When the father spoke to my supervisor, his position became clear. His atypical choice was informed by his cultural background and personal character. An immigrant from Eastern Europe, he was adamantly against yielding control of his life to his daughter. He had tried the medicines, and found they sapped his strength and made him weak. He would rather go on strong for as long as possible and remain his own master.

At the hearing, the lawyer told the judge that his client understood his illness and the prospect of oncoming death, and still chose for his own reasons to turn down further treatment. After confirming this with the man himself, the judge denied the daughter’s request, leaving him to live or die on his own terms.

In the aftermath, it occurred to me that there had been no true issue concerning the man’s ability to comprehend the situation or express his feelings. Yet, he was still forced into a court fight because he decided to turn down treatment. Shouldn’t his clearly stated opinions be enough?

Dr. Alec Buchanan of the Yale Department of Psychiatry evaluated the existing state of law and practice concerning informed consent and reported his findings in a paper in the Journal of the Royal Society of Medicine. Examining medical and legal approaches to the issue of capacity in such matters, he found that “mental capacity is not the sole determinant of what will happen when a patient chooses a course of treatment that doctors consider against the patient’s best interests.” Other factors included the views of relatives, “previous expressed views of the patient,” the opinions of medical staff, and the values of society as a whole.

Buchanan pointed out that acceptance of a patient’s medical decision by professionals and family depends in part on the complexity and gravity of the issue. The harder the choice, or the more grave the potential outcome, the higher the level of scrutiny to which any choice will be subjected. Legal opinions have also followed this logic, holding that “the more serious the decision, the greater the capacity required.”

Such scrutiny is in conflict with the value of autonomy, the ability of the individual to act freely in accordance with their own perceptions and belief. Buchanan says that in the context of medical consent, the importance of autonomy increases with the level of a person’s capacity.

While it is clear that these observations correctly describe how the real world works, it is disturbing that they reflect true disrespect of individual autonomy. If it is acceptable to drag clearly lucid people into court to measure their mental capacity for medical consent, why not question capacity for other decisions? The potential outcome of a poorly chosen marriage might be a devastating divorce, with tragic paths for children of the union. A business contract might eventually lead to unforeseen results which could end in someone’s lifetime ruin. Yet we do not find clearly lucid individuals brought into court in advance so they may be judged as to their ability to make those decisions. At most, poor outcomes in domestic or business pursuits might result in a later determination of incompetence.

Of course, in the area of medical treatment, a poor choice may result in permanent injury or death. For this reason, the law permits family, medical staff, and “other interested parties” the option of advance intervention in health care decisions. Such action is a direct negation of the individual’s right to choose in the most crucial and intimate of matters.

How to both assure competence and maintain autonomy?

From the standpoint of the medical profession, the appropriate emphasis should be on ethical and legal education for professionals to assure that the rights of individuals are not violated.

From the standpoint of the patient, there is no substitute for a properly drafted advanced medical directive or power of attorney which clearly sets forth his or her specific desires and which names an individual who can honestly, quickly, and accurately discern a patient’s wishes in the context of medical treatment. Such an individual can sustain the decision of a patient if a question of capacity arises.

The ability of a physician or of the state to override the wishes of a patient and to violate their body should be closely and exhaustively controlled. It should not depend on the subjective assessment of capacity made by someone else, regardless of their qualifications.

Reference

Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment Journal of the Royal Society of Medicine, 97 (9), 415-420 DOI: 10.1258/jrsm.97.9.415

The Physician Payments Sunshine Act — a bipartisan piece of legislation introduced by Senators Chuck Grassley (R-Iowa) and Herb Kohl (D-Wisconsin) — was first introduced in 2007, but has failed passage to date. With ever-increasing scrutiny of government and corporate organizations, many expect the amended bill to pass successfully this year. The bill would require drug companies to submit a report to the Secretary of Health and Human Services detailing any payments, gifts, food, trips, samples, rebates, or other type of compensation given to physicians.

While almost no one would argue that transparency in industry — any industry — is bad, and patients and the rest of the public have a right to know for whom their doctors are working, some income should be a private matter. Most professions consider the thought of having the details of all income given or received published on the Internet for general consumption anathema. Plenty of the work carried out by physicians for pharmaceutical companies is legitimate, and the particulars about the amount and quantity of honoraria or compensation are no one’s business except the person completing the work. Many physicians have already declared an end to any work with pharmaceutical companies if the payment details are released. This means that physicians may not be willing to participate in much-needed clinical trials or speak at conferences. These may be unfortunate consequences of a well-intentioned plan.

The line between compensation and bribery becomes blurrier when conflicts of interest are present that affect patient care and professional responsibility. Any financial or proprietary agreement that makes a physician more or less likely to support a particular drug or product than he otherwise would creates an impression of distrust and weakens the medical establishment. Physicians receive support from drug companies in many ways: research support, assistance with manuscript preparation and publication, speaking fees, consulting services, grants, stocks, and many other material items. While many physicians argue vehemently that these arrangements do no harm to patients or the medical profession, and that a drug company can never unduly influence physicians, stacks of literature report otherwise. Not only are physicians, in fact, influenced by these relationships with the pharmaceutical industry, but also these relationships are driving up the cost of health care. For example, one study reports that physicians are many times more likely to prescribe a particular drug after meetings with drug company representatives or participation in conferences sponsored by the industry, even if that drug was not the best-choice agent. When newer, often more expensive agents, are prescribed, the costs to the patient and the insurance carriers increase unnecessarily.

Safeguarding the public is paramount in today’s medical climate. Change is likely coming to the organization and structure of the American health care model, and the public is paying more attention to conflicts created by inappropriate relationships between physicians and drug companies. Americans spend approximately $200 billion annually on prescription drugs, and this is the fastest growing piece of the health care budget. Patients want to make sure that this money is being used appropriately and for the right reasons.

Make no mistake: the pharmaceutical industry is not all bad. Certainly, modern medicine would not be where it is today were it not for the innovative research and development of the drugs and devices made possible by private pharmaceutical companies. Drug companies do provide low- and no-cost drugs to uninsured and indigent patients and do help fund professional meetings and medical journals that provide current and candid information. But, the industry is a for-profit business whose sole purpose is to make money. Like any for-profit company, the pharmaceutical industry seeks profits through wise investments. The investments, in this case, are relationships with physicians.

Why do physicians engage in relationships that some deem, at the very least, questionable? Many are motivated by entitlement. One study reported that, despite strong efforts of medical schools to discourage gift taking from pharmaceutical companies, an overwhelming majority of medical students felt entitled to these gifts. Even those that reported being troubled by the gifts accepted them. Recognition and belonging motivates other physicians to accept the largesse offered by the drug industry. It is undeniably desirable to be recognized as an expert, or at least invited to a fancy steak dinner to mingle with colleagues. And, in this day of decreased reimbursement and increasing costs of medical education and business ownership, money is an irrefutable, and understandable, motivator for many physicians.

Many academic medical centers and professional organizations, including the American Medical Association, support the new federal legislation and have previously renounced the idea of industry handouts. Gifts — in any form — from the pharmaceutical industry to physicians have the potential to compromise the objectivity of treatment decisions, increase the costs of health care, and erode the trust of the patient-physician relationship. While federal legislation disclosing financial details of these relationships may not be the answer, physicians need to carefully examine their own relationships with the pharmaceutical industry and consider the implications on their professional relationships.

References

Kondro, W. (2008). Pharma giants to create databases on gifts to physicians Canadian Medical Association Journal, 179 (11), 1118-1118 DOI: 10.1503/cmaj.081669

LICHTER, P. (2008). Debunking Myths in Physician–Industry Conflicts of Interest American Journal of Ophthalmology, 146 (2), 159-171 DOI: 10.1016/j.ajo.2008.04.007

MARCO, C., MOSKOP, J., SOLOMON, R., GEIDERMAN, J., & LARKIN, G. (2006). Gifts to Physicians from the Pharmaceutical Industry: An Ethical Analysis Annals of Emergency Medicine, 48 (5), 513-521 DOI: 10.1016/j.annemergmed.2005.12.013

As Election Day draws near, I imagine that both McCain and Obama are exhausted; both have been run through the ringer. After all, they must endure non-stop campaigning schedules, high pressure debates, and the constant scrutiny of the press. Along with this, every aspect of their lives are being examined under the most powerful of microscopes. From tax records to religious affiliations to personal friendships, both men are left bare, no secrets uncovered.

This openness extends to their health histories as well. Both candidates issued records or statements detailing major health issues. Not surprisingly, Obama, 25 years younger than McCain, has a clean bill of health; the only exception is his difficulty kicking the smoking habit.

McCain’s record is fairly impressive as well even though he is 72. Along with his past problems with melanoma he may need joint replacement therapy down the road, a result of his time spent as a Prisoner of War (POW). Along with this, his records note that he tried to hang himself, eight months into his 5+ years spent as a POW. He was found to be mentally stable after being examined for mental disorders and we can assume that his suicide attempt was a rational decision considering the circumstances he was in.

Initially I was surprised upon reading this. After all, McCain’s strength of character, proven by his perseverance during his POW days as well as through other reports from those who know him well, seems to be contrary to this act of desperation. Don’t get me wrong, I don’t fault McCain because of this; he is a human susceptible to human weaknesses and certainly he was in the midst of more devastation and pain than many of us can imagine. This image just didn’t concur with the fiery candidate that I see on TV.

But eventually my surprise over his health details gave way to curiosity. Today he still suffers from ailments related to his time spent representing our country. This coincides with the reports that McCain’s patriotism and dedication to his country is intense. And it seems as if this would go a long way towards drawing voters. After all, for a future president, what speaks louder than loving your country so much that you are willing to suffer intensely?

Well, quite a bit it seems.

Most polls show McCain trailing Obama by a substantial margin. It seems that there is something more important to people than patriotism, the good old-fashioned War World II Generation-goodness. Don’t get me wrong, I do not doubt Obama’s patriotism but McCain’s past is textbook-flag-waving-country-first-stuff.

What is it that Americans value more highly than what McCain offers? Obama’s calmer and steadier demeanor? Liberal views? A change in ranks? Do our changing values represent progress? I don’t know.

But what I do know is that McCain’s type of patriotism may be dying. Excluding the military, you seldom hear young people talk about their country in endearing terms. And you certainly don’t see many who feel so strongly for their country that they are willing to put country above all else.

Obama may be the face of the future but for the sake of our country, I hope that McCain’s brand of patriotism isn’t a thing of the past.

Reference

F. Charatan (2008). Records of presidential candidates show McCain has had melanoma and Obama is using nicotine replacement therapy BMJ, 337 (oct27 2) DOI: 10.1136/bmj.a2260

Since the debate Obama’s running mate, Joe Biden, responded to McCain’s implications with, “If it walks like a duck, if it looks like a duck and it quacks like a duck, it’s a duck!”

But regardless of the promises or perceived merits of either candidate, no one really knows what a McCain or an Obama country would look like. We listen to their words, review their records, and seek out the truth but as to the reality of their campaign promises, it’s anybody’s guess. And as to Biden’s duck analogy… well, it’s a possibility but not a guarantee.

Still though, McCain’s ties to the conservative voter base rattles me somewhat. Not that I’m against his views particularly but I worry about the attitude that seems to be prevalent among some republican supporters. In extreme cases, there seems to be an undercurrent of intolerance, sometimes to the point of crazed hatred. When your supporters yell, “Kill him,” that’s taking campaigning too far. It makes me wonder if the Republican base is healthy? Are common sensibilities and the ability to be un-objective when necessary less prevalent among this group?

I direct this question to republicans instead of democrats for two reasons. One, mentioned above, has to do with the dangerously frenzied sort of atmosphere that has been reported at republican rallies. And my second reason has to do with Bush, the current republican president. It seems that the Bush administration hasn’t exercised common sensibilities regarding health issues. In a BMJ article, Douglas Kamerow points out that over the last eight years this administration has made choices in regards to health issues and policies that seems to shrug off scientific knowledge in favor of personal views and interests. It seems that many times Bush was “an army of one” when dealing with hot-button and high-profile issues — refusing to use science as a basis for decisions and doing… well, what he (or his administration) just wanted to do. The Union of Concerned Scientist has documented many of these instances including:

• Insisting on and publicizing the effectiveness of abstinence only sex education, despite a lack of evidence for it.
• Censoring testimony before Congress by the Centers for Disease Control and Prevention (CDC) on the health hazards of climate change.
• Posting erroneous data linking abortion and breast cancer on CDC’s website.
• Distorting evidence on the effectiveness of condoms in preventing HIV transmission and prevention
• “Stacking” a federal advisory committee on prevention of lead poisoning to prevent more stringent standards.
• Adding non-scientific proponents of positions favored by the administration to sessions at scientific meetings in the guise of providing “balance.”

Along with these actions, this administration directly influenced other key issues by refusing to publish evidence, allowing invalid data to influence decisions, and changing test results. Even more disturbing is that this administration, “…prevented its own surgeon general from speaking out on topics in the areas of mental health, global health, and secondhand smoking.” In other words our health policies have been based, at least partly, on a very biased and self-serving administration.

Is this pattern related to the republican’s large evangelical christian voter base? Possibly knowing that many of your constituents agree with the outcome, if not the means, may have allowed Bush to endorse these methods. But I am going to venture to say that most members of this subgroup would not sanction these unethical methods. Most rational opponents of say, sex education or abortion would not want misinformation to lead the argument for policy changes. Logical arguments that are not based in science exist for every issue so there is no need to distort scientific results; this only leads to more governmental distrust and is misguided.

Both ideologies, support bases, and candidates have taken on a life of their own by this point in the race. Will McCain’s views cause him to do the same as his party’s predecessor? Could Obama push his views or his constituent’s views via this same avenue? I hope not. An intolerance to science is dangerous for everyone — regardless of party ties.

Reference

D. Kamerow (2008). Politics and science: a cautionary tale for the presidential candidates BMJ, 337 (oct14 4) DOI: 10.1136/bmj.a2093

The ADA opens up wonderful opportunities for people wanting to pursue their careers even after a severe medical condition. It also has several guidelines for accessibility of the community — from specifications of the height of water fountains and sinks to measurements on width of doorways and hallways. These regulations allow easy maneuvering of wheelchairs and other equipment, making the community completely accessible to everyone without discrimination.

It is extremely heartening to see children and adults with disabilities benefiting from these legal guidelines. Because of such regulations, families can attend local community events, travel, and even take long vacations together. Granted, it takes some additional planning and effort, but at least they have the option. Not all countries are so accessible or inviting to persons with disabilities. In some countries, a disability pretty much means the end of life as one knew it.

The terms “disability” and “handicap” take on a much more literal and ominous meaning in developing nations. A young boy with a complete spinal cord injury in the cervical area will be confined to bed; unless carried by his family member or an aide. An elderly gentleman with a stroke will remain restricted to mobility within his apartment because he cannot navigate stairs, and his multi-storey apartment does not have an elevator. The concept of wheelchairs is a luxury — available only to the really affluent who can afford to have equipment custom built or imported from other countries. Corrective bracing and artificial limbs for persons with muscle imbalance or amputations is available, but very rarely used effectively. This is due to many factors like cost, lack of awareness, poor education and social stigma.

One hopes that the trend will gradually change. More businesses in the USA are taking ownership for issues around the world. Some companies that manufacture limb prosthetics and braces work closely with patients and their families. They collect old braces that patients have outgrown and donate them to countries that require them. Other companies offer financial support to smaller businesses in poorer nations. The World Health Organization (WHO) also funds educational programs that spread awareness about issues such as these. They even provide specific training programs for bracing and prosthetics.

All of this will lead to a more global solution to the effects of disability and loss of function.

Online Resources

The Americans with Disabilities Act.

The World Health Organization.

Should the government mandate a health care plan or should insurance carriers do a better job of providing coverage?

The Democrats, led by Presidential candidate Senator Barack Obama, plan to rely on a “play or pay” system that would improve access to insurance and move the United States toward universal coverage. This system builds on the predominating employer-sponsored insurance coverage that has been a cornerstone of the American workforce since the 1940’s. Under the Democrat’s plan — which is a resurgence of the plan of choice for many Democrats in the 1990’s — employers would be required to offer employees insurance coverage or pay a tax.

This plan would retain private insurers, but would heavily regulate the industry to ensure that all Americans had access to coverage. Provisions are in place to allow currently insured Americans to keep their current coverage, if they so choose. Under Obama’s plan, Americans without access to other group coverage could either choose a new government health care plan that would be similar to Medicare, or choose a private insurance option from a national health insurance exchange.

Obama also plans to establish purchasing pools for businesses to increase access to coverage, provide subsidies to low-income families for the purchase of health insurance, and expand current government programs, like Medicaid and the State Children’s Health Insurance Program to cover more low-income Americans. Further, regulations would be in place to prevent insurance companies from denying coverage for pre-existing conditions or charging high premiums to sicker individuals.

The impact that Obama’s plan might have on coverage is impossible to assess. It depends on the extent of subsidies offered, prices of premiums, and total payroll tax offered to employers. For example, if the employer’s tax is set too low, many employers would likely choose to pay it rather than continuing to offer coverage, and enrollment in a national plan could be substantial – substantial enough that the funds may not exist.

Also, like McCain’s plan, Obama’s plan may not cover all of the uninsured Americans today. The Republican’s plan offers no mandates for coverage, but the Democrats do mandate coverage for children. With no mandate on adult health care, many uninsured adults could remain without health insurance. (Obama has not ruled out a mandate for adults in the future if the plan does not lead to universal coverage.)

The Democrats plan to finance this new health care system by repealing tax cuts adopted by the Bush administration for families making more than $250,000 annually. (Interestingly, the Congressional Budget Office already plans on these tax cuts expiring in 2010, so their expiration may not generate the necessary $50 to $65 billion to finance the program.) The tax paid by employers who do not offer coverage would also help fund government coverage.

Like the Republican plan, the Democrats also plan to control costs by encouraging the use of electronic medical records, promoting disease management, emphasizing prevention and public health, and paying providers based on health outcomes. All of these are certainly laudable goals for either side of the political aisle, but it is unlikely that any of these measures will significantly reduce costs in the short run.

Senator John McCain and the Republicans support a system of free markets and deregulation, while Senator Barack Obama and the Democrats support employer mandates and new regulation as a means of reforming our broken health care system and expanding access to health coverage. Both of the candidates promote a platform of health care reform, but there are certainly no guarantees that any reform will come about in a timely fashion. Even if he can incite reform, the likelihood of a new system looking anything like either of these two plans is remote. Both plans still leave behind uninsured Americans and lack significant funding sources. Change is coming, but which change is best for all Americans?

References

J. Oberlander (2007). Presidential Politics and the Resurgence of Health Care Reform New England Journal of Medicine, 357 (21), 2101-2104 DOI: 10.1056/NEJMp078202

J. Oberlander (2008). The Partisan Divide — The McCain and Obama Plans for U.S. Health Care Reform New England Journal of Medicine, 359 (8), 781-784 DOI: 10.1056/NEJMp0804659

R. Steinbrook (2007). Election 2008 — Campaign Contributions, Lobbying, and the U.S. Health Sector New England Journal of Medicine, 357 (8), 736-739 DOI: 10.1056/NEJMp078151

Health care reform is an important issue of the 2008 Presidential election, and both Republicans and Democrats are proposing radical changes that will change the face of health care delivery in this country. Both sides of the political aisle aim to make health care more affordable and control escalating costs. Both Republicans and Democrats also plan for employers having a smaller role in medical benefits. The differences in how each side wants to achieve these goals are striking, however.

The Republican plan, lead by Presidential nominee Senator John McCain, creates a national insurance market that gives consumers more power and choice than we currently have. McCain plans on eliminating the tax break given to employees if their employer provides health care. This tax exclusion dates back to the 1940’s and originally allowed employers to compete for workers by offering tax-free benefits instead of higher salaries. This also allowed employers to provide better benefit packages than employees could buy with their own after-tax dollars.

Under McCain’s plan, benefits would be taxed as income, generating nearly $3.6 trillion in government revenue over 10 years. However, he proposes a $2500 tax rebate for individuals, $5000 for families, to compensate for the increased tax burden. This is a more equitable allocation of resources, as each American — employed or unemployed — receives the same tax rebate under the new plan, while the tax exclusion now in place is based on the employee’s tax bracket. On the other hand, while employees would now be able to buy the same benefit packages as employers, the incentive for employers to provide coverage would come to an end. Some experts believe that under McCain’s plan, employers would stop paying for heath care within 3 to 4 years.

Without employer-provided coverage, individuals could choose a plan that better meets their needs, age, health status, and stage of life. McCain’s plan deregulates insurance markets and encourages competition. He would allow people to purchase insurance plans across state lines, enabling us to shop for lower-cost, more comprehensive plans that suit each person or family’s needs.

John McCain also plans to change the way Medicare receives payment for services. Rather than fee-for-service reimbursement, he proposes payment for episodes of care, and payments based on outcomes. These changes would encourage broader reform in the health care system and promote accountability among health care providers.

Further, John McCain plans to speed up generic drug development, encourage prevention in health care and the management of chronic diseases, adopt malpractice reform, and enhance the use of health information technology. However, under McCain’s plan, most uninsured Americans would remain uninsured. The high prices of health insurance, even with a tax rebate, may be unaffordable to low-income workers, especially if employers discontinue providing benefits. To improve access to coverage, McCain proposes a “guaranteed access plan” to create insurance alternatives for people still unable to afford or obtain health care. Currently, 34 states operate similar plans for medically uninsurable residents. Sadly, these plans encounter high costs, limited benefits, and exclusions for pre-existing conditions and offer no real relief from commercial insurance plans.

The Republican’s health care reform package is far from perfect, but is an interesting comment on the Republican’s view of free markets. This plan aims to treat health care as a resource, not an entitlement, and encourage nationwide competition. The Republicans believe that an important step in controlling health care costs is to treat Americans, not just as patients, but also as consumers.

In health care and politics: The Democrats, we will examine the health care reform plan of Barack Obama and the Democrats.

References

J. Oberlander (2007). Presidential Politics and the Resurgence of Health Care Reform New England Journal of Medicine, 357 (21), 2101-2104 DOI: 10.1056/NEJMp078202

J. Oberlander (2008). The Partisan Divide — The McCain and Obama Plans for U.S. Health Care Reform New England Journal of Medicine, 359 (8), 781-784 DOI: 10.1056/NEJMp0804659

R. Steinbrook (2007). Election 2008 — Campaign Contributions, Lobbying, and the U.S. Health Sector New England Journal of Medicine, 357 (8), 736-739 DOI: 10.1056/NEJMp078151

In 2006, the military outlawed harsh interrogation techniques such as waterboarding, hooding, and using military dogs. However, detainees can be kept in complete isolation for up to 30 days, which could result in post-traumatic stress. Some military psychiatrists and psychologists have been involved in teaching specific psychological concepts, such as learned helplessness, to military personnel. Physicians and psychologists do have a responsibility, not only ethically, but also mandated by the military to report inappropriate and coercive interrogations to the proper authorities. However, that means that the physicians have to be involved on some level in the interrogation, even if it only viewing it, which goes against the issued statements by the APA and AMA.

Some military psychologists have argued that they should be involved to make sure that the detainees and prisoners are treated well. In other words, they feel that if they were not there to supervise, the interrogations of the prisoners would be harsher than necessary. However, this position goes against what the professional organizations recommend. This leaves some military physicians and psychologists in a bind; on one hand they feel morally obligated to monitor the well-being of detainees but on the other hand, it is unethical for them to do so.

Many physicians believe that treating prisoners well, being kind to them is much more effective than harsh interrogation or even other more mild but aversive interrogation techniques. There is evidence so support that belief. Information given when under duress is often unreliable; social psychologists have been studying a related topic –- eyewitness testimony –- for a number of years. They have found that individuals under a lot of stress, such as having a gun pointed at them, are much more unreliable than outside observers. So, there is considerable theoretical evidence that treating prisoners as humanely as possible both inside and outside interrogations leads to the most reliable information.

Should medical and health care professionals be directly or indirectly involved in interrogation? If so, what should their roles be? If not, why shouldn’t they be involved? Do you agree with the position of the APA and AMA? Should physicians and psychologists even be involved in the general training of military interrogators?

Reference

J. H. Marks, M. G. Bloche (2008). The Ethics of Interrogation — The U.S. Military’s Ongoing Use of Psychiatrists New England Journal of Medicine, 359 (11), 1090-1092 DOI: 10.1056/NEJMp0806689

BMJ’s article, New York’s road to health, quickly brought to mind one of those sayings in just two simple words:

Money Talks

If you’ll allow me to though, I’m going to add three words to this saying to make it even more apropos for this topic:

Across the Board Money Talks

In Karen McColl’s feature story, New York’s daring health initiatives are summarized with an emphasis on the role that current New York City mayor, Michael Bloomberg, plays in these events.

New York City has plenty to boast about when it comes to health mandates that have successfully been put in place: the Smoke Free Air Act, the phasing out of trans fatty acids from many restaurants, and requiring certain restaurant menu items to list calorie information. But the most recent health initiative is the one that I found surprising.

As part of a pilot project, selected low-income families can earn money for taking care of themselves and their families. How much money?

• Maintaining subsidized health insurance — $20 per parent group, $20 for all children
• Keeping up private or employer insurance for the entire family — $50/month
• Attending an annual medical check-up — $200 per family member
• Attending suggested follow-up visits within the correct timeframe — $100 per family member
• Attending regular preventive dental check-ups — $100 per family member

It is suggested that Mayor Bloomberg’s unique leadership and personal qualities are largely responsible for enabling New York City to make such huge and powerful public health gains. Not only is he highly dedicated to public health in general, he has money.

Bloomberg is a private philanthropist who donates vast amounts of money to health causes. Plus, his connections and personal monetary strength means that he has a wide breadth of influence.

I’m not suggesting that the city’s success hinges upon Bloomberg’s wealth. In fact, Dr. Frieden, the health commissioner doesn’t mince words. He states:

None of these things would have been possible without [Mayor Bloomberg's] leadership. It took a lot of political effort to get these things through, and it involved taking a lot of political heat to do the right thing. They are all now very popular, but getting them through meant standing up to vested interests and doing things that lead to a fairly brutal critique in the tabloid newspapers. And Mayor Bloomberg was willing to do that because he knew that it would save lives.

The barriers that prevent disadvantaged families from taking care of their health are beyond the scoop of this article but I am optimistic that this plan will work because money is behind the initiatives. From both the man who is the “face” of the program to the money provided to the families who follow the requirements, money is involved. And money talks.

Reference

McColl, K. (2008). New York’s road to health. BMJ, 337(jul08 3), a673-a673. DOI: 10.1136/bmj.a673

People in persistent vegetative states usually cannot survive on their own and have to have a feeding tube. They do not, usually, have to be on full life support because the brainstem is intact. This differs from brain death (not technically a medical term — it’s a legal term) where the brain and brainstem also have no activity; people in this state have to be on full life support. While many people can spontaneously recover from a persistent vegetative state, it is possible that those who do so were misdiagnosed to start.

Politics comes into play because some people clash over how to deal with people in persistent vegetative states. In 2005 the Terri Schiavo case brought national media attention to this condition. Terri’s husband finally prevailed and Terri’s feeding tube was removed. She died within two weeks. A CT scan of hers is readily available online. It shows considerably enlarged lateral ventricles and marked cortical atrophy. Her pathology report indicated severe loss of cortical neurons in nearly every part of the cortex. There was no chance that she could ever recover functioning.

Ms. Schiavo had been in the vegetative state for 15 years at the time of her death. Some people still consider her death a court-sanctioned murder (these generally are people without any knowledge of the functioning of the brain). Her brain was in such poor condition that it was likely very similar to what would happen if all the white matter connecting brain regions together was severed and most cortical and many subcortical neurons destroyed, leaving her brainstem mostly intact. The political-legal conflict occurred in part because her parents kept hoping beyond hope for a miracle while her husband stated that Terri wouldn’t want to live how she was living.

Again, my belief is that people who spontaneously recover from persistent vegetative states were misdiagnosed to begin with. In any case, as time goes on recovery from a vegetative state becomes more unlikely with greater cognitive deficits. Schiavo was in a state where even if she had recovered she would have had very little cognitive abilities. One of the positive outcomes of Schiavo’s case was the scrutiny of vegetative states, with neurologists seeking for clearer definitions and more sensitive tests.

Medical malpractice is a form of tort law. What this means is that a tort is a civil wrong or grievance for which a remedy must be obtained. Basically the remedy is in the form of damages. Thus in tort law someone is upset and wants repayment for an action.

The key question at hand is when does a patient have a legal grievance against a physician? Essentially, a patient must show that a physician had a duty to him/her and that it was violated, and that the violation harmed the patient. Typically, it is easy to show that a physician had duty to a patient. Similarly, it is easy to show that a patient is harmed when it is a physical outcome that they are concerned about. It is usually difficult to show that the physician violated his duty to the patient and that the violation caused harm.

It gets complicated because in medicine there is a standard of care that varies according to region, specialty, and circumstance. There are some absolute standards that cannot be violated. These would typically fall under the emergent care scenario where a person must be resuscitated and hemodynamically stable before further care can be given. But what about the grey area?

Should a homeless person who needs elective surgery be operated on when the chances of post-operative infection are unreasonable?

Should every elderly patient who has symptoms of pneumonia be admitted to the hospital?

The problem with medical tort cases is that the standard of care varies according to which expert you speak with. A practitioner in Boston may not agree with a practitioner in San Francisco.

Thus if you are a physician, it is very important to get to know other practitioners in your area and to stay up to date with the community standard of care. If you are a patient it is wise before bringing a tort action to get several opinions.

One important thing is to know that most physicians do not like to testify in court against other physicians. You will be able to find someone who will testify, but in general we all take the Oath of Hippocrates and do whatever we can for the patient. Mistakes can be made, differences in treatment can be made. It is not with intention that bad outcomes happen.

Despite physician’s fear of litigation as well as the threat of litigation from patients, the language used by both parties often reveals that most doctors and most patients really have no idea what type of actions could hold up in court and what types of actions could actually be a valid claim.

I previously mentioned “Sentinel Events“. Those are mostly no-brainer types of events such as operating on the wrong extremity or treating the wrong patient. Aside from those sentinel events, there are generally two key elements required for a physician-patient relationship to be initiated:

1. Contract — There must be a written or non-written contract between the physician and patient. This may be initiated when a patient seeks care and the physician agrees to take care of the patient.

2. Consent — The physician and patient must agree to the physician-patient relationship and each has the right to refuse to enter into it.

If those two elements are not met, then the physician has little to fear and the patient likely does not have a valid claim.

If those elements are met, then a physician-patient relationship is established. What this means is that the physician has Duty and Responsibility to the patient. In other fields of law, this is referred to as Fiduciary Responsibility. Essentially, this means that one person acts in a position of trust or confidence for the benefit of another.

It is usually obvious when a physician-patient relationship exists or is established. Typically, patients see physicians in their offices to establish that relationship. But there are circumstances that question whether both a contract or consent have been fulfilled. One example is when a physician contracts to provide services to a hospital to provide services to patients in the Emergency Room. If the physician declines to treat or admit a patient, he/she probably does not realize that a physician-patient relationship may already be established by the fact that he contracted with the hospital and that the patient came to that hospital’s Emergency Room.

Another example may be when a physician “unofficially” consults another physician for his treatment recommendation for a patient that the consulting physician has never seen or treated before. By providing advice, it may be viewed as that physician entering into the physician-patient relationship.

As you can imagine, all of these laws vary interpretation and enforcement from state to state. In future posts I will bring up some case examples.

Physicians as a voter demographic are a tough nut to crack. Surgeons and wealthier physicians usually align with republican principles of lower taxes, small business support, and separate public and private health systems. Public health and primary care physicians generally tend to align with democratic principles of improving access to care to all individuals and more socialized medicine. In general physicians tend to be altruistic individuals who entered medicine to help others. Yet medicine is a profit driven industry. Thus, there is a little democrat and republican in every physician.

Healthcare is and will continue to be a hot-button issue in presidential politics. Unfortunately, there is no easy solution to the healthcare mess. What is clear is that the government simply cannot afford to pay to take care of its aging population. Additionally, it cannot afford to take care of its young or immigrant population. It really cannot afford to take care of everyone who lives within its borders. Attempting to do so would bankrupt the country, significantly cut the wages of anybody who works in healthcare in any capacity, and would significantly drive down the discovery of new medicines and technological advances to help people.

We live in an economic system of “give and take.” There is no free ride for anyone anymore. To give to someone literally means taking from another in terms of budget allocation.

Unfortunately, the future of budget cuts and decreased reimbursement appear gloomy, regardless of whether you are Republican or Democrat. The end of the current healthcare system will come in this lifetime. The question is to we want the change to be slow and painful or fast and potentially more or less painful?

Any change within the healthcare system will be felt by all — physicians, patients, anybody and everyone who works in and utilizes the healthcare system. Regardless of who is president, we know change is coming soon. How are we going to deal with it?

Fundamentalists need to realize what a big world it is that they have insulated themselves from. One way to get through to them (my educated guess) is to walk them through the history of the science involved in determining the age of the earth, so that they could see the pieces fitting together, and gain a more realistic respect for science, and for what challenges these scientists faced in breaking out of conventional reality.

Fundamentalists don’t realize that there is a vast range and quantity of information behind major scientific theories, and they don’t know how many scientists and researchers have been involved and for how long. They don’t know the extent to which diverse fields offer information that supports a single theory.

But fundamentalists need to realize that when there are discrepancies, this is part of the process. It doesn’t mean that the theory should be abandoned. I saw this kind of thinking in writings on intelligent design, when I participated in a challenge from a fundamentalist. A good theory gets refined or expanded because conflicting information is used to generate better questions and hypotheses. When in history did a major theory not only turn out to be wrong, but also revert back to the superstition or religion that it attempted to supplant? Never. The early theory of autism (that it was caused by cold mothers) was wrong, but it was abandoned when it was subjected to scientific scrutiny. It did not come from scientific thought. The theory was a mashup of ideology, coincidences, and maybe some issues with mom that never got resolved.

Here’s a big challenge, and it is much of my motive for suggesting the games. Normally, when magical thinkers are confronted with new information, they generate post hoc rationalizations. Sociologists have marveled at this for a long time, and published an interesting account of cult members who were anticipating the end of the world. When it didn’t happen, they came up with an explanation about getting a reprieve, and hung onto their belief system.

Imagine this reality TV show, Creationists vs. Scientists. The question wouldn’t be, “Who’s right?” but rather, “Who can debate the most ethically?” The final scoring and money going to a charity would add interest. Or have a series of very polarized debaters, such as Bigots vs. Civil Rights Activists, or Scientologists vs. Psychiatrists. The possibilities may not be endless, but they’re worth a TV season!

Now imagine that our public schools all require a basic knowledge of the ethical rules of debate. Imagine a country in which every citizen can see politicians through this lens. If a democracy depends on having an educated public, then this might be the best possible place to start. Without it, any good idea is vulnerable to unethical attack. Judging from what goes on in what passes for news in the United States, I think democracy is straining under a concerted attack.

Introducing the word “ethical” is an important part of this. After all, what fundamentalist doesn’t want to be a champion of ethics? And it would be very difficult for a person to challenge these rules.

I’d like to see every child play this game at least twice a year from the time they are eight years old. It should also be a structure for political and policy debates, with a profession of moderators who provide the scoring service. I’d also like to see this happening on the news and analysis shows, in which a running score is kept as a percentage of ethical versus unethical statements by leading figures, especially politicians. News services could add a truth percentage as well. What percentage of their assertions is true versus untrue versus “as yet unverified”? Imagine comparing the politicians side by side on the ethical debate and truth telling percentages? How would the public react to this? What kind of public discussions would this create? Some folks posting to YouTube.com are having a lot of fun posting contradictory statements of politicians together in the same video. It’s better than a lie detector!

It’s best to have a trusted, objective third party who will be the Decider. When there is controversy over when to award points, the Decider gets the final say. If there is more than one, it should be an odd number so there is a deciding vote. Each debating party can call to have points awarded to them when the other party violates one of the ten rules.

A variation on the games is to record the discussion, and then listen to it to award points. This isn’t as exciting, though, and it won’t modify behavior during the discussion. But having cash stakes will help keep it interesting.

1. No Personal Attacks – 10 points

When you can’t defend your ideas, admit it. Unethical people try to hide the fact by attacking the other person, as if that attack means that their opinions or facts are wrong. Example, “You hate America.” (Names: The Ad Hominem Attack, Argumentum ad hominem, attack aimed at the person)

2. Stop Repeating Yourself and Getting Louder and being Intimidating – 8 points

Some people think repeating themselves or getting loud makes them right or erases your facts. You may need a third party to decide where to draw the line, after all, debates do get heated, and people do need to restate their positions at times. Each can challenge the other to add something new so that it isn’t just a repetition, or to restate it in a normal tone of voice, to prevent points from being deducted. This is more to keep things from turning into a circus, rather than to win points, because challenging the behavior engages the person who is getting antagonized in something other than reacting at the same low level as the other party. Names: Argument to the point of disgust (argumentum ad nauseam), appeal to force (argumentum ad baculum, latin for appeal to the cudgel or stick, arguing via intimidation).

3. No Rewriting the Other Person’s Opinion – 8 points

Don’t tell the person what their opinion is and attack your version of it. Ask them if you understand their opinion first. Unethical people will change the other party’s opinion into something stupid, immoral, or incorrect, and accuse the other person of being wrong based on that. (Name: The Straw Man Attack)

4. Interruptions Allowed When? – 6 points

Interrupting is usually a manipulative tactic. William F. Buckley was adept at knowing just when to interrupt in order to unethically interfere with others. He could even prevent a brilliant thinker like Noam Chomsky from getting is key points across. However, if your sparring partner is repeating and hogging the conversation, then you may interrupt to renegotiate the discussion without losing points. This can be a point of contention, of course. This is a good reason to have a time-limited turn taking format. If you’re dying to interrupt because of what the person just said, but it wasn’t a chance for you to score a point, then respond to the issue when they are done speaking or you’ll lose points. Coercive questions qualify as interruptions. Don’t try to control your sparring partner with questions such as, “Just answer this yes or no!” This is a debate, not a cross examination or Fox News.

Okay, now we’re past the most barbaric items. However, the remainder are not all that subtle.

5. Don’t Make Stuff Up – 4 points

People who put winning ahead of ethics will make things up. If you have source materials or an Internet connection, you can stop the clock and look it up. You should both be prepared with materials or links to defend your assertions as to factual information. This rule can only apply to single facts that can be checked. Broader assertions are the kind of thing that gets debated, so they are not subject to this rule. A checkable fact would be the number of dead that credible authorities have estimated occurred as the result of a war. A broader assertion would be that a country has only entered certain conflicts to enhance the power of the super wealthy interests that it serves.

6. No Gross Generalizations – 2 points

A few examples don’t make a general fact. If some criminal CEO’s were Christians, not all Christians are criminals. There is a television commentator who will respond to a good challenge in a debate by throwing out one of each of these: a newspaper headline, a cliche, a stereotype, and a familiar media image. Then he looks at his opponent with this Mona Lisa smile, as if he’d just made a point. Names: I invented a name for this move, the Cornpone 360, because of the ridiculous rhetoric used in the play Lil’ Abner by politician Jubilation T. Cornpone, and the way the commentator would work around this circle of items to achieve a generalization (actually clocking around his imaginary circle with gestures and eye movements). Also: The fallacy of the undistributed middle, and sweeping generalization (dicto simpliciter, latin for “spoken simply.”)

7. No Invisible Authorities – 1 point

Specify who you are talking about. Here’s an example of unethical rhetoric: “Science lost its credibility when ‘consensus’ was inserted as validation of science. (i.e. Global Warming)” The idea that science lost it’s credibility is a real howler. Who are the people that stopped believing in science, exactly? Who changed science so that consensus alone validated it? This statement is really meaningless, and when the person is challenged to specify who the people are, it becomes more obvious. Often, these statements require the passive voice to hide the fact that they don’t know who they are talking about. If you ask “who?,” and the other party can’t tell you, then you win a point. The example above would net you two points. Name: Appeal to authority (ad verecundiam)

8. No Mythical Authorities – 1 point

The facts don’t care if George Washington believed it. If you are debating about facts, then debate about whether you can verify them. If you believe that people will do unethical things because they believe in evolution, don’t say evolution is untrue, discuss your basis for believing that these unethical things will happen, and how they can be prevented. If you think something is unnatural and therefore wrong, don’t waste my time with that. Hemlock is natural, getting an X-ray of a broken bone is unnatural, lightening rods are unnatural. Tell me what bad thing will happen as a result of this unnatural thing. Is homosexuality unnatural? What bad things have happened where communities have accepted homosexuality, then tell me how you know those things happened and that they don’t happen in other communities. (Names: The appeal to authority (argumentum ad verecundiam), and the appeal to nature, the argument to antiquity or tradition (argumentum ad antiquitatem).

9. Incomplete Theories are Not Completely Wrong – 1 point

Don’t throw the baby out with the bath water. You can find glitches in evolutionary theory and in the aging of the earth. That doesn’t automatically mean that evolution does not exist and that the Biblical age of the earth is automatically proven. Name: Argument to logic (argumentum ad logicam, the fallacy of assuming that something is false just because you found an argument for it that is wrong).

10. A Million Flies Can’t be Wrong! – 1 point

Don’t insist that it’s true just because a lot of people believe it. I don’t care if everybody knows it, support your opinion. Name: Appeal to numbers (argumentum ad numerum), appeal to the public (argumentum ad populum).

There are other notable violations of good rhetoric, but I believe the above are the most important “wedge” concepts to create an intellectual environment where a functional debate is possible at all. If just these were widely understood, then we’d all be better off.

Wikipedia lists logical fallacies. As of this writing, there are 75. There is a page for each, and there are categorical listings. It is a good idea to be ready to respond to each type of fallacy in a way that makes it obviously wrong.

In part three, I’ll provide some additional ideas to help you discuss things with fundamentalists in a productive way. These ideas also bear consideration for our schools. Debate is a structured activity at many schools, and scoring systems deal with matters such as how well the students were armed with information, but all students should have experience in games or debates using these ten rules.