It is always frustrating when you enter a store, looking for something to buy, and none of the prices are on display. I have often found that this is particularly the case with things in fancy glass display cases that often house expensive things. Jewelery stores are often prime culprits of such behavior. The unsaid message seems to be, "If you knew how much this cost, you probably would not be looking at this, so first fall in love with the item, and then lets talk about price." On another level, the suggestion is that price should not be a significant factor in deciding whether you really want to buy some item that otherwise satisfies your needs and/or desires. But for most average human beings, price does matter, and thus the dilemma of mediating our needs and desires by shopping in stores seeking to maximize profit in a world of finite resources.
But perhaps jewelery stores are too far afield for our purposes here. To be sure, buying jewelery or any other luxury item is rarely a matter of need, but rather of sheer desire. So lets consider food, that basic building block of human life. It is a common experience for many that when they eat outside of the home in a restaurant, they are presented with a menu, and that menu has prices next to each of the items. Few people would eat at a restaurant that offered them no semblance of how much a meal would cost, as many would likely regard such a place as elitist or deceptive, or both. But yet, when we deal with doctors of most any stripe, it is something like going to a restaurant and choosing items from a menu without any attention to cost. And yet, we accept such a system of health care. The mentality is, if the doctor says so, then it must be good and right. But why do we play the part of the skeptical consumer looking for a worthy deal in every other area of our life, but not in the doctor's office?
Patients seem to rarely know how much procedures cost, and yet they consent to them as so called "informed patients." Is price really not a significant matter to be informed on in the world of health care? I think most patients would say it is significant when they eventually receive their bills. To be sure, life is life, and its value is beyond the ability and right of any human being to assign, but...(and yes there is always a "but" when health care must work within a system of limited resources) there is not necessarily any correlation between higher prices for treatment and increased effectiveness. Certainly there are times when the more expensive treatment is the best one, and perhaps even the only real option, but there are other instances where multiple treatments exist with radically different prices, and little to no data on whether one treatment is more effective than another. And there we come to the crux of the issue. Health care providers have shown little regard for controlling costs and rationing care wisely. Granted, such negligence is in large part due to the belief that a person's health should not be subject to the sometimes cold math of cost/benefit calculations. But that belief is mistaken insofar as it is out of touch with any real evidence of cost considerations being detrimental to patients. Studies examining the comparative effectiveness of treatments combined with cost/benefit calculations can offer a powerful tool in saving countless individuals from a bloated health care system that tolerates a shocking amount of waste and error, and subsequently passes on its mistakes in the form of rising costs to the patients it supposedly serves.
If we are frustrated when items in glass display cases have hidden price tags, and few of us would consider eating in a restaurant that offered us no prices for the food, but only a bill at the end of meal, then why do we put up with such behavior in the world of health care? I am not urging that the authority of doctors be usurped, but rather only that there be some degree of transparency about how much health care really costs. Perhaps in time such transparency will lend itself to the deeper question of whether any given thing should cost as much as it does, but everything begins with transparency.
Wednesday, July 8, 2009
Monday, June 29, 2009
Health care reform, not just health insurance reform
In a culture obsessed with numbers and quantitative measures, it is little surprise that much of the debate about health insurance reform has focused on how much it will cost, how many are uninsured, and other suitably massive statistics. But in the midst of all of this, I think we need to ask some deeper questions, ones not easily answered with numeric assessments, and supposedly hard data. That is, what is it we are actually trying to pay for? Even if health insurance does get structured differently, what are we getting in terms of how health care is delivered? To be sure, health insurance does influence how the delivery of care is handled in hospitals and clinics throughout the country, but are we so naive to think we have the chicken and egg question figured out with respect to health care and health insurance? It is not unreasonable to imagine that even if the economics of health care change, the quality of and delivery of it may not substantially change.
It seems that we are slow to learn this lesson. The recent economic recession has revealed an ailing market system, and has invited a myriad of economic analysis from anyone with half an idea of what happened. We have heard that the problem was with bad credit swaps, debt defaults, subprime loans, and distorted interest yields. But amidst all of this, there has been little talk about the kinds of people that have been involved in both creating and manipulating this kind of economic system.
Today, the infamous ponzi schemer, Bernie Madoff, will be sentenced. Some part of me imagines that as the news goes out on the networks about his sentence, people will breath a collective sigh of relief thinking that greed and corruption have been put behind bars. America does love a good scapegoat. Don't get me wrong, I think Madoff is a crook, and should rightly be punished. But the idea that he is somehow an exception, or a lone bad sheep in an otherwise relatively good herd of financial investors and traders is a joke. Perhaps Madoff is an exception in order of magnitude, but to believe that his greed is somehow unique is wishful thinking. Such thinking was witnessed in the media coverage of the Enron debacle and CEO Jeffrey Skilling, where one person or company was highlighted as the problem, while the surrounding system remained unexamined. Perhaps this is a defense mechanism, because the truth is that if we admitted that greed and corruption are likely rife throughout the system then we will be forced to eventually see our own part in encouraging and benefiting from, even taking part in, such a system.
My point in all of this is to say this. Yes, the numbers of health insurance reform need to add up and be organized in such a way as to create a capable and comprehensive system of reimbursement and payment. But numbers are just numbers, abstract quantities of nothingness outside of the human persons that utilize them and assign them to meaningful things. The other shoe that still remains to drop in the debate around health insurance reform is preceisely the human factor in all of this. That is, what kinds of people are leading our health insurance companies, what kinds of people are we training our doctors and nurses to be, who are our hospital administrators, what kinds of people populate hospital or insurance company boards, who are the receptionists that are sitting behind the desks in waiting rooms? The list goes on, but the trend is the same, that is, a radical assesment of the character of the myriad of persons that either directly or indirectly hold other peoples' lives in their hands. If the human beings in the health care sector are anything like those human beings in the financial sector of our society, than I expect that a sizable amount of greed, corruption, laziness, and deceipt is to be found (along with much good as well). In which case, consideration of the human factor in health care leads us to also consider proper safegaurds, checks and balances, error controls, well-placed incentives/rewards, and disciplinary controls that can be incorporated into the delivery of health care.
My proposal here is that we not abandon talk of health insurance reform, but that if we are going to be serious about reform, than lets consider the whole system at play, otherwise we are merely doing an extremely expensive, but ineffective, patch on a system that has deeper issues than just numbers. We need to consider the character of people involved in every level of the delivery of health care, and be honest about both the good and the bad in everyone. Accordingly, we should strive to create a system of care that takes into account this dual potential in human beings and the various tendencies we have. In short, I am asking that we actually take on the monolithic beast of health care reform, and not merely health insurance reform.
It seems that we are slow to learn this lesson. The recent economic recession has revealed an ailing market system, and has invited a myriad of economic analysis from anyone with half an idea of what happened. We have heard that the problem was with bad credit swaps, debt defaults, subprime loans, and distorted interest yields. But amidst all of this, there has been little talk about the kinds of people that have been involved in both creating and manipulating this kind of economic system.
Today, the infamous ponzi schemer, Bernie Madoff, will be sentenced. Some part of me imagines that as the news goes out on the networks about his sentence, people will breath a collective sigh of relief thinking that greed and corruption have been put behind bars. America does love a good scapegoat. Don't get me wrong, I think Madoff is a crook, and should rightly be punished. But the idea that he is somehow an exception, or a lone bad sheep in an otherwise relatively good herd of financial investors and traders is a joke. Perhaps Madoff is an exception in order of magnitude, but to believe that his greed is somehow unique is wishful thinking. Such thinking was witnessed in the media coverage of the Enron debacle and CEO Jeffrey Skilling, where one person or company was highlighted as the problem, while the surrounding system remained unexamined. Perhaps this is a defense mechanism, because the truth is that if we admitted that greed and corruption are likely rife throughout the system then we will be forced to eventually see our own part in encouraging and benefiting from, even taking part in, such a system.
My point in all of this is to say this. Yes, the numbers of health insurance reform need to add up and be organized in such a way as to create a capable and comprehensive system of reimbursement and payment. But numbers are just numbers, abstract quantities of nothingness outside of the human persons that utilize them and assign them to meaningful things. The other shoe that still remains to drop in the debate around health insurance reform is preceisely the human factor in all of this. That is, what kinds of people are leading our health insurance companies, what kinds of people are we training our doctors and nurses to be, who are our hospital administrators, what kinds of people populate hospital or insurance company boards, who are the receptionists that are sitting behind the desks in waiting rooms? The list goes on, but the trend is the same, that is, a radical assesment of the character of the myriad of persons that either directly or indirectly hold other peoples' lives in their hands. If the human beings in the health care sector are anything like those human beings in the financial sector of our society, than I expect that a sizable amount of greed, corruption, laziness, and deceipt is to be found (along with much good as well). In which case, consideration of the human factor in health care leads us to also consider proper safegaurds, checks and balances, error controls, well-placed incentives/rewards, and disciplinary controls that can be incorporated into the delivery of health care.
My proposal here is that we not abandon talk of health insurance reform, but that if we are going to be serious about reform, than lets consider the whole system at play, otherwise we are merely doing an extremely expensive, but ineffective, patch on a system that has deeper issues than just numbers. We need to consider the character of people involved in every level of the delivery of health care, and be honest about both the good and the bad in everyone. Accordingly, we should strive to create a system of care that takes into account this dual potential in human beings and the various tendencies we have. In short, I am asking that we actually take on the monolithic beast of health care reform, and not merely health insurance reform.
Monday, March 23, 2009
Health Care Reform
Since the election of President Obama, there has been considerable discussion about health care reform. Such discussion has been needed, as we surely have an ailing health care system. The problems rest with no particular entity, but are dispersed throughout the system of health care in America, and on every level of care and business. However, as I listen to such discussions, and particularly the call for universal health care, I cannot help but think about the deeper question being overlooked. Are we as a society prepared to sacrifice highly individualized and easily accessible advanced care for a common standard of basic care available to everyone? I am not here trying to set up a dichotomy between the current system and a system of universal health care, and I am not trying to imply that the former provides excellent care, while the latter provides merely "okay" care. My point in asking the question is to raise the fact that as Americans, we are not good at considering the big picture questions, and taking macroscopic concerns seriously.
In order to ensure a basic standard of minimum care for every single person in America will require that we re-configure what we expect when we go to the doctor's office. A system that supports everyone cannot indulge the whims of every patient that wants a full body scan without any significant symptoms to prompt such a diagnostic test. The list of exotic therapies can go on, but the trend is the same. As human beings, we are very good at looking out for ourselves alone, and even more so when we are sick or in pain. We often have a deep sense of entitlement to access advanced and expensive technologies and treatments that might possibly save or prolong our lives and those of our friends and family. However, such tunnel vision cannot persist if we are to adopt a policy of universal care. Universal care will require a greater appreciation for the ways in which medical resources and technologies are allocated across an entire population. We cannot expect that ourselves alone will have any monopoly on a medical team's time or available resources.
Though it may be true that, as human beings, we are deeply focused on ourselves alone, and subsequently experience a substantial amount of entitlement to the resources society has to offer, we should not regard this as a "game-stopper" for the advancement and reform of healthcare. Instead, we should strive to come to terms with our self-centered nature, and work to improve upon it by considering the real needs of our neighbors. A universal health care system will rise or fall on the backs of people that commit or do not commit themselves to grasping the needs of their community in addition to their own. It is understandable to consider one's own needs, and we will likely never leave these behind, but to consider our individual needs, blind to those of our neighbor, is a pressing failure that endangers real and substantial healthcare reform.
In order to ensure a basic standard of minimum care for every single person in America will require that we re-configure what we expect when we go to the doctor's office. A system that supports everyone cannot indulge the whims of every patient that wants a full body scan without any significant symptoms to prompt such a diagnostic test. The list of exotic therapies can go on, but the trend is the same. As human beings, we are very good at looking out for ourselves alone, and even more so when we are sick or in pain. We often have a deep sense of entitlement to access advanced and expensive technologies and treatments that might possibly save or prolong our lives and those of our friends and family. However, such tunnel vision cannot persist if we are to adopt a policy of universal care. Universal care will require a greater appreciation for the ways in which medical resources and technologies are allocated across an entire population. We cannot expect that ourselves alone will have any monopoly on a medical team's time or available resources.
Though it may be true that, as human beings, we are deeply focused on ourselves alone, and subsequently experience a substantial amount of entitlement to the resources society has to offer, we should not regard this as a "game-stopper" for the advancement and reform of healthcare. Instead, we should strive to come to terms with our self-centered nature, and work to improve upon it by considering the real needs of our neighbors. A universal health care system will rise or fall on the backs of people that commit or do not commit themselves to grasping the needs of their community in addition to their own. It is understandable to consider one's own needs, and we will likely never leave these behind, but to consider our individual needs, blind to those of our neighbor, is a pressing failure that endangers real and substantial healthcare reform.
Monday, December 29, 2008
Health Care Ethicists Amidst the Crowd
In my observations of hospital life, I have come to realize that among those most important things when you are sick are the people waiting for you when you are discharged from the hospital. While there is a certain amount of sterile loneliness in hospital examination rooms or operating rooms, those people that arrive to greet you and pick you up bring a sense of home and companionship that even in the best hospitals are missing. Whether family or friends, the distinction matters little, because the result is the same, that is, after being poked and prodded, studied and stared at, a friendly face is there to remind you of life in supportive communities outside of the acute care of a hospital.
I think that this observation is important because in the field of health care ethics it can be easy to see the patient and health care provider as the sole parties of interest in any given ethical dilemma. But such tunnel vision would fail to take into account the very real and important role that other individuals and communities play in any patient's life. At the end of the day it is not a doctor or nurse that a patient goes home with (or a health care ethicist for that matter), but rather it is a spouse, a brother, a sister, a mother, a father, a friend, a co-worker, or any number of other important persons in that patient's life.
I say all of this not to advocate for demolishing a confidential and private professional relationship between patient and health care provider, but rather to say that medicine and health care ethics are driven by their broader context, and should be constantly re-affirmed as such. In a hospital, where health care providers often stand at the edges of life and death with their patients, the everydayness of life can fade into the background as profound and acute medical issues arise that bring with them complex ethical problems. It is in a patient's best interests for a doctor to be substantially focused on the medical issue at hand, but the health care ethicist occupies a more qualified role, wherein they can bear the task of considering both life inside of a hospital and outside of a hospital when resolving ethical dilemmas.
Rather than an increased burden, such a mediating function is where the meaning of hospital visits is to be found. That is, it is life outside of a hospital that makes going to the hospital worthwhile in the first place. While health care providers may stand at the edges of life and death with their patients, it is the role of health care ethicists to stand with the patient amidst existence, to negotiate the relationships between past, present, and future, or more tangibly, between life outside of the hospital and life inside of the hospital.
I think that this observation is important because in the field of health care ethics it can be easy to see the patient and health care provider as the sole parties of interest in any given ethical dilemma. But such tunnel vision would fail to take into account the very real and important role that other individuals and communities play in any patient's life. At the end of the day it is not a doctor or nurse that a patient goes home with (or a health care ethicist for that matter), but rather it is a spouse, a brother, a sister, a mother, a father, a friend, a co-worker, or any number of other important persons in that patient's life.
I say all of this not to advocate for demolishing a confidential and private professional relationship between patient and health care provider, but rather to say that medicine and health care ethics are driven by their broader context, and should be constantly re-affirmed as such. In a hospital, where health care providers often stand at the edges of life and death with their patients, the everydayness of life can fade into the background as profound and acute medical issues arise that bring with them complex ethical problems. It is in a patient's best interests for a doctor to be substantially focused on the medical issue at hand, but the health care ethicist occupies a more qualified role, wherein they can bear the task of considering both life inside of a hospital and outside of a hospital when resolving ethical dilemmas.
Rather than an increased burden, such a mediating function is where the meaning of hospital visits is to be found. That is, it is life outside of a hospital that makes going to the hospital worthwhile in the first place. While health care providers may stand at the edges of life and death with their patients, it is the role of health care ethicists to stand with the patient amidst existence, to negotiate the relationships between past, present, and future, or more tangibly, between life outside of the hospital and life inside of the hospital.
Sunday, December 14, 2008
Of Tattoos and Patient Autonomy
When I was younger, I always saw tattoos as the definitive symbol of defiance and rebellion; a true sign of the independent spirit. It seems that my ideas were not so far off, though not perhaps in the ways that I imagined. A 79 year old women in New Zealand is tattooing the command "Do not resuscitate" onto her chest as a sign of her autonomy, that is, as her right to choose what medical treatment she receives. It seems that, amidst the swell of exotic lifesaving therapies in recent years, patient autonomy has become the rebel's cause as it inspires people like the woman in New Zealand to take ever more dramatic efforts to ensure that their wishes are honored in a medical setting.
As referenced in the article that the story was reported in, a looming concern is that doctors will not know what to do when confronted with the tattoo in an emergency room after this woman has had a heart attack or stroke. Has she changed her mind? Was she under compulsion when she got the tattoo? Was she depressed when she got the tattoo? A "yes" to any of these questions would certainly endanger the force of the "Do not resuscitate" command. And therein lies the problem, if the woman is unconscious, which way does the hospital err in providing care? Generally hospitals have erred on the side of resuscitating so as to preserve life, and thus the reason why this woman has taken such a bold effort to ensure that her message is loud and clear. It is very interesting, though, to observe that the greater effort a person goes to refusing medical care, or otherwise bucking the status quo of modern medical care, the more they are questioned and examined for signs of compromised autonomy.
To be fair, patients do change their minds, and sometimes they do things under some degree of duress that compromises their ability to make a fully informed decision. As such, it is somewhat understandable why medical providers hesitate to consider whether to honor a patient's request (particularly when they are unconscious). However, outside of epistemic humility, is there a failure on the part of the medical establishment to respect the value of patient autonomy? In the last 40 years, the four primary values utilized in the vast majority of medical ethics decisions have been autonomy, beneficence, non-maleficence, and justice. Oftentimes, discussions center around issues of autonomy, but do such discussions ever actually lead to a more credible place for autonomy in the medical clinic? Certainly beneficence is an undisputed part of the medical establishment. Doctors, nurses, and other health care providers are all dedicated to serving the needs of sick individuals and bringing about a great good in their lives through healing.
Sometimes, though, it seems that the medical establishment just does not know what to do with instances of patient autonomy? Certainly inside of a model of paternalism, where an attitude of "doctor knows best" reigns, we would expect some degree of dissonance with a patient's attempt to assert an alternative perspective that they expect to be honored against that of a doctor. But these are the days of the doctor-patient alliance, wherein doctors and patients collaborate to develop a treatment plan for medical care, right? It is worth wondering whether, after centuries of utilizing the model of paternalism in medical practice, the medical establishment has so quickly left the attitudes of paternalism behind. Could it be that the dogged inquisition of a patient that chooses to reject medical care or otherwise buck the status quo, is not a sign of epistemic humility on the part of medical professionals, but more sinisterly the specter of paternalism? If so, are these rebel patients, so to speak, to be regarded not as incompetent, but rather, as the brave individuals who dared to challenge an entrenched system of power?
As referenced in the article that the story was reported in, a looming concern is that doctors will not know what to do when confronted with the tattoo in an emergency room after this woman has had a heart attack or stroke. Has she changed her mind? Was she under compulsion when she got the tattoo? Was she depressed when she got the tattoo? A "yes" to any of these questions would certainly endanger the force of the "Do not resuscitate" command. And therein lies the problem, if the woman is unconscious, which way does the hospital err in providing care? Generally hospitals have erred on the side of resuscitating so as to preserve life, and thus the reason why this woman has taken such a bold effort to ensure that her message is loud and clear. It is very interesting, though, to observe that the greater effort a person goes to refusing medical care, or otherwise bucking the status quo of modern medical care, the more they are questioned and examined for signs of compromised autonomy.
To be fair, patients do change their minds, and sometimes they do things under some degree of duress that compromises their ability to make a fully informed decision. As such, it is somewhat understandable why medical providers hesitate to consider whether to honor a patient's request (particularly when they are unconscious). However, outside of epistemic humility, is there a failure on the part of the medical establishment to respect the value of patient autonomy? In the last 40 years, the four primary values utilized in the vast majority of medical ethics decisions have been autonomy, beneficence, non-maleficence, and justice. Oftentimes, discussions center around issues of autonomy, but do such discussions ever actually lead to a more credible place for autonomy in the medical clinic? Certainly beneficence is an undisputed part of the medical establishment. Doctors, nurses, and other health care providers are all dedicated to serving the needs of sick individuals and bringing about a great good in their lives through healing.
Sometimes, though, it seems that the medical establishment just does not know what to do with instances of patient autonomy? Certainly inside of a model of paternalism, where an attitude of "doctor knows best" reigns, we would expect some degree of dissonance with a patient's attempt to assert an alternative perspective that they expect to be honored against that of a doctor. But these are the days of the doctor-patient alliance, wherein doctors and patients collaborate to develop a treatment plan for medical care, right? It is worth wondering whether, after centuries of utilizing the model of paternalism in medical practice, the medical establishment has so quickly left the attitudes of paternalism behind. Could it be that the dogged inquisition of a patient that chooses to reject medical care or otherwise buck the status quo, is not a sign of epistemic humility on the part of medical professionals, but more sinisterly the specter of paternalism? If so, are these rebel patients, so to speak, to be regarded not as incompetent, but rather, as the brave individuals who dared to challenge an entrenched system of power?
Wednesday, November 12, 2008
From bedside to examination room, and back again
New developments in technology ranging from secure email and chat to devices like Intel's digital Health Guide, are changing the way that medicine is being practiced. These new technologies allow patients and doctors to interact at a distance, from the home, from the office, or perhaps even while out for a morning walk.
In the case of Intel's Health Guide, the device is essentially a compact, portable computer that has been engineered to collect data from any number of medical devices such as blood pressure monitors or glucose readers, and shares the data with doctors in the clinic via the internet. The device also is designed to offer patients helpful health information as they need it, even videos on various subjects.
Once upon a time, it was not uncommon for doctors to make house calls, visiting patients amidst their illness as contextualized by their everyday life. Today such house calls are rare, and the examination room where doctors and patients meet in isolation from the busy world around them has become the central space for diagnosis and prognosis. However, with some of thes new technologies the dynamics are changing. While not physically present, doctors can interact with patients as they live out their daily life.
I think that this is an important development in medicine, and a trend to pay close attention to because I believe that it may change the way that we imagine the doctor-patient relationship. That is, particularly as patients interact with doctors via the internet, they have between them the vast potential of a wealth of third party health information from online databases and websites. Whether doctors like it or not, patients are and will continue to come with ever increasing ideas about diagnosis, treatment, and care. But then doctors are not without resources either, what the web offers patients, it also offers doctors. Both doctors and patients are interacting with more information then ever before, and this is going to change the way that medicine is done. One might imagine that it will lead to more creative treatments, better monitoring of dangerous drug interactions, faster peer review, more readily accessible support groups for various illnesses or disabilities, and maybe even more collaboration between doctor and patient.
There is a saying, give a man a fish and he will eat for a day, but teach a man to fish and he will eat for a lifetime. These new technologies are like teaching a person to fish. There real value is that, as potential avenues of good information and ongoing dialogue, they could help to switch the dominant medical model from treatment after the fact to establishing healthy habits and a lifetime of preventive care.
If this is the way that medicine is going, then we may need to re-think the kind of ethical issues that we occupy our time with. Issues of privacy and trust and truthfulness will loom large amidst the information revolution, but we will also need to complicate our concepts of the doctor-patient relationship. It is no longer just doctors and patients in the examination room together, it is also online support groups, recent medical articles, Google searches and electronic medical records with notes from multiple caregivers.
In the case of Intel's Health Guide, the device is essentially a compact, portable computer that has been engineered to collect data from any number of medical devices such as blood pressure monitors or glucose readers, and shares the data with doctors in the clinic via the internet. The device also is designed to offer patients helpful health information as they need it, even videos on various subjects.
Once upon a time, it was not uncommon for doctors to make house calls, visiting patients amidst their illness as contextualized by their everyday life. Today such house calls are rare, and the examination room where doctors and patients meet in isolation from the busy world around them has become the central space for diagnosis and prognosis. However, with some of thes new technologies the dynamics are changing. While not physically present, doctors can interact with patients as they live out their daily life.
I think that this is an important development in medicine, and a trend to pay close attention to because I believe that it may change the way that we imagine the doctor-patient relationship. That is, particularly as patients interact with doctors via the internet, they have between them the vast potential of a wealth of third party health information from online databases and websites. Whether doctors like it or not, patients are and will continue to come with ever increasing ideas about diagnosis, treatment, and care. But then doctors are not without resources either, what the web offers patients, it also offers doctors. Both doctors and patients are interacting with more information then ever before, and this is going to change the way that medicine is done. One might imagine that it will lead to more creative treatments, better monitoring of dangerous drug interactions, faster peer review, more readily accessible support groups for various illnesses or disabilities, and maybe even more collaboration between doctor and patient.
There is a saying, give a man a fish and he will eat for a day, but teach a man to fish and he will eat for a lifetime. These new technologies are like teaching a person to fish. There real value is that, as potential avenues of good information and ongoing dialogue, they could help to switch the dominant medical model from treatment after the fact to establishing healthy habits and a lifetime of preventive care.
If this is the way that medicine is going, then we may need to re-think the kind of ethical issues that we occupy our time with. Issues of privacy and trust and truthfulness will loom large amidst the information revolution, but we will also need to complicate our concepts of the doctor-patient relationship. It is no longer just doctors and patients in the examination room together, it is also online support groups, recent medical articles, Google searches and electronic medical records with notes from multiple caregivers.
Wednesday, November 5, 2008
A-T-C-G Who Am I? A-T-C-G
Who am I? What am I? It is questions like these that philosophers have considered and wrestled with for thousands of years. While many have offered answers to such questions, little consensus persists. These are challenging questions in which the personal stakes are high because the way that we answer them can affect the myriad of choices that we make regarding ourselves on a daily bases. How we conceptualize our identities as self-conscious living organisms sets the imaginative parameters on how we anticipate and react to daily events.
It is then sobering to consider that with the rise of personalized medicine facilitated by cheaper and convenient genetic testing, we as a society must come to terms with some kind of answer to these questions Who am I ? What am I? With a credit card and a spit sample I can now choose from one of several companies that will screen my genome for genetic markers of particular diseases, abilities, dispositions, and/or disabilities. When I receive the results, I am left wondering, what am I holding. Is this me? Does this genetic analysis set the boundaries for how I conceptualize who I am, what I am? And so I go to my doctor to help me interpret the results...but there lies the rub.
Doctors are increasingly going to be put in the difficult position of interpreting genetic screening results for patients that want an ever more personalized approach to medicine. On one level the patient's questions may be, How likely is it that I will develop symptoms of this or that disease? What kinds of treatments are available? What can I do to prevent this? Do or will my children face the same risks? But on the profound level, the question that will always hang in the medical examination room is Who am I? What am I? Am I merely the physical expression of this genetic readout of my genes?
Are doctors prepared to grapple with such questions? Do we as a society have an answer to supply the doctors? We, as a society expressed in collections of specific communities, need to deliberately wrestle with questions of identity, and specifically with what the implications of genetic identity might be.
It is then sobering to consider that with the rise of personalized medicine facilitated by cheaper and convenient genetic testing, we as a society must come to terms with some kind of answer to these questions Who am I ? What am I? With a credit card and a spit sample I can now choose from one of several companies that will screen my genome for genetic markers of particular diseases, abilities, dispositions, and/or disabilities. When I receive the results, I am left wondering, what am I holding. Is this me? Does this genetic analysis set the boundaries for how I conceptualize who I am, what I am? And so I go to my doctor to help me interpret the results...but there lies the rub.
Doctors are increasingly going to be put in the difficult position of interpreting genetic screening results for patients that want an ever more personalized approach to medicine. On one level the patient's questions may be, How likely is it that I will develop symptoms of this or that disease? What kinds of treatments are available? What can I do to prevent this? Do or will my children face the same risks? But on the profound level, the question that will always hang in the medical examination room is Who am I? What am I? Am I merely the physical expression of this genetic readout of my genes?
Are doctors prepared to grapple with such questions? Do we as a society have an answer to supply the doctors? We, as a society expressed in collections of specific communities, need to deliberately wrestle with questions of identity, and specifically with what the implications of genetic identity might be.
Monday, November 3, 2008
A Film Review: Sick Around the World (2008)
It is difficult to do a documentary film well. As such, it is refreshing when one comes along. The documentary is called Sick Around the World, and was released this past year (2008) by Frontline Documentaries, a PBS company.
In this film, Washington Post correspondent T. R. Reid travels around the world to get a look at how, outside of the US system, other advanced capitalistic countries organize and operate their health care systems. In a well balanced and engaging manner, Reid explores 5 different health systems (Britain, Japan, Taiwan, Germany, and Switzerland). As he interacts with politicians and doctors from each country, Reid asks a common set of questions in order to establish an excellent compare and contrast, wherein both pros and cons are considered. In particular, Reid's questions, as he makes clear in the film, are fueled by the crisis of the US health care system, which spends the most money in the world on health care, but is ranked 37th in terms of overall health, and moreover sees as much as 700,000 people go bankrupt each year from paying doctor's bills, while millions of Americans remain uninsured.
The principle of justice, as it bears down on particular ethical issues of care in medicine, often implicates the system that creates such problems. As such, discussions of health care policy reform loom large on the horizon. Anticipating such discussions amidst the serious crisis of the American health care system, Sick Around the World (2008) is a great resource to be utilized, and an important step towards allowing other people and cultures to inform policy decisions, and help us in navigating out of the moral quagmires that our American health care system so ably creates.
To view the film, visit the Frontline Website: Sick Around the World, or the film can be downloaded from the iTunes store for 2 dollars.
In this film, Washington Post correspondent T. R. Reid travels around the world to get a look at how, outside of the US system, other advanced capitalistic countries organize and operate their health care systems. In a well balanced and engaging manner, Reid explores 5 different health systems (Britain, Japan, Taiwan, Germany, and Switzerland). As he interacts with politicians and doctors from each country, Reid asks a common set of questions in order to establish an excellent compare and contrast, wherein both pros and cons are considered. In particular, Reid's questions, as he makes clear in the film, are fueled by the crisis of the US health care system, which spends the most money in the world on health care, but is ranked 37th in terms of overall health, and moreover sees as much as 700,000 people go bankrupt each year from paying doctor's bills, while millions of Americans remain uninsured.
The principle of justice, as it bears down on particular ethical issues of care in medicine, often implicates the system that creates such problems. As such, discussions of health care policy reform loom large on the horizon. Anticipating such discussions amidst the serious crisis of the American health care system, Sick Around the World (2008) is a great resource to be utilized, and an important step towards allowing other people and cultures to inform policy decisions, and help us in navigating out of the moral quagmires that our American health care system so ably creates.
To view the film, visit the Frontline Website: Sick Around the World, or the film can be downloaded from the iTunes store for 2 dollars.
Thursday, October 30, 2008
Tune in tonight to learn...that the news media exhibits considerable control over your perceptions of health and risk of disease
"If it bleeds it leads," such is the adage of journalism, particularly broadcast journalism. There is a gross tendency to offer hyped and sensational stories to the public for regular consumption. And insofar as news companies function as companies looking to earn a profit, who can blame them? Sensational stories get the ratings, as viewers tune in night after night to follow a particular story, or maybe just to find out what new item from their daily life could be killing them. But as soon as we consider the other function of journalism, that is, the duty to serve the public with responsible news gathering that fosters their increased wellbeing, well then now these sensational stories seem out of place, even manipulative and harmful.
A recent study released in the journal, Public Library of Science: One, details how media coverage of certain diseases affects the publics' perception of the severity of diseases. It is a very interesting study, and well worth reading, but here I will only summarize. Diseases that are reported on frequently in the media (SARS, West Nile Virus, Anthrax infections, Avian Flu) were judged to be more severe by a selection of undergraduate psychology students and medical students than other less well known diseases (tularemia, human babesiosis, yellow fever, Lassa fever and hantavirus). However, when the diseases were described without names, test subjects rated the less well known diseases as more severe. The study presents compelling evidence that the media has a strong influence on the public's perception of risk regarding diseases and general health, and that it is generating ill founded conceptions of diseases and risk.
It would appear that just as sensationalism rules the media's choices of political and national coverage, so also it is guiding reporting on health matters. This is a failure on the part of journalists to effectively serve the public. The implications of a misinformed public about disease awareness and control are considerable and raise some ethical concerns. The media, unlike our friends, family, teachers, and coworkers represents a dedicated and organized network of information gathering and distribution, and as such its efforts are far more deliberate and effective on the large scale. This combination of deliberation and high potency on a broad scale combine to make broadcasters and print journalists culpable for their shortcomings in serving the public. I am not saying that it is the exclusive responsibility of journalism to educate the public, and while I can talk of journalism generally, there are admitted exceptions to the dominant trends when you look more closely at the journalistic landscape. However, journalists do have some responsibility, and often certain core or common stories are covered by multiple television networks, newspapers, and magazines. If journalists let sensationalism guide their reporting on health matters than they threaten an effective response to disease otubreaks when they do arise. Perhaps people will not even be aware of some disease outbreaks because they are not among those commonly selected for media coverage. Perhaps the public will react with fear and hysteria during some disease outbreaks because their awareness of the associated risk has been artificially inflated. The list could go on, but the point is that, when it comes to health, something that affects each and every person, journalists need to have a heightened awareness of the impact their reporting has on individuals.
The way that health concerns are reported in the media needs to be done differently than the way political or national coverage stories are hyped and presented. The objective presentation of well established findings and research should more often guide health reporters. When reports focus on a special case of a disease theatening an individual or community, there should be the proper contextualization of scope and actual risk. In turn, we, as a viewing public, should both demand higher standards of health reporting, and also break ourselves of the habit of being more tuned into sensational news stories.
A recent study released in the journal, Public Library of Science: One, details how media coverage of certain diseases affects the publics' perception of the severity of diseases. It is a very interesting study, and well worth reading, but here I will only summarize. Diseases that are reported on frequently in the media (SARS, West Nile Virus, Anthrax infections, Avian Flu) were judged to be more severe by a selection of undergraduate psychology students and medical students than other less well known diseases (tularemia, human babesiosis, yellow fever, Lassa fever and hantavirus). However, when the diseases were described without names, test subjects rated the less well known diseases as more severe. The study presents compelling evidence that the media has a strong influence on the public's perception of risk regarding diseases and general health, and that it is generating ill founded conceptions of diseases and risk.
It would appear that just as sensationalism rules the media's choices of political and national coverage, so also it is guiding reporting on health matters. This is a failure on the part of journalists to effectively serve the public. The implications of a misinformed public about disease awareness and control are considerable and raise some ethical concerns. The media, unlike our friends, family, teachers, and coworkers represents a dedicated and organized network of information gathering and distribution, and as such its efforts are far more deliberate and effective on the large scale. This combination of deliberation and high potency on a broad scale combine to make broadcasters and print journalists culpable for their shortcomings in serving the public. I am not saying that it is the exclusive responsibility of journalism to educate the public, and while I can talk of journalism generally, there are admitted exceptions to the dominant trends when you look more closely at the journalistic landscape. However, journalists do have some responsibility, and often certain core or common stories are covered by multiple television networks, newspapers, and magazines. If journalists let sensationalism guide their reporting on health matters than they threaten an effective response to disease otubreaks when they do arise. Perhaps people will not even be aware of some disease outbreaks because they are not among those commonly selected for media coverage. Perhaps the public will react with fear and hysteria during some disease outbreaks because their awareness of the associated risk has been artificially inflated. The list could go on, but the point is that, when it comes to health, something that affects each and every person, journalists need to have a heightened awareness of the impact their reporting has on individuals.
The way that health concerns are reported in the media needs to be done differently than the way political or national coverage stories are hyped and presented. The objective presentation of well established findings and research should more often guide health reporters. When reports focus on a special case of a disease theatening an individual or community, there should be the proper contextualization of scope and actual risk. In turn, we, as a viewing public, should both demand higher standards of health reporting, and also break ourselves of the habit of being more tuned into sensational news stories.
Sunday, October 26, 2008
Placebo Culture
Why am I taking this medication? More patients may want to start asking this question when they visit the doctor’s office. An article in the New York Times recently highlighted the findings of a new survey of medical doctors in America that reveals that half of all doctors prescribe placebos of some kind. Placebos are prescribed when patients present with psycho-somatic conditions. In such cases, doctors may prescribe vitamins, large doses of Aleve or ibuprofen, or even antibiotics or sedatives. While these medications do have actual physical affects on the body, doctors use them primarily as a means to trick the patient’s brain into restored health, and thus qualify in a loose sense as placebos.
While I do not contest the value of placebo use in the case of alleviating psycho-somatic symptoms, the ethical issue of doctors lying to their patients looms large. Undoubtedly, this is a difficult position for doctors and patients because when placebos might be warranted, it would be contrary to the effectiveness of the placebo treatment for a doctor to tell the patient the truth about their medication. The doctor, while valuing trust and truthfulness, also values the restoration of health, both as a personal experience and verifiable fact. In the case of placebos the good of truth and the experience of health appear to be at odds with one another. The question then remains whether in this situation trustworthiness is damaged, and thereby, also, is the doctor-patient relationship where trustworthiness figures so prominently diminished as well? One might think that if the patient never learns of the deception, the trustworthy relationship persists as before, perhaps even bolstered by the experience of restored health. This type of thinking is reflected in the idea that what you don’t know can’t hurt you. According to that line of thought, the researchers of this particular study in question should not have even published their findings. But while it may be true that what you don’t know will not directly and immediately hurt you, it cannot be said that in the infinitely complex, but always interrelated chain of cause and effect and indirect relationships that we should be so nonchalant about our pursuit of knowledge. My concern is that whether patients know about the deception of placebos or not, there is a culture of deception that develops among doctors and other clinical professionals that are, so to speak, in the “know” about prescriptions versus the patients who are in the “dark.” Does this culture of deception inspire a sense of superiority, as the saying goes, “knowledge is power.” If this is happening, then the doctor-patient relationship built on trust is a mere façade for a power game that is operating subtly to establish traditional paternalistic notions of superior and inferior in the clinical examination room.
Immanuel Kant, a philosopher, held that the absolute ethical imperative to follow was, "Act only according to that maxim whereby you can at the same time will that it should become a universal law." So if a doctor lies to a patient about the nature of their medications for the sake of prescribing a placebo, that doctor must consider whether his or her action that appears to be justified then and there could be carried out by every single human being in all times. If every human being lied, there could be no discourse because there would be no reason to believe that anyone told the truth. The initial appearance of a justified case of lying breaks down when shown to be illogical on the grand scale. Although Kant's ethical ideal is a difficult one to follow, it does offer a rebuttal to any temporary, local justification for moral deception in the case of placebo use. Most importantly, Kant's thinking takes into account the larger system at play that is affected by individual choices at a specific time and place. And so we ask, what kind of cultures are created by the decisions and practices that we justify at specific times and places? Does the rampant use of placebos by medical doctors lead to a culture of deception? If so, then perhaps there is a need to restrict placebo use, or at least monitor it?
While I do not contest the value of placebo use in the case of alleviating psycho-somatic symptoms, the ethical issue of doctors lying to their patients looms large. Undoubtedly, this is a difficult position for doctors and patients because when placebos might be warranted, it would be contrary to the effectiveness of the placebo treatment for a doctor to tell the patient the truth about their medication. The doctor, while valuing trust and truthfulness, also values the restoration of health, both as a personal experience and verifiable fact. In the case of placebos the good of truth and the experience of health appear to be at odds with one another. The question then remains whether in this situation trustworthiness is damaged, and thereby, also, is the doctor-patient relationship where trustworthiness figures so prominently diminished as well? One might think that if the patient never learns of the deception, the trustworthy relationship persists as before, perhaps even bolstered by the experience of restored health. This type of thinking is reflected in the idea that what you don’t know can’t hurt you. According to that line of thought, the researchers of this particular study in question should not have even published their findings. But while it may be true that what you don’t know will not directly and immediately hurt you, it cannot be said that in the infinitely complex, but always interrelated chain of cause and effect and indirect relationships that we should be so nonchalant about our pursuit of knowledge. My concern is that whether patients know about the deception of placebos or not, there is a culture of deception that develops among doctors and other clinical professionals that are, so to speak, in the “know” about prescriptions versus the patients who are in the “dark.” Does this culture of deception inspire a sense of superiority, as the saying goes, “knowledge is power.” If this is happening, then the doctor-patient relationship built on trust is a mere façade for a power game that is operating subtly to establish traditional paternalistic notions of superior and inferior in the clinical examination room.
Immanuel Kant, a philosopher, held that the absolute ethical imperative to follow was, "Act only according to that maxim whereby you can at the same time will that it should become a universal law." So if a doctor lies to a patient about the nature of their medications for the sake of prescribing a placebo, that doctor must consider whether his or her action that appears to be justified then and there could be carried out by every single human being in all times. If every human being lied, there could be no discourse because there would be no reason to believe that anyone told the truth. The initial appearance of a justified case of lying breaks down when shown to be illogical on the grand scale. Although Kant's ethical ideal is a difficult one to follow, it does offer a rebuttal to any temporary, local justification for moral deception in the case of placebo use. Most importantly, Kant's thinking takes into account the larger system at play that is affected by individual choices at a specific time and place. And so we ask, what kind of cultures are created by the decisions and practices that we justify at specific times and places? Does the rampant use of placebos by medical doctors lead to a culture of deception? If so, then perhaps there is a need to restrict placebo use, or at least monitor it?
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