The American Dilemma and How We Can Fix It

ON MEDICAL ETHICS

My physician in Chicago, Dr. Sherman and I had a long-term relationship until his retirement.  He ran a practice in which he knew his patients and never seemed to be overly interested in expanding his business.  His staff consisted of one nurse – a woman who happened to be Mrs. Sherman.

When I called for an appointment, there was no menu to get through to reach the right party.  Either Dr. Sherman or his wife took the call.  I could hear them turning the pages of the appointment book to find a time that was good for both of us.

All his patients had his home telephone number in case of an emergency.  I used it one time in the thirty years I saw him when I had an extremely bad case of the flu.  Dr. Sherman decided that I needed to see him right away – so he made a house call.

Dr. Sherman treated adults and he treated children.  And most of all, he treated his patients with compassion and respect.  After an appointment he always took time to sit down with me to find out how my life was going.  These conversations inevitably concluded with the statement, “I hope I don’t see you until next year for your physical – unless it’s at the symphony.”  I knew he meant that.

Hippocrates would have been proud of Dr. Sherman and other professionals like him.

Are there any Dr. Shermans left today in the practice of medicine?  If so they are well camouflaged.  Today the practice has taken on all the characteristics of our technological age and incorporated some of the worst elements of factory farming as well.

The personal relationship between the physician and patient has been replaced by the more highly efficient bar code where the individual is simply numerically identified as one of the herd, milling about the overcrowded stall.

With the lack of interpersonal relationships between physician and patient, it is easy to see how the following situation might occur.

A 23 year-old  man in Philadelphia was denied a heart transplant.  Although he is a good candidate for the procedure, the reason he was declined was because he is autistic and has other psychiatric issues.  In making the determination to reject his application, reasons that were cited included the possibility of steroidal interference with his general health.  Steroids are necessary in order to maximize the patient’s ability to accept the new organ.

There are, perhaps, better candidates for a heart transplant than this young man.  And there is a shortage of hearts and other organs which are available for that purpose.  But it’s difficult to avoid wondering about the procedures and the people who will make these determinations for all of us should Obamacare survive and go into effect.

Under the Affordable Care Act, seven as yet unnamed bureaucrats will effectively be in charge of our dispensation of medicine.  If that doesn’t frighten you it should.  Simply look at how well bureaucracy has bungled most matters with which it has been entrusted.  It’s been that way since Joseph invented the concept in ancient Egypt.

What is most disturbing to me is that when you have an impersonal bureaucracy viewing the general public as merely components which make up a herd, it is not a difficult step to begin to decide that perhaps that herd should be culled and the weak sacrificed for “the greater good.”

With no personal relationship with the victims it’s not too hard to arrive at that view, if you think of them merely as statistics – a mindset not much different from that held by the mass shooters we hear so much about of late.

If you believe that could never happen in America you are wrong.  It has happened.  It was called the Tuskegee syphilis experiment  (also known as the Public Health Service syphilis study).  If you want more details on how 600 impoverished black sharecroppers went untreated for their disease so that we could analyze its progression, you will find it at this link to the Wikipedia article.

http://en.wikipedia.org/wiki/Tuskegee_syphilis_experiment

It doesn’t take a particularly fertile imagination to question that if this one experiment has made its way to the light of exposure, are there others about which we have never heard?  And if so, how many and who are those who were victimized?

The greater good is a nice phrase.  But the good or ill that any society does must always be measured by the way it treats it’s least important member.

We must always be mindful that if we stand by silently as another group is selected as the sacrificial lambs, we have opened the door to a shift in attitude or policy and we may be the next group of sheep on the way to the slaughter house.  Both ethics and common sense suggest that we should oppose any such policy or program with all our might and strength.

Dr. Sherman passed away several years ago at the age of 87.  I suspect there are few left who are like him – physicians who have a true sense of compassion and a relationship with their patients.  People whose lives embodied the very essence of medical ethics.  Their passing is a great loss for all of us.

Comments on: "ON MEDICAL ETHICS" (10)

  1. I enjoyed this piece, but I am inclined to kind of disagree on one general conclusion you stated:

    “But the good or ill that any society does must always be measured by the way it treats it’s least important member – and on this our track record is poor.”

    I agree with the first part of your statement, and also that we are progressively forgetting the importance of this idea. However, I believe our “track record” is one of the best, if not THE best, in the world (with notable failures, also) — perhaps in the history of the world. In my opinion, Americans have done an extraordinary job, over time, of recognizing the worth of every individual, becoming a beacon of caring for not only its own poor but for the poor of other nations. And those poor in other nations would kill to live as well as poor Americans do.

    I think it’s true that some of this “caring” has been done through inefficient, misguided, and ineffective government programs, and that the direction those programs are taking today will further erode our ability to retain this focus on the individual, but current direction doesn’t make me any less proud of the positive legacy we have built – it makes me hope we can change the current direction.

    • I firmly believe that constructive criticism when given by thoughtful people is how we learn and grow. The phrase to which you refer was a last minute addition on my part. I agree that it is overreaching – and as a result, I have edited and removed it. Your point is well taken.

      Thank you for your comment and helping me in my on-going education. I appreciate both.

  2. In the case of the heart transplant, I know just enough to make an uninformed decision. But the question really does depend on whether he was able to take care of himself and the heart after transplant. The fact that he is autistic alone should not disqualify him if he can still see to his needs. Add the schizophrenia and it makes the survival rate decrease significantly. (Schizophrenics are notoriously non-compliant) so in a sense you risk that you have “wasted” a heart. Sounds cold and cruel but until we have the ability to grow spare organs in a lab, hearts are difficult to come by. And if that heart went to a better candidate, who says medical ethics did not prevail.

    I have a lot of concerns about what ObamaCare will and will not allow in the future. But we must also look at the rationale for performing all of these procedures. There are estimates that put 40-50% of the healthcare dollar are spent on tests and procedures in the last 6 months of life. Maybe that is not the ethical or even the best use of our money. Why are these tests being done? I have patients who have decided to not have chemotherapy whose oncologist still wants them to have a PET scan. Why? IF we are not treating the cancer, what is the purpose of this test other than to line someone’s pocket book.

    There is no way that government can be involved in healthcare without rationing, though this is not a new thing, despite the recent headlines. The problem with the system is that the consumer is no longer the patient regardless of what you might think. We have removed them from the responsibility of paying directly, and thus for years buffered them from the reality of what it might cost. The consumer is not the patient but the insurance company, and they are very aware of what it might cost. And maybe it is in there where the problem truly lies. (But I don’t know if we could as a society get rid of insurance or third party payers all together)

    • Thanks for your comment, Melissa. I appreciate your medical perspective on the young autistic man’s transplant. The doctors who declined him from consideration cited exactly the same arguments you advanced.

      Let’s take another case. Two patients need a liver transplant. The one is a perfect candidate for this particular organ but is a convicted serial killer. The second is not as good a match but is a pillar of the community. Who gets this organ? I think most of us would vote for the second candidate.

      Is this a far-fetched idea? Consider the late Mickey Mantle who received his transplant far in advance of his place on the official list.

      When we have an impersonal bureaucracy making decisions about our health we leave ourselves open to making those decisions not based on fact but on the prejudices which the decision maker might hold – including issues of race, gender, sexual orientation, national origin, etc.

      To me that is the real question – not only in medicine but in every aspect of government.

      • I agree. Unfortunately medicine is not black and white, and we as a profession are not as perfect as we should be. I, too, have great concerns about allowing government into the business of deciding who should get a transplant and who shouldn’t. And like it or not, financial considerations are taken into consideration with transplants. Because after a transplant the person is not magically better. There are years often lifelong treatment with anti-rejection drugs that are often ridiculously expensive. I am not saying only those that can afford transplants should get one, merely pointing out what the implications of receiving such a transplant is.
        That being said, Dick Cheney’s heart should not have been given to him, since his age alone would have disqualified him on every list. The serial killer- to me that is easy, he is the ward of the state, and I would be on the hook for his medications for the rest of his life. When we are looking to make cuts in government programs I am sure that paying for anti-rejection drugs for our prison population will probably not be accepted when granny needs help paying for her medications.
        I fully agree with your comments. I am not an expert in transplants, but do know some of the qualifications and criteria, and have treated patients who wait on the transplant lists. People are actually very charitable, I see benefits for kiddos who get their hearts but parents can’t afford their 10% to help defray medical costs, so there are ways to work with payment issues. But I don’t know how they will stay in place once the ACA is in full effect. And yet I am not willing yet to say it is the worse thing ever, because at the very least it is opening up the discussion for how we do finance our healthcare in this society and who gets what and why. I am glad though, I am not the one who has to make that decision, I only have to refer.

      • Per haps if we want medical justice truly to be blind, what we should do in the case of a transplant between two individuals who are equally qualified as recipients is to conduct a lottery. (I’m serious).

        What with the craze for Power Ball, people could at least understand that. And that’s how we decided who would be drafted in the Vietnam War.

        Just a thought.

      • I see nothing wrong with applying rules of chance, once all other criteria are found to result in multiple equally deserving, qualified, responsible, etc. candidates. Coming up with standard criteria that will allow us to conclude equivalence of “worthiness” might be tricky, but — hey! — I’m sure a federal government committee can set a fair standard. Don’t you agree?

  3. Yes the illustration you gave which I’m familiar with shows just how low uncontrolled experimentation can go. It’s somewhat in line with the Nazis who experimented on poor prisoners in the death camps. I also note that the takeover of people’s health by the governments of the day do much the same thing though they don’t intend to. The huge oversight organizations we have today squeeze doctors either through government systems or health provider systems to the point where doctors feel compelled to offer minimal services to save money for the government or health fund provider. I don’t feel these systems have patients interests in mind, only the bottom line counts.

    • “It is amazing that people who think we cannot afford to pay for doctors, hospitals, and medication somehow think that we can afford to pay for doctors, hospitals, medication and a government bureaucracy to administer it.”

      -Thomas Sowell

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