Wednesday, August 31, 2011

Shopping for Medical Care

A recent article in the highly-regarded New England Journal of Medicine began with the following sentences: "Most physicians want to deliver 'appropriate' care. Most want to practice 'ethically.'" (N Eng J Med, Aug 18, 2011)

Isn't it interesting how the author divides the medical profession into two groups: Group 1 - those who practice appropriately and ethically and Group 2 - those who apparently do not. The author does not give us any indication as to where the dividing line lies. Is the Group 1/Group 2 ratio around 90/10, or is it closer to 60/40? I hopefully and candidly believe he is alluding to the first ratio rather than the latter.

Today physicians are frequently referred to has "health-care providers" and their patients as "consumers." Merely the use of these terms has, rightly or wrongly, helped move this encounter from "doctor-patient" to "product-shopper." When one "shops" one considers a number of possibilities before purchasing. Hence the "second opinion" and sometimes even "the third (or more) opinion."

Not that there is anything wrong with that!

As some products are better than others, so are some doctors better than others. In calculating the cost of medical care, I have seen no data that speak to the cost of such "shopping." When such costs are discussed, it is assumed that one family practitioner or specialist is no different from another. We physicians know, in fact, that this is far from factual, and so do our patients. And so the "consumer (patient) shops."

But in doing so, our consumer-patient must recognize that this, too, will necessarily add to the general expense of medical care - whether it is governmentally or privately provided. Controlling health care costs is very difficult for a society that will shop for the best and the brightest who deliver appropriate care in an ethical manner!

Monday, August 15, 2011

"Ethical Boundaries" in Multiple Pregnancies

A recent article in the New York Times Magazine discussed the issue of reductions in cases of multiple pregnancies (twins, triplets, etc.) This has become an issue because of the high incidence of such pregnancies when in vitro fertilization is performed - a process necessitating the implantation of multiple eggs into the uterus of the recipient. Physicians seem to have no difficulty in agreeing to reduce a resultant quadruplet or triplet pregnancy to a twin pregnancy, but ethical issues have arisen when the mother expresses the desire to reduce twins to a "singleton." In the past twin pregnancies carried an increased risk to a normal outcome, but this is no longer the case.

Many physicians perfectly willing to perform a routine choice abortion are not amenable to reduce below twins in cases of in vitro pregnancies. One obstetrician was quoted as saying that reduction to singletons "crosses the line between doing a procedure for a medical indication versus one for a social indication." Apparently a standard singleton abortion for a "social indication" is somehow different. Another, after consultation with his staff, similarly decided against such reductions because of the lack of medical justification. One could conclude that such lack of justification is immaterial when considering a routine choice abortion

Isn't it interesting, in our world of "choice," that how a fetus is regarded is dependent on the conditions of his existence. A physician who would readily abort a product of a normal conception, is not willing to abort the product of an in vitro conception because, as one obstetrician put it: "We were in the business to improve pregnancy outcomes" and reductions of twin in-vitro pregnancies "didn't fit the criteria."

Somehow an abortion intended to reduce a twin to a singleton in an in vitro pregnancy is said to bring on a new "ethical boundary." Is there really an ethical boundary between a woman choosing to abort a single normal pregnancy and a woman choosing to abort one of a normal twin pregnancy conceived in vitro?

It is altogether possible that with future medical advances, triplets, or perhaps even quadruplets could have an outcome no different from that of a singleton or a twin. What then?
When the medical indications disappear, will the physicians quoted above refuse to reduce four to two or three to two if it be solely for "social reasons?"

It seems to me that the choice to abort either belongs to the woman, or it does not. It is black or white - there can be no gray. A woman choosing to abort or reduce a twin pregnancy, or a triplet pregnancy should be regarded no differently from one choosing a routine abortion of a single pregnancy, no matter the manner of conception. The existence of a product of conception is being terminated in both cases. Why should it make any difference whether it be one, or two, or three, or four, or what the style of conception was?

The so-called ethical boundary can not be conditional on the "style" of conception or on the number of fetuses contained in the uterus. The ethical boundary, if it exists at all, must continue to lie between "pro-choice" and "pro-life."

Tuesday, August 2, 2011

The "Nanny State", Taxes, and "Bad Behavior"

In a recent New York Times article, food columnist Mark Bittman advocated a tax on " bad food." He argues that such a tax would result in "billions of dollars annually" which he feels should be used to support the consumption of "healthy food." He also advocates that the taxes take the form of an excise tax, not a sales tax, in that the former are included in the price, whereas the latter are added at the check-out counter. There is little doubt that such tax manipulation would have some of Bittman's desired effects, but of course the burden would primarily be borne by low-income families and individuals - those who must carefully watch their dollars - whereas the rest of us would hardly bat an eye at the Bittman-estimated extra $1.44 per six-pack of Pepsi.

This raises two interesting issues - the rise of the "nanny state" and the taxing of "bad" behavior or "bad" habits, or "bad" foods as a means of generating government revenue.

The "nanny state" dictates behavior. Usually, via some form of tax, it strongly discourages certain behavior which is considered generally harmful to a person's health and welfare, thereby having a major negative economic impact on society. In its race to do so, however, it treads on individual rights that are not directly detrimental to others.

One could argue that the government, as the major underwriter of health care and general welfare, has not only the right, but the fiscal responsibility to impose "good behavior," "good nutrition," etc. on its citizens for the benefit of the country's interests and security. By virtue of its capacity as the principal provider of health care, the government acquires the right to impose regulations on how a citizen's health care should be managed. Should this be the case, the government ("nanny state") could influence not only our nutritional behavior, but the scheduling of mammograms, colonoscopies, genetic evaluations, etc. and other preventive initiatives.

Governments always need money. Our representatives are constantly searching for new revenue sources. So why not tax "bad behavior," "bad food," etc. as a means of raising dollars? This is a tax plan which is targeted to eliminate itself. If one actually terminates the taxable "bad behavior," etc. then the tax dollars would disappear! If these dollars are dedicated solely to eliminating the taxable "bad behavior," and this behavior is, in fact, eradicated, then we have a beneficial outcome. On the other hand, government may become dependent on these " behavior" taxes as a source of general income - income that was originally intended for a dedicated purpose, but in time of fiscal need, may be "borrowed" to meet pressing obligations.

Should taxes be punitive and be levied as a means of raising income? If certain behavior is deemed "bad for the nation" then shouldn't it be eliminated rather than taxed, and participation in such behavior be a misdemeanor or a felony? Bad food shouldn't be taxed - it should be removed. Cigarettes shouldn't be taxed - they should be illegal.

Where should a society draw the line between individual rights that have no direct effect on others, and societal rights imposed on all members for the general welfare.