Category Archives: Health care

Doctors as professionals

I ran across this interesting post recently which contrasts physicians with other professionals.

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Filed under Health care, Musings

My welfare check doesn’t cover the iPhone plan

Soapbox alert: This post has a deceivingly fair and balanced beginning.

Sorry for yet another post of socio-political musings, but at least I came up with a somewhat interesting title. The thought has crossed, and continues to cross my mind that the richer America has become, the more its citizens expect as a fundamental standard of living.

Perceptions about a “basic” standard of living (is this term redundant?) are affected both by time and space. Air-conditioners, weekly (or daily) fast food, cable television, cellular phones…these are all things that fifty years ago would have been considered amazingly luxurious (if they were even around), but are all things that now, I suspect, can easily be had with a typical welfare check. Even moving from Texas to New York City where the cost of living is much higher, I notice people doing without (no car, no air conditioner, no spacious apartment, no dishwasher, no in-apartment washer and dryer) and not complaining about it. Granted, unless you happen to live on Central Park West, these concessions are out of necessity. But the point remains that just as in this time period, geography factors into basic standard of living, so too within a set geographical domain (the United States), the time period affect the expectations of standard of living.

As a side note, looking historically just a generation or two will show our grandparents doing with less sugar and fewer pairs of pantyhose during World War II in order to focus our nation’s resources and attention to where they were needed most. The idea of going without, however, is entirely unknown to Generation X’ers like me. Like it or not, we’ve been fighting a war for the last four years in Iraq, but our standard of living has changed not one bit. True, this probably reflects a richer country, but it also means that societal economic sacrifice is about as foreign to me as sacrificing a goat at city hall.

But should time and geography affect our perception of whether we are barely getting by or whether we have an abundance? The poor in Africa are just as poor today as they were in 1950. The rich here are far richer. So should the poverty level be an absolute (food, clothing, shelter) or a relative index? I think I could argue effecively either way, but perhaps it should be both. Or one tempered by the other, if that makes sense.

In other words, the thought that a family can afford an SUV, cable television, a couple cellular phones on a family plan, year-round home temperature regulation, monthly movie tickets, and weekly (daily?) restaurant visits, but cannot afford basic health insurance is absurd, especially when viewed from the historical and geographical perspectives I mentioned above. Anyone who can afford all of the above is incredibly wealthy both historically and compared to all people living today. Hence, this situation is not one of wealth versus poverty, but one of wise versus misplaced priorities.

I want you to remember this the next time the discussion of universial health insurance comes up, or the next time you’re tempted to complain about the $20 co-pay for your visit to the doctor.

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Filed under Health care, Musings

Thank you, Ganden Thurman

Not too long ago, I was read with interest this letter to the editor of the free daily amNew York:

U.S. deserves better health care
Our health care system and the health of the general population of our country are a disgrace–plain and simple. It’s high time the government lived up to its constitutional duty to tend to “the welfare of the people” they are supposed to represent. Please grow up and tend to the issues at hand directly rather than blithering about such gross pseudo concepts such as globalization, privatization and capitalism. None of these abstractions has anything to do with our jobs, our country and its potential to become a more perfect union.

Ganden Thurman, Manhattan

Goodness, where to begin?

  • I would argue that it is not axiomatic that the United States’ health care system is a disgrace. By many measures we have a very effective and cutting edge medical system. (Anyone care to get an elective gallbladder done in Canada or Britain? That’s right…you’ll have to wait. A long time. That is, unless you have money to go the private route, I’d assume.) Yes, one might argue that the richest nation in the world should provide health insurance or coverage to every citizen. This is not, however, an inalienable right granted by our constitution, and I think its time we stop treating it as such. In other words, discussions about universal health coverage should begin, “Since we’ve progressed to where we are as a nation, let us consider as a society the advantages and disadvantages of providing universal health insurance to all citizens,” not, “Our health care system is a disgrace.”
  • I might agree with you that the health of the general population is a disgrace. The difference, however, is to whom to assign blame. You clearly blame the government. I, from my humble 6 years in the field of medicine, blame the population. People who make bad choices and then expect the government to fix the problem are dead weight on society. If every American ate appropriately, exercised 30 minutes a day 4 to 5 days per week, stopped smoking, did not abuse drugs, drank alcohol in moderation, and followed his doctor’s recommendations, I suspect that the Medicare coffers would burst at the seams. So perhaps that righteous indignation, sir, should be focused not on the government but on our societal sloth and excesses.
  • “Welfare of the people.” Constitutionally, this includes life, liberty, the pursuit of happiness, universal health insurance, cable television, and fewer dropped calls.
  • “It’s high time the government [took care of the people] they are supposed to represent.” If you’re going to write a letter to the editor, please proofread it, or at least ask a friend to edit it. A sixth grader should know that the proper pronoun for “government” is “it,” not “they.” (Sorry, I’m getting tacky here.)
  • This is where it gets fun. The government is instructed to “grow up.” Fair enough.
  • “…[stop] blithering about such pseudo concepts such as globalization, privatization and capitalism. None of these abstractions has anything to do with our jobs, our country…” This makes me smile every time I read it. There’s a story about an economist who visits China during Chairman Mao’s regime. There he sees one hundred men digging a pit, while a backhoe sits unused. On asking why they don’t simply use the backhoe to dig the pit much more quickly, the Chairman explains that then the men would be out of work. The economist replies, “Oh, well then if its work you’re looking for, why not have the men dig with spoons?” The anecdote illustrates the difference between work and productivity, abstractions that have everything to do with our jobs and why our country is even at the place where we can talk about universal health insurance. People that don’t grasp the difference between work and productivity, or between income and wealth, are the same people who think raising minimum wage helps poor people, that outsourcing hurts our economy, and that Wal-Mart has made people poorer, not wealthier. These are mindsets that, sadly, I cannot deconstruct in one post. But yes, Ganden Thurman, globalization and capitalism have everything to do with our jobs and our country.

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Filed under Economics, Health care

The blur that is ethics

This was a rather interesting article from CNN.com today. Although more likely to run across poems, anecdotes, and grammatical philosophizing as one strolls down Mulberry Street, sometimes the reader might encounter something a bit more complicated. In these cases, one should tread carefully, remembering that there are two sides of the street.

Take that to mean whatever you want. I found this article interesting since I remember hearing a different spin on the story a year or two ago after the hurricane. “Euthanasia” and “homicide” were terms more apt than “abandoned by his government.” I don’t mean to imply that all ethical issues are gray, but reading the doctor’s perspective provided me with another occasion to imagine the sights and sounds of Memorial Medical Center in the aftermath of the post-Katrina flooding. (It was the fact that the city is built below sea level and that the levees could not hold the surge, more so than the actual hurricane, that did so much damage, if I recall correctly.)

In this sweltering hospital with no electricity and no operational pharmacy, patients languish and the staff is stretched thin in terms of both numbers and emotions. At the time, no one knows if help will come in a day, a week, or weeks. (Pre-Katrina, a week would have been inconceivable. However, now’s not the time to discuss the politics of it.) Doctors and nurses are doing their best to take care of patients, night and day, that they may know little about. If the staff’s suffering is difficult to imagine, how much more so that of the ailing patients.

The facts are that morphine and midazolam hydrochloride were given to some patients. This sounds like a very reasonable regimen for ICU sedation. The doses given, curiously, are absent from the article. In any case, I suppose the question comes down to one of intent: did the physician intend to kill the patients, or to relieve their suffering? The ethical dilemma stems from the paradox that actions based on divergent intentions may appear very similar.

In other words, a dose of morphine and midazolam that is necessary to treat a patient who is hyperventilating, anxious, in pain, or otherwise decompensating may lead to a fatal respiratory depression. Goodness knows that if the congestive heart failure exacerbation patients weren’t getting their diurectics and ACE inhibitors (because, as I understand, the pharmacies were shut down), or if the septic patients were not getting their antibiotics, then there is no fine line between easing suffering and hastening death in these patients already on the brink. Rather, they overlap to the degree that there may be no difference, other than that of intent.

As I recall, the Hippocratic Oath does state that the physician shall not “prescribe a deadly drug…” To take this literally would mean that nearly no drug could be prescribed. After all, Tylenol is deadly in large doses. So is water. Coumadin (a common blood thinner) was developed first as rat poison. So what the oath is getting at, I believe, is the intention behind the prescription. Medicines don’t treat patients; physicians do.

In this case I cannot make a clear judgement, other than simply to say that from the facts presented, I cannot disprove that the doctor intended only to relieve suffering. And I can also say that I noticed the author used the everyday term “morphine” but included the very technical “midazolam hydrochloride”, the latter word being thoroughly unnecessary to all but the pharmacosynthetic chemists out there.

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Filed under Ethics, Health care