better for his health if he walked? OK, perhaps the last example was reductio ad absurdum, but I think you see my point when I ask what limitations, if any, on "the conscience objection" should be imposed.
Wesley. Ok, and I'm glad you pointed out that patients go to doctors feeling safe because they know that the doctor has taken the Hippocratic Oath.
HW: No that is not why I went to law school. In fact being a classicist made the idea of doing that distasteful to me for years before I went. I remember a discussion about the wording re pessary in graduate school but the context makes it clear that it meant abortion. There were other means of abortion at that time in that culture, which have remained in use into the 20th century in at least some parts of Greece, but they were herbal, and available without a doctor's help. Aside from that, it makes no more sense to say that the oath would say a particular thing if it meant a particular thing over two millenia ago than it would to read something into a statute today, plus they are two different types of writing written for two different purposes in two different contexts at two different times over two millenia apart. Having studied classics does not necessarily mean that one has learned what the study is meant to impart, either. The doctor who seems to have been a driving force behind my mother's involuntary euthanasia was very full of himself over having been a classics major and told me, when I asked how he had become the head of the hospital's ethics committee, in which capacity he, as a nephrologist, decides who gets a kidney and lives and who doesn't, and lives and thinks in a world of percentages according to risk, that it was because he is a "philosopher" because he was a classics major. The same guy told me when I asked him what if it was his mother that he didn't have to answer that question because he already knows what his mother wants and that she had told him that she has had a good life and would not want life support; I had to ask him whether I was his sister and he didn't get it; somehow, being a classics major had not been enough for him to acquire critical reasoning ability, though it certainly did seem to have fed his arrogance. First he was sure, a month into her hospitalization, that she was going to die the next week but threatened me with "court" if I didn't agree to a peg tube which her "living will" said she wouldn't want and to which I'd already agreed a week before and was waiting for the consent form, and told me he didn't understand her advanced directive and "didn't like" it and was going to have to read it again; a few weeks later, he came up to the i.c.u., sat and studied her chart for half an hour, examined her, and told me that she was dying and all her major organs were failing and that he was going to convene a meeting of experts on all the major organs of the body and go to court to have me removed as health care proxy, and that he still didn't understand her "living will" and was going to read it again (all this in the same conversation), and stormed off with fury on his face when I stood up for her actual current wishes to remain on life support; none of her major organs was even close to failing and none ever did, and the i.c.u. head had to straighten him out. Eight months later, he day before her murder, I saw him in the corridor by chance and asked him how she could have been in the hospital for over nine months and only now, after having declared her brain dead in affidavit after I won two appellate motions as part of an effort to get their way and then having to reverse themselves in affidavit because she was not, they discovered that she had cancer, he said to me, "Oh, I saw the nodule in her lung last November," and when I asked why he hadn't told me then, he replied, "Because I didn't think I had to tell you. I didn't think it was important. I knew she was going to die anyway." Well, she did die, and against her current actual wishes, but only because they removed her ventilator, despite the fear on her face, immediately after having security guards who had tears in their eyes physically drag me out of the room and down the hall, because of the disorganization, incompetence, negligence, and arrogance of a hospital whose "ethics committee" chairman had been a classics major but never learned the things that the study of classics is meant to impart. In fact my mother was afraid of the guy and read his character accurately early on in the hospitalization. I'd learned he'd been a classics major in one of the "meetings" the hospital was constantly calling to try to get me to override her desire, which was indicated on her "living will," not to be DNR, when in frustration I said hasn't anyone here read Suetonius and the story of Nero's mother (where when the boat designed to fall apart in the water does and Nero's henchmen try to drown her she picks up pieces of the boat and hits them over the head with it), that's my mother's nature, she's a survivor and a fighter and wants to live, and he said he could't believe anyone else was in the room who had; but as it turned out, it wasn't enough that he had read it. There is a lesson in there about "living wills," too, but that hospital has done likewise to older people on ventilators who wanted to continue to live on them, and who did not have "living wills," and for whom no "living will" was even purported to exist. This is the kind of thing that really goes on, and trust in doctors and modern medicine at a time when the Hippocratic Oath is devalued is not wise. Socrates was right about wisdom being founded in knowing that one does not know everything, and that comes out to the same thing as the first error of logical reasoning being assuming anything.
Wesley: I think that the very necessity of the existence of the Bush guidelines, or any other guidelines that come from the government, is the problem, and part of why they can't be adequate. The guidelines ought to come from within the medical profession itself, and they don't because in an atmosphere in which the Hippocratic Oath is devalued, the medical profession is no longer based in ethics and morality, of which the very existence of a field called "bioethics" is a telling symptom. This is supposed to be a free society, and a free market; a pharmacist, a doctor, anyone should be able to follow their own conscience, and the customer find what they want, as long as it is legal, from whoever is willing to provide it. The issue goes much deeper than abortion or birth control, which again are mere symptoms of the fundamental problem of lack of ethics, morality, and, underlying those, sound thinking and priorityies. Money has become the first priority; parents' ambitions since the last world war were for their children to be doctors or lawyers and have a certain status and make a good living, rather than for them simply to be good at whatever they did; the country has ended up with all kinds of social ills and not producing what we now import from China, with everyone having to have a college education and then unhappily "settling" for careers in which they could make a living, myriad magazines and publications, the law and medicine, formerly professions, now industries and businesses, etc. because everyone just feels too important and too entitled to do actual work, and incompetence everywhere as the acceptable standard. Then the government and religion get involved where they should not belong and there is more divisiveness over that. The medical profession doesn't set proper standards for itself any more because it doesn't feel it has to and those who go into it were never taught values in the first place. No one feels responsible for anything, people don't even know that they don't know what they should know, and the more the government gets involved the worse it gets. I don't see any way to straighten it out except for people to wake up and start thinking and regain a sense of themselves and stop going along with the program, and demand that the medical profession abide by the Hippocratic Oath, refuse to patronize pharmaceutical and insurance companies, stop wanting "cures" and trusting "researchers," etc. Again, ending animal experimentation would enable a lot of this to happen, and that's not for the sake of the other animals, it's for our own sake. Things simply cannot go on the way they are, religion can't fix it, the government will only make it worse, people have to grow up, and something radical has to be tried to turn things around and to force people to think and to stand on their own two feet and actually be free, which is what this country is supposed to be all about. It would solve some economic problems and free up "resources" for actual medical care, by doctors who would become more humane, as well. A president who said no more animal experimentation would do us a lot more good, and do more to improve the state of medical care and the respect for ethics without which it cannot do no harm, than one who wants to nationalize "health care" and just sent a bunch of money abroad for the purpose of encouraging abortion as a means of birth control, that's for sure.
It seems to me that the focus on the Hippocratic Oath's meaning wrt "prescribe a pessary" is a red herring; I think that invoking the Hippocratic Oath is rather to invoke its historical meaning as an oath to "Do no harm."
Doctors don't all take the oath anymore; this is obviously because ethical systems vary so much in a pluralistic culture. They are free to take that oath, another, or none.
So, really, conscience clauses are not (or, should not be) to uphold one interpretation of that Oath, but rather to allow as much as possible for the ethical understandings that dosctors will have when approaching "respect for all life," in the words of the Declaration of Geneva.
The Bush-enacted law was well-intentioned, but somewhat sloppy in that it needs to be more clear about the difference between action and inaction, wherein the issue for doctors really lies.
Also, I was not able to read the whole thing again (that link from your December 18 post doesn't go to it anymore, Wesley) but I am unsure if it only applies to certain health care workers, or it could be construed to include, well, janitors, as those fearmongers from the Sun editorial said.
Also, lanthe, the guidelines ideally would come from the medical community. But history, especially in the last few decades, shows us how prone that community is to fads and to the worship of science as the cure for everything.
They are just as capable of being clannish, bigoted and grossly self-righteous as any other group of humans; perhaps moreso because of the lifeanddeath nature of the work, and the intellectual shift of the last 100 years toward a myopia of science: "Whatever we just discovered has got to be the final piece!! Let's go with that!!!"
I always think of the practice of Obstetrics to epitomize the mind-numbing backwardness of medical trends in "Ethics" and practice. There, you can see it all: paternalism, sexism, resistance to change, and a desire to arrange things for convenience despite scientific proof otherwise, not to mention the witch hunt that will follow if you dissent (as some doctor friends have told me about the threats and sabatoge they received for refusing to perform abortions, for example.)
Holyrerror: You're right; that's exactly what it is, a red herring. I didn't realize that doctors no longer have to take the Hippocratic oath and they all don't do that. Well, no wonder we've got what we've got now. I agree about obstetrics epitomizing it. They're also capable of being clannish, greedy, self-righteous and bigoted, and moreso, because of the way society treats them, and arrogance is built into the whole thing. From what I've seen, a lot of them are simply quite unintelligent, on top of everything else, and rather dysfunctional in real life. So Geneva said "respect all life," did it? If that doesn't proscribe vivisection, I don't know what does. And if there can be a Geneva decree, there can be an oath that incorporates the Hippocratic Oath and whatever oaths there may be that other cultures have devised for the same purpose, or a worldwide institutionalization of the Hippocratic Oath, that every doctor in the world has to take. As long as God forbid it isn't written in Switzerland, Holland, England, Scotland, China, Oregon, Montana, Washington State, Texas, Virginia, Cold Spring Harbor...yeah, maybe they'd better stick with the Hippocratic one we've already got, which worked fine for long enough. Maybe Malaysia, where they put those who attempt suicide in jail and try to straighten them out, would be a good place to look for further input...
(I meant holyterror)
They don't even have to take an OATH any more? How universally do patients and their families know this? Ye gods and little fishes...and no wonder.
What "ethical systems vary so much in a pluralistic culture"? It's ok to lie, cheat, steal, kill in some parts of a pluralistic culture? It's ok for doctors to do harm in some parts of a pluralistic culture? The value of life means different things in a pluralistic culture? No wonder we've got medical murder. This is enough to make a person want to go live in the woods with a barbed wire fence, a dog, a still, and a shotgun. They don't all have to take an OATH now? Why not just let them get their paychecks on Wall Street?
Wesley, could a case be made by Lanthe (and us) against this misnamed "ethics" chairman?
In my opinion, anyone who is labelled as an ethics expert ought to be looked at with suspicion.
Lanthe, by differing ethics in a pluralistic society, I was referring to the fact that there are different ways to define personhood, and also different weights placed on the value of the developing fetus vs the mother.
Our culture has not been allowed to really hash out in discussion, or try to reach any consensus on the fetus' personhood in the law. AS it stands now, it was decided for us, and powerful groups push for the continuation of the idea that there is no way the fetus ever takes priority, legally, over the mother.
Now, when you get down to the individual level, this is a MAJOR philosophical problem, because people who are against abortion are free to not have them... in a culture of exchange and interaction the helath care workers are going to have to be involved in other people's lives. And there will be differing understandings of the life inside the mother. For some it will be that it is a potential life whose value is second to the desires of the mother, and for some it will be that it's a unique life, and to deliberately end it for any reason other than to stop the woman from dying very soon, is murder.
Holyterror: Yes they should, and from what I've seen, a lot of them would not pass the test. That was a very good explanation of pluralistic society (thanks) and of the philosophical problem that has been foisted upon us. Someone belonging to the same religion I was born into once told me that in that religion, abortion is considered to be a matter between the woman and her priest, and not being religious myself, I've never sought out verification on whether that's true, but it seems to me that that's the wisest approach to the matter, rather than having an entire society weigh in on it and its becoming a matter of law, with all the attendant and concommitant problems we now have to deal with that make it even more difficult to preserve a sense of the value of life.
Not that every woman has a priest of that religion to turn to, but every woman does have a conscience at some level, and the experience of living in a woman's body, and if the rest of the world stuck its nose out of the matter, she would be more able to feel free to make the decision appropriate to the circumstances, guided by her own natural instincts, and seek out guidance, if needed, that suited her as an individual. No one, not parents, not religion, not society, has any more right to intrude on her decision than the medical establishment has the right to insist that any doctor or "health care provider" violate their own individual conscience -- or to have abandoned the principle of "First, do no harm" and the practice of every doctor having had to swear an oath to that effect. Left to their own devices, in a society that was in better order, very few women would choose abortion of their own accord; it's not physically or emotionally good for us and the natural instinct is to bear the child, unless the father was a poor choice of breeding partner to whose gene pool the mother would prefer her child not belong (and she of all people knows this, her having made a mistake being beside the point at that point) or foisted on her involuntarily, etc.; even then she may choose to bear the child rather than abort it. The child is going to have the parents' genes, and I'm not sure that even Nature would want a mother whose own choice is to abort to be reproduced. It's the devaluation of women in the first place that led to the prevalence of abortion and its becoming a social issue, at the same time that the fundamental ethical values of medicine have ended up being set aside, life (itself which now can be "created" in the i.v.f. lab) has become devalued, and the COD has taken hold.
And when a woman chooses a doctor, which she could do more easily in a society where insurance companies didn't interfere with that process, she could choose one whose views concerning birth control were consistent with her own; in a more healthy society there would not be pressure on the very young to behave in a way that called for birth control (societal pressures and behavior that is to the advantage of pharmaceutical companies, of course) before they were able to choose what doctor to go to, either. Abortion need not, either, necessarily require the participation of a doctor; the "wonders of science" are giving us more and more immediate after-the-fact means of birth control which already existed in natural forms that were ignored by the scientific-medical-industrial complex. In any event, these issues can't be resolved in isolation; the entire society within which they have arisen has to be straightened out in order for them to fall into place and be dealt with rationally, without the ill-defined "pro-life" v. "pro-choice" battle that is a red herring and a smokescreen for much deeper problems that threaten life even for those already alive and who are able to express choice to live that are nonetheless disrepected. Making those who can't speak for themselves the focal point of the battle merely distracts attention and respect from those who can, and if they aren't respected, how do we expect to be able to defend those who can't? I think the focus on abortion as a life issue has things backwards, and I'm not sure that that is not the result of a deliberate tactic on the part of the "pro-choicers," and that "pro-lifers" haven't just taken the bait, because the fish now caught in the net are not just embryoes and foetuses. It's even moved beyond the elderly and the disabled to doctors themselves.
lanthe. I was deeply moved by your experiences during your mother's final illness. Although I don't condone doctors "playing God" I know that there are times when the availability of resources makes some very tough calls necessary. While in military service during the Vietnam War I was exposed to the concept of triage. You are probably familiar with the term; but for the benefit of readers who may not be, let me explain. Triage is a method by which medical care is ethically rationed during mass casualty situations. Casualties are classified as objectively as possible under the circumstances as: (a) those who are going to die no matter what the medical intervention; (b) those whose injuries are sufficiently minor that they can wait to receive medical care without endangering them, and; (c) those for whom immediate medical intervention means the difference between life and death. The third group is treated first, and the second group next. Those who are going to die regardless are made comfortable, given pain-killers, and left. The concept of triage is applied in most hospital emergency rooms, which accounts for someone with a broken wrist having to wait for an hour while another, whose heart is fibrillating, is treated immediately on admittance. The ethical consideration of triage are that all patients are equal, and since medical treatment is not unlimited that which is available must be dispensed in a rational manner. Thus I can reasonably expect that if Bill Gates comes into my hospital with a cut finger and offers to build a new wing if they will see him first and let him get back to the office, the doctors on duty will make him wait his turn as against someone whose life is hanging in the balance. Mind, I am not trying to condone the decisions made in your mother's case which, by your account, seem to have been motivated more by animus than by reason. But people often must compete for organ transplants, dialysis machine time and hospital facilities. You may recall that several years ago baseball great Mickey Mantle, a former alcoholic who had ruined his liver, was given a liver transplant but died shortly afterward. At that time the question was raised as to whether he was given the transplant because he was Mickey Mantle, or because he was really a good candidate for it. The fact remains that someone else on the transplant list DIDN'T get the liver that appears to have been wasted on Mr. Mantle. Should the reason he needed a transplant --- the result of uncontrolled alcohol consumption --- have been a consideration? Someone, or some group of "ethicists" obviously made the call. How DO we resolve these issues? Should we try to establish a cut-and-dried set of eligibility criteria to determine when and if patients should receive particular levels of medical care, or should we treat all patients equally regardless of prognosis and despite the cost and scarcity of resources? If I may borrow a phrase from our new President, this is a matter that's "above my pay grade." What do you think about it?
HW: I do appreciate your understanding of what I've described of what went on in my mother's situation, and I know you wouldn't want it to happen to anyone. One of the reasons I've been adamant in addressing you is that it sounds from what you've said here as if you weren't aware of what can happen re "living wills," in a hospital, especially to an older person, etc. -- which most people are not, and which I certainly wasn't. I'm familiar with the concept of triage, in war and in hospitals, and thank you for taking the time to explain it.
What happened in my mother's case was not triage- or cost-related, unfortunately, though I agree that overall policy makes the elderly not the first priority in triage and cost-consideration terms; I disagree that that should be the case, since any system that triages re the most vulnerable is apt to be less careful in general than it should be, which in turn leads to unnecessary use of resources in all respects.
She was in the hospital for over nine months, with her "excellent" insurance covering everything (my father, who had the same coverage, got put through hell for months in two different teaching hospitals, while writing briefs with an i.v. in his arm; when the patient's insurance covers a long stay, there is less incentive for the hospital to get them well and out the door quickly, and on top of that teaching hospitals often seem to be disorganized and to make more mistakes and cause longer stays), and there were other facilities to which she could have gone, and there were treatments she could have received which she was denied and that would have gotten her out of there a lot sooner and in one piece. The hospital simply did not want to let her out alive, and had I known its nature, and that it has had the habit for decades of not letting patients it has messed up out alive for the world to see what it has done to them, unless it can shunt them into a facility it owns where they can die conveniently out of sight of the community, obviously I never would have taken her there, where "the best" was available.
What happened to her has happened to other older people, there and in other hospitals, but this was a particularly egregious case in a particularly egregious hospital that has been getting away with things it shouldn't get away with for far too long. She went in with a bladder-related infection, and never should have ended up on a vent, or needing to stay in hospital for all that time, taking up a bed, or using life-support resources, in the first place. It was the hospital's disorganization, carelessness, gross negligence, arrogance, and self-centeredness and self-interest, coupled with an anti-geriatric attitude, that caused her to end up on a vent in the first place, and that has happened to older people there, as elsewhere, over and over when it need not have.
Yes there is a limit to the amount of available resources, but the way to address that problem is not to cause them to have to be used as the result of negligence in the first place. That is the most effective way to address the cost and resource problem, but it seems to require too much intelligence and too much work for hospitals to comprehend and implement such a solution.
I've been informed by the Center for Disability Rights that that hospital has pulled the same stunt over and over, and is "spiteful"; one doesn't expect such things from a hospital, which is supposed to be a place of care, but institutions are insular places where strange things can go on; I know of an instance in a hospital in Manhattan in which, in order to get rid of a particular sought-after doctor who had a habit of breaking the hospital's rules, the hospital actually set things up so that a patient would be grievously injured, which happened, with life-long results and terrible consequences for the family as well. We don't think in terms of these kinds of things being able to happen when we trust the medical establishment with our lives, but they do, and what can happen can be so far beyond the pale of what we have a right to expect that we can't believe it until we actually see it. Plus, until the most recent head of the NYS dept. of health, who immediately made an issue of it, was appointed, that department has been notoriously slow, often taking decades, to discipline doctors, revoke licenses, etc. Plus, some institutions exert influence where we wouldn't expect them to, at first thought, in their communities and politically, financially, as employers, etc.
The Center for Disability Rights, having seen this scenario before, also told me, "They know you must be getting tired." The hospital was willing to put the family member who was the patient's chosen health care proxy through hell, deliberately, in order to make it more difficult to prevail against it and get its way, and there is no justification for that. It didn't say right out, look, these are our priorities; it couldn't, anyway, because its own errors had caused her to be using resources she shouldn't have needed, and in any event the issue wasn't resources, which it itself was causing to need to be employed; it was simply an institution insisting on getting its way via underhanded and vicious methods which, unfortunately, go hand in hand with the backwards priorities that put "cost" ahead of the value and rights of the patient and resort to "ethics committees" to succeed in its agenda.
This same hospital is the home base of a leading proponent of assisted suicide, and got rid of its geriatric program a few years ago, swallowed up one of the other hospitals in town that people loved, and bought another one that until it did had been a good place for geriatrics to go and now behaves the same way as this one does toward them. My mother's long-time internist is affiliated with it and told her some years ago, when she asked about her longevity, that she had already had her longevity, began to ignore her concerns outright some months before she went to hospital, and acted in such a bizarre manner that it appeared that he wanted her to die. She didn't want to, her desire to live was at odds the hospital's agenda, and no one who seeks medical care deserves to be at the mercy of a hospital's agenda, costs or no costs, triage or no triage, and if it has such an agenda it should be upfront about it.
Such an agenda, from what I've seen, goes hand in hand with the kind of carelessness that should preclude a hospital even from being able to take in patients; once priorities are not in proper order, everything else is substandard as well. Those who work at the hospital know things are not right there; those who run the place call the tune and it is a bullying institution that those in town who know of it refer to as "sick." And it is, as is the state of medicine overall these days; this place is riding the same train as the rest, and gets away with what it does because, as it knows full well, people give medicine respect and trust that a profession that has abandoned the necessity of taking an oath to do no harm hardly continues to deserve. But how many people know that doctors don't even have to take the oath any more? I didn't, until yesterday.
An attending too concerned, like the rest of them, for his job to be supportive of my mother's rights and wishes had come there a year before from Johns Hopkins and told me that this hospital is very similar to Johns Hopkins, which did not surprise me; I've long suspected that that leading institution is responsible to a significant extent for the parlous state of the medical establishment in this country. My late uncle was trained at Johns Hopkins and used to tell the story of how the professor in his obstetrics course told him always to make sure to deliver babies by appointment for the sake of his own convenience. The hospital I'm talking about, which trained the current heads of Harvard and Yale medical schools, operates as if the concerns of the doctors and those it is training and its staff in general are more important than those of its patients.
This is what happens when priorities get out of whack, and putting money first is the first step in priorities getting out of whack. It's not an overly crowded hospital, and it's not a battlefield, and there is no reason my mother, and many others, could not have left it alive; it's just a matter of how the place regards itself and does things, and I wasn't surprised to learn, too late, in the course of my own research, that it gets sued much more frequently than the leading hospitals in Manhattan, which receive their share of justified malpractice suits, do.
This hospital, of course, is on the "ethics," "dispense with the elderly," "end-of-life," "assisted suicide," and "resources" bandwagon, and egregious or not, that it remains in operation and people don't know what they've become the victim of until it's to late is symptomatic of the prevailing attitudes in hospitals and medicine today, all over, and people are too vulnerable when they are admitted to or take someone to a hospital, and then have to battle the hospital for their very life, through one act of negligence after another, to be able do enough about it, and the survivors are exhausted afterwards, as the institution knows full well that they will be. In fact, this one is rated as one of the 100 best hospitals in the world, and is focused on expanding and improving its high standing even further, despite its patient care problems.
The problem is not as much cost-and-resource as it is arrogance and attitude, and those this one trains are superb residents who go on to leading institutions all over the country. The residents, to their credit, didn't like what was going on, but were afraid to speak up; the attendings went along with the hospital administration's agenda, and that's the way institutions work. The patient relations guy obviously agreed when I told him that the whole place could be straightened out in five minutes via a change in attitude and organization, but it's an institution on which he and everyone else there depend for employment, and once policy is set, no matter how many people there know it's wrong, no one can do anything about it. In this economy, such policies, and such situations, are only going to get worse.
I've lost count of how many times a resident or an attending who had never even seen my mother before came into her room and said to me, deliberately in her hearing, "I don't think she'll make it through the night," from the very beginning, and I'd drag them out into the hall and tell them not to say such a thing in her hearing, and they'd say, "The thinking is that they should know," and when I'd say well then why not tell her direct rather than make her overhear it, they'd go sheepish. This went on for months despite it being obvious that she was not about to leave the planet; they were taught to do this by the same "star" at the hospital who is a leading proponent of assisted suicide and a "pioneer" of palliative care, which has replaced geriatric care at that hospital. Nurses and attendings would come into the room and deliberately say things intended to break her spirit and make her give up and die. "Cost" and "triage" considerations do not justify that kind of behavior; nothing does; she wouldn't even still have been there if they had treated her competently. It's one thing to make the elderly less of a priority, if there is only one ventilator available and a 20-year-old with a good chance of survival has just come in by helicopter, and quite another to cause an older person to have to stay in hospital when they shouldn't have had to, find a legal means of preventing their leaving and going to another institution (which would discover their errors) as they wish to, mistreat them, and try to get them to leave life when they don't want to, via outright abuse and via negligence that constitutes manslaughter at the very least. They were too slick and practiced at what they were doing for it to have been the first time, either.
But that is what is in store for the elderly on an even wider scale than it is already if the culture of death is not stopped, and living wills, assisted suicide, etc., which on their face seem cut and dried, and might be in a different atmosphere than the one that actually exists, are more dangerous than people think. What seems rational, and what we may think can be trusted, does not necessarily play out rationally and in a trustworthy manner in the current atmosphere, aside from no one being able to know exactly what the circumstances will be, and what one will actually want, at the time the document comes into play and doctors who are strangers and not necessarily as competent or ethical as we have a right to expect them to be, and who work in an institution which has made cost a priority and divorced themselves from the obligation to be ethical by delegating ethics to committees that follow the hospital's agenda, have our lives in their hands.
An expert who lives in the "end-of-life" world told me flat out that the purpose of living wills was to get rid of the elderly and the disabled in order to save costs. That may or may not be ok with you, and you may be willing for whatever reason to be a willing participant in that syndrome, but it's not with me, especially after what I've seen happen, and if I were to tell you the circumstances under which my mother ended up being purported to have an advanced directive that should be followed, you'd know how much even more scary and untrustworthy the scenario can be when a hospital is involved. The Hastings Institute in fact released a report a few years ago that concluded that these documents are not a good idea because of the rapidity with which medical technology and its innovations are advancing. If the existence of these documents, and of legalized assisted suicide, did not pose a threat to those who want to continue to live, it would be different, but unfortunately, they do, especially in a society in which costs are a consideration.
What I think is that cost, and scarcity of resources, would not be the issues they are if certain radical and absolutely essential changes were made in "the health care system" and in society as well, and if people got out of the habit of thinking of money and costs first. Of course all patients should be treated equally. This is not the chaos of a battlefield; it is society in peacetime which the horrors of the battlefield are endured in order to protect, and it cannot function in a way which benefits its members unless its priorities are in proper order. A society exists so that people can be able to live, and if ethics and morality, and the civil rights of every one of its people, which don't stop at the hospital door, are not its first priority, the whole thing is going to collapse, which is what we've got going on now.
Without honesty, competence, ethics, and discipline at the top of the list, priorities fail no matter what they are. Money is a servant which only serves us well when we adhere to those priorities and keep it in is proper place. Consider the number of malpractice cases that get filed, and that most victims of malpractice don't even file suit. Yes, doctors are only human and mistakes happen despite their best efforts, and we can't expect them to be perfect. But we can, and have a right to (after all, our lives are in their hands and we pay them), expect them to be ethical and to put the patients' concerns ahead of their own, and for hospitals to be well-organized, and for care to be careful and competent rather than careless, sloppy, and negligent.
The most careful, hard-working, and competent doctor can't get a patient out of a hospital in one piece and have time for others patients, or even keep his or her job at that hospital, when the whole institution is disorganized, and has its priorities upside-down, and is run by a panoply of myriad superfluous administrators, social workers, billing specialists, et al. whose focus is handling insurance payments, etc., and with insurance companies dictating what care can be given, etc. Similarly doctors' offices, where on top of everything else pharmaceutical salesmen constantly hound physicians who are additionally stressed by the interference of insurance companies and whose time they know full well is scarce. No wonder doctors as well as patients are unhappy. How can they, or medicine itself, think of themselves in terms of profession when business aspects have taken over rather than remaining in their rightful subservient place, let alone do the job patients have a right to expect them to do.
Costs would come down, and money freed up, and resources become less "scarce," if insurance companies didn't run the show. Then there are the pharmaceutical companies sticking their nose into the proceedings as well. Before we had the current system, hospitals didn't go out of business or get swallowed up into "health care corporations," nuns, among others, knew how to run a good hospital (it's the element of discipline and responsibility that's been lost along with those generations), doctors and hospitals didn't have to pay numerous staff to be professional billers and deal with insurance companies, etc.
Another way to save costs is to spend the vast amount of money, much of it wasted, that now goes to research on animals on actually providing medical care, and slow down with the quest for "advances," at least for a time, while things are reorganizing on better foundations, and stop giving "researchers" the free rein they have now. If they have to end up selling shoes, whether they like it or not, that's better than patients being the victims of medical negligence.
Another way is to stop trusting the pharmaceutical companies as we do; stopping animal research would slow them down as well, and we can't keep drugging everyone the way we are now without more and more disastrous results. The callousness that doctors and scientists acquire as the result of doing animal research is another thing that has to go, along with the belief that they are entitled to take up medicine as a profession in order to receive status and financial reward, and don't even have to take an oath to do no harm. Sure they take money from pharmaceutical companies and are unethical about it; they went to medical school thinking that being a doctor would entitle them to make money and didn't even have to take an oath.
Research now done for reasons of ambition should be done instead into methods used in other parts of the world that are better and more sophisticated than our own, of which U.S. medicine is ignorant and which it ignores. That, too, would end up both improving care and saving costs. They've got things in Germany, Switzerland, Russia, France, and Italy that are far superior to what our "best in the world" medicine and doctors never even have heard of, and as the world grows smaller, we should be learning about and adopting what they've got, and they should be doing the same re what we've got that they don't. That requires a revamping of the FDA, which could use it anyway, and which shouldn't be impossible to accomplish. I don't see how this new president we've got shouldn't and wouldn't like that, either.
The difference has to begin in medical education as well as elsewhere in the medical establishment. Doctors have to regain ethics, and along with that their status and ability to be trusted, and we can't have this "health care professional" nonsense any more. Whatever one's job is in medicine, it should be called that. I don't know what we're going to do with all these females who have to be in the work force and if they don't become real estate agents go to work in "social services," insurance companies, pharmaceutical p.r. and sales departments, doctors' offices and hospitals as "medical billing specialists," etc.; their needing jobs is part of what caused this whole mess. But surely there are other things they can do, and would probably enjoy more, in a sounder and better-functioning society. We can always use more teachers, among other things. How to wean people off dependency on health insurance is another problem. I don't care what happens to the people who have created the institutions -- insurance, the pharmaceutical industry, hospitals, among others -- that have created the mess we've got now, but again, better they should end up selling shoes than that the rest of us be at their mercy. Medicine, along with the law, has to stop thinking of itself as a business and return to considering itself a profession, or none of this can get anywhere.
An suggestion was posted on SHS that the uninsured, who are now, if what we've been told in the media constantly, almost as large a percentage of the population as the percentage of voters that elected Obama, begin a grass-roots "underground" health care network which can be designed to do what medical care is supposed to do. I think that's a great idea. Just as "mainstream" medicine has begun to incorporate "alternative" methods that patients have found successful land prefer, with enough people finding another way to get care rather than feeling desperate without the insurance that would allow them to patronize the "medical establishment," this might help the latter to make some changes as well. Those who want refugees and illegal immigrants to be here should make it their business to make sure that they get medical care through such an alternative system, rather than using the resources of hospitals they cannot pay and and government services paid for by the taxes of those who cannot even get those services themselves. Or else send them back and do the work that "no one wants to do" here ourselves. It has to be clear that their own countries are going to have to take care of them and that they cannot get free care if they come here. That's another way to alleviate part of the "costs" and "resources" problem. Personally I think we should also cut off trade with China; our backbone has deserted us; they sent us product that caused some of our precious pets, and we put up with it? We're better off making the products we import from them ourselves.
All these things require a fundamental change in society and attitudes and a re-emphasis on values and discipline. We need to focus otherwise than we have been doing. The busier we are actually doing things than whining, and the less lazy we are able to be, the happier we will be, and that would help to alleviate the desire for assisted suicide, which now of all times we just can't afford to legalize. The good thing about the financial crisis the country seems to be in is that openings for such change to become possible might appear. What's scary is that no one seems to be willing to take responsibility for anything (which is how we got into this mess in the first place), and who is supposed to turn things around if the President of the United States terms things "above my pay grade"? What, he wants a salary raise? Who's above his pay grade? Hillary? The Skull and Bones? Wall Street? The mob? Who? It's not a good sign, that he even said that. But if people really want change, they need to be willing to have the courage and confidence to make it happen, the changes needed are radical ones, and these are the changes that I think are needed, along with an acknowledged priority of every patient having a right to the best possible care, which would be more possible if these changes, which would address the cost problem, took place. I'm not saying that they could happen easily, but I am saying that they are necessary. That's my answer to your question.
p.s. HW, the expectation that Bill Gates will have to wait his turn is indeed reasonable, but unfortunately, the way things really happen, from what I've seen in other situations from the one I've been describing here, he may not have to. I believe that Mickey Mantle got the liver because he was Mickey Mantle, too. There is no way that he wasn't going to get it in the U.S.A., and that ethics committee worked for a hospital that wasn't about to risk the negative publicity of Mickey Mantle dying because he didn't get a liver whether it was going to do any good or not; it was bad enough that he was going to die there; they didn't want the whole country saying that they'd let him down, and they didn't want a lawsuit filed by the estate of a national baseball hero, either. (My grandfather used to say that overenthusiasm for baseball, which was the sport of the time, was going to ruin the American character, and in this context he might have been on to something.) The kind of character on a hospital's part which Socrates and Republican are held up as ideal examples might have given the "nobody" with a better chance to live, and at Mantle's own behest (not that anyone should be expected to be willing to die, but it would have obviated the necessity for an ethics committee), but that sort of thing is no longer in fashion, which of course I've long been saying is the result of Latin falling out of favor as a subject taught in high schools at the same time "science" became the priority. All that is along the lines of the same principle as "cost considerations," having become first priority, too, because this is a society which accepts money and success as its first priority (and hence the problems with the ambition-and-greed-laden institution of medical research), all the way down the line, and the kind of values our high school Latin teachers, among others, taught us have gone out the window. Latin isn't even taught in the way that makes it most valuable any more; the new genre of texts that came in in the 70s spoon-feed it and try to keep the kids interested with stories about everyday life, etc.; the latter is fine as icing on the cake after what the study is meant to teach has been taught, but the profession caved because of changes in society. I remember some of my students, and these were very bright college sophomores and juniors, who presumably had studied history, which must have been taught Lord only knows how, in high school, asking, "Did they really do that? Did they really kill people in wars?" At first I thought they were kidding, but they weren't. With even the best and the brightest that far at sea, it's not possible to expect anything to proceed as we have a reasonable right to expect it to any more. If there really was only one liver, of course the younger person should have been first in line, if there are cut and dried rules. But those kinds of cut and dried rules, and the existence of ethics committees, lead to problems when it's not a matter of only one liver on earth and two people to choose between, which it usually isn't. What faces the elderly and the disabled is not really the question of "resources," but a mind-set which uses "resources" as an excuse, and that mindset goes along with the lack of standards that gives negligence a free pass as a result of medical arrogance. You're a veteran; if you and someone else your own age, or younger, who isn't, and shirked his duty to serve his country, needs a liver, and has a better chance of survival, to whom should it go? My guess is that you would say to the other guy, as a veteran would be apt to. But I'd prefer it go to the veteran as a matter of respect, just as I believe the elderly deserve extra respect, while someone(s) sitting on an "ethics committee" who idolizes John Lennon, opposed the Vietnam war, and was sitting around smoking pot, perhaps while doing a sit-in in the dean's office, or fleeing to Canada while you were answering the call to duty, might vote against your getting it. That's part of the problem with "ethics committees"; all kinds of other things that don't belong there end up getting into the mix. My guess in my mother's case is that they didn't want it found out that they'd ignored the incipient cancer, which they were only forced to "find" and reveal information about when they weren't getting their way in court and their brain-death gambit failed. Shocking, but it happened, the hospital has been doing that re cancer diagnoses in the elderly as a matter of course and getting away with it for years, and we can't trust what doctors and hospitals say, or their "ethics committees" either. What puzzles me is how, it having been Mickey Mantle, they couldn't find another liver for him anywhere. That would have taken some extra effort, and doctors and hospitals are so arrogant that they don't care who it is, they aren't willing to go the extra mile and depart from their own habitual ways of doing things; with the stress of the situation in the mix, it was even harder for his family to get them to do that. They'd have been much better off doing it that way, of course, than ending up with all that publicity and controversy. But they aren't trained to think, their judgement is lousy in non-medical terms, and the minute they think they may be in danger of a lawsuit and/or bad p.r., they make that their first priority, ahead of ethics. I wouldn't be surprised if the ethics' committee's "decision" in that situation was preceded by a meeting with hospital administration, risk exposure management people, their p.r. department, their corporate board of directors, insurance people, and their attorneys who advised that the family of the "nobody" was going to be less able to sue, let alone successfully, and that in any event that suit would bring less trouble and public outcry than one by Mantle's family, and that maybe the "nobody's" family would buy some lie or other, and followed by some assiduous getting it into the media about some other thing the hospital had just done for the community, science, or something. The same hospital that murdered my mother just was in the news because OSHA had fined it heavily, and the same day made sure that the local tv news station (the same one, same reporter, that covered my mother's situation as favorably to her cause as possible, but not as well as she needed) ran a story about how it has invented a better form of laparoscopy. These institutions aren't honorable places of care any more; they're businesses, and their own interests come first as far as they are concerned, and those who sit on their boards aren't necessarily saints.
Darn, I paragraphed that and made some relevant additions, and the computer lost the connection for a moment and when it came back it had gone up without the paragraphing and other points. Apologies for the big block of print; it wasn't intentional.
I did want to add, aside from a couple of other short salient points I've now forgotten, HW, that I would not be surprised if you expected triage and everything else to be done as honorably in hospitals as it is done according to military standards. Of course nothing happens perfectly in the military or anywhere else, but the ethos there is different and uncorrupted by financial concerns, arrogance, greed, ambition, etc. in the way things are corrupted in hospitals, where many who run them have never even served in the military and don't have the same kind of discipline, sense of duty to comrades, and mindset; the same ethos does not apply, in reality, in hospitals, unfortunately. When a soldier goes into combat he can reasonably expect as a matter of course that he may not come out in much worse condition than he went in, or that he may not come out alive at all; it's not reasonable for a patient to have to expect likewise when going into a hospital; those who have served have a right to expect that what they have fought to protect is in better order than what goes on here is, as it should be, but unfortunately, it isn't.
p.s. I mentioned her having been denied treatments; that wasn't because of her insurance coverage; it was just the way the hospital had decided to do things, without even informing her or her health care proxy of her diagnosis. When the same hospital is home to a leading proponent of assisted suicide and feels entitled to decide that someone "should" die, which it has done in other cases as well, and refuses to respect the patient's actual wishes, there is indeed cause for concern over assisted suicide.
Sorry for the extra "not" in post before last; of course, the soldier's reasonable expectation is that he may very well leave the battlefield in much worse condition than he was in when he went onto it, or that he may not even leave it alive at all.
Nor do the same conditions and premises apply in a hospital, in peacetime and in a civilized society, that is supposed to be well run and where on top of everything else care is to be paid for and one has chosen to go (in a competing "health care market" to boot, and hospitals even advertise for business these days) as on a battlefield. One has a right to expect things to run as well in a hospital as they do on in a wartime battlefield, where the least soldiers deserve is the best treatment and judgement possible, but in a civilian hospital is peacetime, triage is not to the fore with the same constant unremitting split-second-by-split-second urgency all the time; thus, while triage is necessary in a hospital, it's not the same. The standards should be just as good, but the priority of triage and exigency of limited resources isn't as great in a hospital. On a battlefield, it's one life or another with grievous injuries all around; in a hospital, an elderly or disabled person who is a customer like every other patient there has a right not to be shunted aside just because the hospital hasn't figured out how to run itself in a proper manner. And what if the elderly or disabled person is a veteran, as many are? Haven't they been through and contributed and suffered enough without being disrespected when they are at their most vulnerable and go to a hospital for care? And in the case of the elderly, aren't they more apt to have contributed more to society, and don't they deserve respect for their age as well? The hospitals' attitude toward them, expressed by doctors who have no idea what it is like to be old, is "well, they have had their life." That's not the point. Their lives are precious to them, and they have earned the right not to be mistreated, which everyone has in the first place. A society can be judged by how it treats its elderly, and character shows in how we treat the most vulnerable. Look at the mess we're in, and look at how we treat those groups. And we're talking about costs and resources, despite how obvious the connection between the dots is.
Rereading, I see that I misread and it wasn't just one liver and two people, simultaneous, Mickey Mantle who had destroyed his own liver by drinking and wasn't apt to live long even with a new liver, and somebody else, younger, who hadn't, and who was, but rather should Mantle have gotten one at all. Yes I think he should. If it were the former situation, he himself might have taken the Republican Roman high road, but he wouldn't have been obliged to. We don't know how many other people were on the list, how many other livers were available, etc. at that particular time, and there he was, he needed one, there was a liver available, and he got it. To have told him sorry, it's your own fault that you need it, it's not going to do you any good, and there are others who need it, would have been cruel and uncivilized. What kind of a society would have such clear-cut rules? Plus there was no way the hospital wasn't going to give it to him, for the reasons I noted. We simply don't know the situations of the others on the list and can't make assumptions. What if the next person on the list had also destroyed his own liver by drinking and had contributed nothing to society at all, but been a drug dealer? What if the next person on the list had not destroyed their own liver by alcoholism, but also had no chance of survival? What if the next person on the list had not destroyed their own liver by alcoholism, had an excellent chance of survival, and got run over by a beer truck whose wheels into the bargain pulverized the newly transplanted liver the day after s/he was released from the hospital? It's unwise to make assumptions, and impossible to make them when all the facts are not even known. What if the liver had been denied to Mickey Mantle and the next hour a new liver came in unexpectedly that would have taken care of the person next in line? No he shouldn't have destroyed his liver by drinking. But are we going to stop giving people treatment for lung cancer or heart disease because they smoked? That's the next logical step. Sometimes we don't even know whether a condition was the person's own fault or not. And it's not the same as battlefield triage. I'd say give the guy the liver whether he's Mickey Mantle or not; it would be inhuman not to, he's the patient before one, and one can't control everything else that happens in the world. As a matter of fact, aren't partial liver transplants from living donors that grow back to full size in both donor and recipient available these days? In that case, the criterion should have been who has a match and a willing donor, not who "deserved" it, and it if was impossible to know that, give the patient in front of you who needs it the liver if you can get it for him, doc; it's your job; what happens after that is out of your hands and in God's, and doctors most definitely are not supposed to play God.
HW:
Triage makes sense in the middle of a war, or some large disaster.
I mean, it is "doing the best you can." But, of course, the way you run your life when the bullets are flying and the enemy is invading cannot be the way that you run it all the time.
Running a hospital based on some extrapolated notion of triage is just ridiculous, and only leads to a materialistic attitude to human beings which, as Wesley points out over and over, is untilitarian and unethical.
Our whole culture's attitude toward medical care is screwed up. The desire for younger people to have access to bells and whistles and with the least amount of effort is partly what drives us to hysterically decide that the old, the sick and the disabled must go in order to leave some supplies for the rest of us.
But I agree with lanthe's suggestion about alternative networks. I believe this already happense in communities that, aided by the internet, shar resources and ideas about self-care that can be done without any doctor. I myself do a lot of this for me and my family. (Avoiding antibiotics and a lot of other prescription meds, for example.)
I also think that, if we can avoid a government controlled health care system, then we might do well for communities to band together to buy health insurance in large groups, to share risk as companies now do. But, instead of the companies carrying the policy, it will be, say, the members of the ARchdiocese of Baltimore churches.... or Anne Arundle County..... or the members of the Comic Book Fans of America, or Homebirthers of Washington State, or whatever. YOu get my point? This would enable people to carry their helath insurance no matter what their job, and also these groups could potentially have more control over the administration of health care policies.
I think that we need to get away from the concept of health insurance altogether, and I don't think that the government should be involved in medical care at all, and I think that the health insurance companies going out of business would free up a lot of money and lead to reduced cost of medical care as well as more money being available in the economy that people could earn and save for when they need it to pay their own medical bills themselves, which in turn would give patients more control and hospitals and the rest of the medical establishment less control over the way patients get treated by doctors and hospitals. In the end, it would be easier for doctors to make a living and focus on their work, and hospitals to remain solvent, with a lot less overhead and without interference by insurance companies, and with renewed emphasis on medicine as a profession rather than a business.
Holyterror: The suggestion about alternative health care networks was not mine; I just think it's a great idea. I can't find the post in which someone else suggested it to make sure, but I think it was SAFEpres who suggested it.
There is so much that can be done with holistic medicine, herbs, etc. that if enough people made them their first choice of treatment, as more and more are, using "the medical establishment" as mechanics and only for what those treatments cannot do, that it would be easy to force the medical establishment to come to heel if people put their minds to it. Traditional western medicine should be spending more time and energy studying and incorporating them, and those of Europe and the rest of the world, and less time and energy ostentatiously fretting about "costs." But they don't cost as much, much of what's done outside the U.S. works better and faster and is safer, and the pharmaceutical companies wouldn't like it. Well isn't that just too bad.
If we can't get rid of health insurance, it would most certainly be better for it not to be tied to people's employment. People often take jobs based on the benefits package, and that's no way to approach one's work and life; the result is a less honest, committed, and competent workforce, a lowering of standards, an acceptance of the prevalence of incompetence and irresponsibility, lowering of expectation that things be done right, loss of job satisfaction, self-respect and of a sense of control and self-determination, not imparting the right values to children, etc., etc., with inevitable detrimental effects throughout society. It makes things harder for employers as well. Has to go. Along with insurance, period. The minute there is a pool of funds into which everyone pays something but out of which some use more than others at a given time, the door is open to "relative cost considerations," and the trouble starts.
You said what I was trying to say about triage and the rest, and much better.
Amazing how possible it is to survive without pharmaceuticals and antibiotics every five minutes, isn't it.
Holyterror: I just found it. WATERBABIES made that great suggestion.
As with the "documents" people sign thinking they are in their own interest, people think insurance is for their benefit, but it's really for the benefit of the medical establishment, which it ensures gets paid no matter what, and in the process the patient/customer loses control and ethic go out the window and medicine turns from a profession into a business. When did insurance, health insurance, get started? People and medicine managed before it and the part about "advances" and "cost" necessitating it is just a bunch of baloney. Get RID of it. Get rid of insurance and animal research and watch how things straighten out. Instead of everybody sitting around wringing their hands and bemoaning the "crisis in health care." Get rid of that stupid phrase "health care" too while we're at it. The solutions are simple. No one wants to give up anything, be responsible for anything,or pay for anything; it's just all part of people feeling entitled and having no guts let alone sense. Get RID of both those things entirely or things are just going to keep getting worse.
lanthe: Actually, insurance is for the benefit of the insurance companies. The more cost accountants are factored into the health-care equation, the more we're going to experience problems with delivery of services. We've gotten somewhat off the track of our original discussion on assisted suicide, but it's been very enlightening. Frankly I didn't think the sort of thing you experienced could happen. I'd still like to think it was an exception, and that I don't have to keep looking over my shoulder to be sure of what my own doctor is up to. I've been his patient (and friend) for 25 years, and he's totally familiar with my health care directive. [shudder]
HW: I didn't think it could happen either. It was egregious and I myself would like to think it was an exception, but it wasn't an exception; they've done it before. It's like Bizarro World. Who would have thunk it?
But it does happen. An attorney from Texas, from either a firm or Westlaw, called the county clerk's office here saying something about Westlaw and looking for information on the case because "we thought it was interesting and wanted to know how they were able to do it"; I think it's Texas that has a medical futility statute (as is in the works in Virginia) and there are elder-law attorneys there who have this agenda. Anyway, I never would have imagined it could happen. But it does. That's why I've been yelling at you here and why people here are concerned about assisted suicide and related issues. I figured you trusted that things would work the way they should, as we all have a right to, and that you didn't realize how dangerous they can turn out to be in reality.
My advice, not that you asked, would be to do a complete revocation of the "living will" right away and get the revocation filed, etc., and have someone you trust as your health care proxy, and have a backup health care proxy, in case something happens to your proxy, and an attorney on deck who's prepared for trouble if you have to go to hospital, and bear in mind that often hospitals don't let one's own doctor get involved when one is admitted to hospital, even if s/he has admitting privileges there, and you can end up at the mercy of an attending who doesn't know you and follows the hospital's agenda, and the attendings can change every week. Plus even if you trust your doctor and are his friend and can trust him and all of that, what if something happens to him?
Also if you're in New York State make sure that you, your proxy, and your attorney are thoroughly familiar with Article 81 of the Mental Hygeine Law re guardianship. That's what the hospital uses to do this when the person has a health care proxy; they get the health care proxy and attorney-in-fact (in my mother's case, me) pushed aside and a "guardian" put into the picture, and the "guardian" is the stooge and "authorizes" pulling the plug; in my mother's case the hospital and the guardian played a shell game making sure she didn't get treatment she needed that would have gotten her out of there alive, and the "guardian" blocked every chance she had to go to another facility where she could get what she needed; this wasn't the first time this hospital had done that. If you have interesting assets, property, etc, it causes even more of a problem.
It's not right; of course there was perjury, defamation, and signicant grounds for appeal, but there is only so much the proxy can do while getting more and more stressed and exhausted between having to keep looking out for the person in the hospital and having to fight in court -- and the hospital knows it. Of course you should be able to trust your doctor and the hospital and your documents and that your rights will be respected. That's the way it's supposed to be. But the legislature in this state ratified these documents (which no legislature or court would for decades after they were first thought up in the 1960s) and they began to get foisted on people not many years before this state abandoned the conservatorship/committee system and passed the Art. 81 MHL "guardianship" statute. Which by the way has been seriously criticized in a study by the inspector general's office appointed by the state office of court administration. On top of everything else at the outset the hospital uses the statute to have your assets frozen which makes it difficult for your proxy or p.o.a. to hire adequate counsel for you -- and, under the statute, you, the person being petitioned against, have to pay the legal bills of all parties.!!! It doesn't cost the hospital a dime that way. Or the "guardians."
It's bizarre, the word more than one attorney in town here has used to describe it, but it does go on, and that's why it's not safe to have a "living will." It's not just one's own doctor one has to worry about; it's the hospital, and the hospital's lawyer(s) who tell the hospital, every time its administration and social work department ask whether they can/should do one of these cases, yes, because that's fees for them and it doesn't cost the hospital anything. Nice, isn't it. And remember the "determination" is made by the attending physician, who may change every week, does not know you or vice versa, and has to go along with the hospital's agenda.
You're right that insurance is for the benefit of the insurance companies; I'm saying that the hospitals see what's in it for them and patients have been whipsawed and brainwashed into depending on it. All those cost accountants and the rest of the insurance industry and its ancillary components and its tentacles have got to go. I don't care where they go, they just have to go.
lanthe: just curious: what do you see as an alternative?
HW: See my answer under the most recent blog subject above re the Montana statute.
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