News Capsules (March/April
Economics, Ethics, and Physician-Assisted
A new study by Richard S. Mangus, MD, MS, Albert Dipiero, MD, MPH, and Claire E. Hawkins, MS, of The Oregon Health Sciences University in Portland that compared the attitudes and experiences of medical students in Oregon regarding physician-assisted suicide (PAS) "demonstrates support for and willingness by many medical students to participate in PAS." In fact, more than 65 percent of all medical students in this study admitted their willingness to participate in PAS and express the opinion that the practice should be legalized.
This figure is in concordance with previous surveys of Oregon physicians who affirm that 60 percent of them agree PAS should be legal in some cases. An interesting part of this study found that the group least willing to write a lethal prescription was fourth-year Oregon medical students at 44 percent. [Mangus RS, Dipiero A, Hawkins CE. Medical students' attitudes toward physician-assisted suicide. MSJAMA 1999;282:2080-2081.]
The authors wrote, "The significant difference between fourth-year Oregon students and other study groups may indicate that a change in willingness to comply occurs when a person is faced with actually writing lethal prescriptions." And yet, a previous study reporting on a national survey of physician-assisted suicide and euthanasia in the United States concluded that 36 percent of physicians would be willing to participate in PAS. [Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998;338:1193-1201.]
Accompanying this study and other articles in the MSJAMA symposium, medical student editor, Stefan C. Weiss, sums up the terms of the debate which was encapsulated in the title of his editorial, "Economics, Ethics, and End-of-Life Care" in socialist terms as follows: "[S]tructuring resources according to a population-based health approach and foregoing care of marginal benefit would potentially achieve greater utility. But to apply a policy of rationing to persons at the end of life --- the necessary consequence of a population-based approach --- is inconsistent with many principles of social justice." [Weiss SC. Economics, ethics, and end-of-life care. MSJAMA 1999;282:2076.]
Aging and Death
Daniel Callahan, PhD, director of the prestigious Hastings Center, also contributed an editorial entitled, "Aging, Death, and Population Health." To him "the key issue for the future is whether this society will continue its present course of using more marginally beneficial technologies to improve health care for the elderly --- refusing, in effect, to accept the historical decline in health associated with aging --- or whether society will take a population-based approach by putting more resources into improving health in younger years..." Furthermore, he contends, "Trying to cope with the inevitably expanding health needs of the elderly by means of ever more expensive technologies with marginal health benefits to the population as a whole makes little economic sense..." Thus, he opines, "War has been declared against death and its historical ally, aging."
Dr. Callahan believes that we must rationally allocate resources. "First, there must be, at some point, a limit on the amount of money deemed worth spending on marginal medical improvements --- a point where the price is too high for too little return. The second is to persuade the public that a population-based approach appears to produce not simply a less expensive way of dealing with health and illness, but overall improved health for most, though not all, individuals."
To him, of all the changes necessary for the proper allocation of "limited" resources, "the third change is the most radical, at least for this culture. We must accept old age and death as part of the course of human life and settle for the more modest goal of a decent average life expectancy of, say, 80 years and a good quality of life before that point." [Callahan D. Aging, death, and population health. MSJAMA 1999;282:2077.]
Nevertheless, these findings are quite troublesome and evinces an erosion
of the Oath and tradition of Hippocrates --- "I will give no deadly
medicine to anyone who asks nor suggest any such counsel" leading to
the slippery slope of acceptance of a physician-assisted suicide and euthanasia.
This troublesome erosion begins in the Ivory Tower of Academia and percolates
down to the impressionable minds of medical students as we have seen in
this survey and some of us have observed in the writings of the AMA's journal
for medical students, The New Physician. (See "The Transformation
of Medical Ethics Through Time [Part I]: Medical Oaths and Statist Controls,"
Medical Sentinel, Jan/Feb 1998).
Hippocrates and MSAs --- Another Opinion
Recent forecasts, now in vogue for propounding the need for the "rational allocation of scarce health care resources," and which thereby promote physician-assisted suicide and euthanasia under the guise of "end-of-life care" for that purpose, need to be rejected, lest they become self-fulfilling prophecies. Then, we will certainly end up with scarcity of new promising medical technologies for diagnosis and treatment, if not frank medical care regression and public health obtundity. We will be, in time, abandoning and negating the great strides made in science and medicine since the turn of the century. Do we want to advance the frontiers of medical knowledge, improve life expectancy and quality of life in our later years, rather than to end it? Do we want to continue to bring forth cutting-edge medical technologies for those purposes, which although necessarily expensive, could be easily affordable in a truly competitive and unrestrained patient-oriented, free market in health care?
I summarily reject the view overt rationing is inevitable and that we should be setting limits to our technological advances. I agree with the great visionary and scientific minds that want to be unfettered to expand the vistas of medical knowledge and advance the horizons of science and medicine. Let us unleash the forces of the free market in medical care and medical innovation. Let us support research particularly in the private sector in the pharmaceutical industries, in our medical schools, and teaching hospitals. Let us empower individuals with the establishment of tax equity for health insurance coverage and the implementation and liberalization of MSAs.
Expanding MSAs offers a golden opportunity to preserve
what remains of the practice of private medicine and the patient-doctor
relationship while improving access and providing the economic incentives
for patients to remain healthy and become prudent consumers of medical care.
MSAs with catastrophic, high deductible coverage provide the needed protection
for the elderly to have coverage for the medical care they need --- not
one-size-fits-all "end-of-life care." We need to return to the
Oath of Hippocrates in medical practice, freedom of choice and real senior
citizen empowerment with private medical care --- not end of the road, duty
to die, and end-of-life care. [Faria MA, Jr. A slippery slope. Internal
Medicine News, May 15,1999; Faria MA, Jr. Slouching towards a duty to die.
Medical Sentinel 1999;4(6):208-210 3; and Medical socialism in Oregon and
the duty to die, Miguel A. Faria, Jr., M.D. audio tape interview with Will
Reishman, KDOV, Medford, OR, 10/06/99.]
E&M Guidelines Update
More than 8 months after the recommended E&M guidelines were proposed by HCFA as an alternative to the 1998 guidelines, no final decision has been made as to what physicians can expect. HCFA reports that it is conducting a feasibility study but has not decided whether it will accept or reject the May 1999 recommendations. At the AMA interim meeting in San Diego this past December, AMA delegates approved a resolution reaffirming the AMA's position against the numeric method of evaluating physician services and reaffirmed the AMA's support of the California plan. The California plan proposes that disputed E&M claims be based on a peer review system rather than review by Medicare carrier staff. (AMNews, 12/27/99)
Hidden Camera Catches Kids' Reaction
to an Unattended Gun
It is important to talk to children about guns because there are already millions of guns in American homes, and a child can come in contact with one at a friend's house or somewhere else with disastrous consequences. In a special assignment, a reporter for KOVR 13 News carried out an experiment inside a Sacramento, California daycare center. A group of three and four-year-old kids were warned about what to do if they came across a gun by a Sacramento County Sheriff, Sergeant Rick Gibson. He told the kids: "If you were to find a gun like this on the floor, you want to leave it alone. You don't want to touch it." This is of course similar to the Eddie Eagle program that states, "If you see a gun, stop! Don't touch. Leave the area. Tell an adult." The children were told also that guns were dangerous. "To find out, we left an unloaded and deactivated Saturday Night Special out with the toys. And with a hidden camera, we saw how the kids reacted to it. We brought in the children in groups of three. They went straight for the table of toys, and within seconds spotted the gun." Interestingly, everyone of the children who had been lectured that morning was careful not to touch the gun.
The reporters and sheriff then went one step further and brought in three
boys who didn't attend the morning lecture to the unattended gun. "This
time the children not only picked up the gun, but one of the children even
aimed the gun at another child playing games. If the gun had been loaded
it would have fired real bullets." The reporter, Paul Joncich, concluded
the experiment by stating that the experiment was conducted with parental
permission and it proved a valuable lesson. Parents must talk to their
kids about guns, whether they keep a gun at home or not.
Universal Health and the Rise of the Uninsured
A study released in 1998 by the Washington-based Galen Institute reveals that between 1990 and 1994, 16 states passed aggressive laws designed to increase access to health insurance for those who remain uninsured. Instead, what was found was that by 1996 the complete opposite of what was intended had taken place. The 16 states that had instituted this reform had an average annual growth in the uninsured ranking eight times that of the other 34.
In New Jersey, health insurance costs have escalated so that most policies
are selling for between $30,000 and $35,000 a year. In Tennessee, sweeping
reform took place in 1993 intended to cover the state's Medicaid population
as well as those remaining uninsured, particularly those denied coverage
because of pre-existing chronic conditions. This proposal, known as TennCare,
was intended to cover 800,000 indigent people in the Medicaid population
as well as another 400,000 uninsured and uninsurable. The reform in this
state was to dump all indigent and Medicaid into managed care to institute
universal coverage at no additional cost. To facilitate the process in the
direction of managed care (corporate socialized medicine), a waiver was
granted by the Clinton administration for Tennessee to implement its plan.
The result: TennCare has been an unmitigated disaster with its price tag
escalating to the point that it now consumes a quarter of the state's budget.
Tennessee lawmakers are therefore considering the heretofore "unthinkable,"
that is instituting an income tax in the state. (Investers Business Daily,
Red Ink Puts AMA Leadership Under Fire
At the AMA's 1999 Interim meeting held in San Diego, California, the AMA leadership was placed under fire after it was found that the Board was operating at a loss of $10 million for 1999. AMNews reported, "an additional $4 million plus in unbudgeted initiatives had sent the organization into a cost-cutting frenzy for the last quarter of 1999."
The operating budget for 2000 is also expected to be completed in the red, $600,000 short. Strategic investments launched by the AMA leadership were also questioned by the House of Delegates. This included strategic initiatives for the year 2000 with $500,000 for the launching of a digital credentialing partnership with Intel Corp. and $1.6 million in funding for the AMAP. Miguel Machado, M.D., an alternate delegate from Florida, complained, "How much longer are we going to continue to put money into a bucket that has holes all over the place?"
Other members were concerned about the persistently flat line membership problem despite a slight increase in actual members this year.
Perhaps, the most troublesome item was that despite the budget problem
for the AMA, the Committee on Trustee Compensation recommended an increase
in compensation from $221,980 to $225,000 annually for the board's officers
and recommended that the rest of the board be paid a per diem rate of $1,120
per day for each weekday devoted to AMA business and $560 per weekend day.
To Err Is Human
"To err is human" is the title of a new report by the Institute of Medicine that states medical mistakes are a stunningly huge problem. It quoted studies that estimated at least 44,000 and perhaps as many as 98,000 hospitalized Americans die every year from errors. The report was co-authored by William Richardson, president of the W.K. Kellogg Foundation The report claimed health care is a "decade" behind other high-risk industries in improving safety. It also recommended that Congress should establish a federal Center for Patient Safety which will require $35 million to start and eventually would consume $100 million in safety research. It estimated $8.8 billion is spent yearly on medical mistakes.
The Institute of Medicine, a part of the National
Academy of Sciences, is a private organization chartered by Congress to
advise the government on scientific matters. The president has asked and
the Congress has just passed legislation ordering the Agency for Health
Care Policy and Research to find strategies to reduce medical mistakes.
"Any error that causes harm to a patient is one error too many,"
commented Nancy Dickey, past president of the AMA. (http://www.newsmax.com,
Cheers for Freedom at Year's End
Freedom loving Americans should pause and thank statesmen who helped preserve our freedoms. At the end of the year, Sen. Mitch McConnell (R-KY) was the mastermind behind the successful filibuster that killed the campaign finance legislation which would have limited political speech of ordinary Americans. Both the Senate bill and (particularly) the House version would have severely restricted the ability of grass roots groups to report on the voting records of incumbents during an election year. Passage of this bill would have allowed only the biased liberal media to enjoy freedom of political speech. We graciously thank Sen. McConnell for his efforts on behalf of political freedom.
On the House side, we should also be thankful to Reps. Ron Paul (R-TX), Bob Barr (R-GA), and those Representatives who helped to kill the plan to institute a national I.D. system. According to Gun Owners of America (GOA) and other liberty-conscience groups, under the provisions of legislation passed two years ago, no one would have been allowed after October 1, 2000 to purchase a gun, board a plane, open a bank account, go to a doctor, enter a school, or take a new private sector job without having a national I.D. card." We agree.
The House of Representatives defeated a national
I.D. scheme in the bill funding the Transportation Department on October
9, 1999. On defeat of this bill, Rep. Bob Barr (R-GA) stated, "Perhaps
nothing is more emblematic of the freedom we enjoy as Americans than the
fact that we do not have to carry a permanent identification card everywhere
we go. Throughout history, national identification systems have been a consistent
feature of dictatorial states that placed a low value on freedom, and a
high value on keeping tabs on everyone."
Health Care Police Raid Private Home
On June 8, 1999, agents from Maine's Department of Human Services raided the Jaricot Home for mentally disabled adults in Lewiston, Maine. The Jaricot Home is a private-pay foster home that does not accept any state funds. According to owner Monique Dostie, "It was like the Gestapo was in here." She went on to say that "the agents walked right into my office, set their copy machine up, and asked for every resident's record, medical and personal records, and began copying them." When she asked agents if they had the legal right to collect all of this private, confidential information without either the residents' or guardians' consent, the supervising inspector said that "she had the power to override the guardian's decision and to see all the files without anyone's permission." When Dostie, on the advice of her attorney, tried to tape all conversations while the raid was in progress, she was forbidden to do so until the agents could obtain a tape recorder of their own. The main focus of the raid was apparently the house rules which the owner posted in her private foster home. It seems that the house rules did not please the bureaucrats and she was subsequently forced by the state to remove the house rules which "barred residents from possessing pornography or engaging in sex acts." The house rules were deemed not to be politically correct because they would inhibit "the natural growth of her mentally handicapped adult residents." As a result of this attack on her private home by state bureaucrats, Ms. Dostie is reportedly looking into moving to another state." (Paul Likoudis, "Bureaucrats intimidate care-giver with raid on home for disabled." The Wanderer, June 24, 1999.) This item provided by Lawrence R. Huntoon, MD, PhD.
NEJM Alleged to Violate Its Own Policy
According to The Los Angeles Times, the Associated Press reported (10/21/99) The New England Journal of Medicine (NEJM) violated its own professed strict disclosure policy by publishing articles from researchers with ties to drug companies which were not disclosed to its readers.
In eight of 36 "Drug Therapy" articles reviewed by The Times that were printed in NEJM since 1997, researchers had financial links to companies that marketed treatments reviewed in the article. That potential conflict of interest was not revealed to the reader.
NEJM has not yet reviewed the articles identified by the newspaper but is developing new ethical guidelines, interim editor-in-chief Dr. Marcia Angell told The Times. "We're going to try to do the right thing and bring our practice into conformity with our policy."
The report did not disclose whether the authors showed a bias toward the companies to which they had links.
"It's highly misleading of journal editors
to say on the one hand they have a strict policy to avoid conflict of interest
and then turn around and violate that policy," said Mildred Cho, a
scholar at the Stanford University Center for Biomedical Ethics.
American Firearm Deaths
American firearm deaths exceed U.S. soldiers killed in battle, claims a new report by the Center to Prevent Handgun Violence reported USA Today, 12/30/99. According to the report, more Americans died in non-military shootings (Firearms Deaths, 1979-1997: 651,697) than in wars since 1775 (650,858). About 51 percent of the gun deaths were suicides, and the vast majority of the rest were murders. Federal statistics on total gun deaths have been kept since 1979. For more on Crime Facts & Myths, see Medical Sentinel, News Capsules, March/April 1999 and http://www.ncpa.org/pi/crime/crime21.html.
Dr. Faria Replies to USA Today (Jan. 3, 2000)
Although I question the overall figures, John Bacon's "Gun Deaths" (USA Today, December 30, 1999), it must be stated that the report merely rehashed gun statistics for sensationalism and the purpose of promoting the draconian gun control agenda of the Center to Prevent Handgun Violence.
Non-military civilian shootings include homicides as well as accidental shootings and suicides --- not to mention genuine acts of self-defense and justified homicides. We now know thanks to the scholarship of Profs. John Lott and Gary Kleck that firearms are used more frequently by law-abiding citizens to deter crime than by criminals to commit crimes. This has even been confirmed by President Clinton's U.S. Dept. of Justice study published in 1997. Because ordinary citizens use guns 2 to 2.5 million times per year, dwarfing the offensive gun uses by criminals, 25 to 75 lives are saved by a gun to every one life lost to a gun.
But, all of these numbers from gun violence pale in comparison to the 35 million babies killed by abortion in the U.S. since 1973, or the 100 million citizens deliberately killed by their own governments (a significant percentage in the process of being disarmed) during the 20th century at the close of the millennium as compiled by Prof. R. J. Rummel in his book, Death by Government (1995) and by J. Simkin, A. Zelman and A. Rice in their book, Lethal Laws (1994).
Miguel A. Faria, Jr., MD
Editor-in-Chief, Medical Sentinel of the AAPS
Upstate Medicare --- Alleged Fraud and
AAPS president Dr. Lawrence Huntoon's efforts at eradicating fraud and abuse in the Medicare system are bearing fruit. After uncovering evidence of Medicare carrier malfeasance that he suspects may be tantamount to fraud and abuse on the part of Upstate Medicare, he has followed through with herculean efforts to correct the problems. This past December, he heard from HCFA, his U.S. Representative, and both of his U.S. Senators, who have referred the charges of fraud to the Office of the Inspector General. Coralyn Collady, Esq., of the Office of HHS and U.S. Senator Charles Schumer (D-NY) responded to Dr. Huntoon acknowledging his efforts. Sen. Schumer actually wrote he had contacted Ms. Judy Berek, New York Regional Director of HCFA, "to share [Dr. Huntoon's] allegations." On Dec. 17, the senior Senator from New York, Daniel Patrick Moynihan, followed suit.
It appears that leaders of organized medicine are also reading the packets of material Dr. Huntoon has been so carefully assembling and sending to them regarding Medicare abuses, particularly Medicare appeals dealing with the "Correct Coding Initiative," which Dr. Huntoon has called "a bundling assault HCFA is using to attack physicians." In his December 1999 column, John A. Ostuni, M.D., Medical Society State of New York president, wrote: "In an era when the term 'fraud and abuse' is freely bantered about by HCFA, it strikes me that HCFA is fraudulently denying many physicians that for which they should be paid...[the practice of bundling is] at best disingenuous, and at worst, a clear signal that budget cutting takes precedence over what is best for the patient." Dr. Ostuni tells us that MSSNY has now asked the state Attorney General to investigate "this egregious practice and to seek a solution to a problem that is inequitable to physicians, unfair to patients, and a clear abuse of what the CPT system was designed to accomplish."
On December 13, Dr. Huntoon also wrote to Thomas R. Reardon, M.D., president
of AMA, explaining that HCFA has "totally bastardized the coding system."
Inappropriately, bundling has become rampant because "government can
no longer pay for the medical care it has promised to those who are trapped
in government programs...It's high time for the AMA to take a stand against
this fraud being committed by HCFA." Our kudos go to Dr. Huntoon!
Books in Brief
Vaccines: Are They Really Safe and Effective? A Parent's Guide to Childhood Shots by Neil Z. Miller. New Atlantean Press, Santa Fe, NM, 1999, 78 pp., $8.95 (Paperback), ISBN: 1-881217-10-8, http://thinktwice.com.
While I don't agree with all the conclusions drawn
in this book, the author has dealt honestly with this subject and has added
pertinent information to the vaccination debate. In fact, he has uncovered
information that is immensely important and that has not been made readily
available by the public health establishment to the general public. This
thin tome, nevertheless, contains graphs showing the precipitous decline
in death rates in such diseases as polio, measles, and pertussis, before
immunization programs had been put in place. While the book is a best seller
among parents and the public, it should also be studied by those reluctant
to question the conventional wisdom regarding mandatory immunization policies.
The Art of Political War, New and Revised Edition by David Horowitz. Los Angeles, CA, 1999, 64 pp. $3.95 (Softcover), ISBN: 1-886442-16-9, http://www.noleft.com.
This political booklet subtitled "How Republicans
Can Fight to Win," despite its optimistic tone, carries a disturbing
message --- namely, that because we live "in a democracy," for
conservatives to win they will have to, in my words, "demagogue"
themselves to victory. Politics is war and politics is about winning. This
brief book by renown author David Horowitz, who has written two bestseller
classics, Destructive Generation and Radical Son, deserves careful attention
from those recognizing the need to master the art of political warfare to
effectively combat further advances of socialism and collectivism in America.
The Seduction of Hillary Rodham by David Brock. Free Press, New York, 1997, 452 pp, $14.00 (Softcover), ISBN: 0-684-83770-6.
After defending Supreme Court Justice Clarence Thomas and exposing The Real Anita Hill in his articles and books, and bringing untold grief to President Bill Clinton with his exposé of the Troopergate sexcapades in The American Spectator articles, journalist David Brock may well have wanted to make piece with the Clintons, at least with Hillary, in this latter book.
Although I cannot vouch for much of what he has
written in the general defense and apologia for the political and professional
life of First Lady Hillary Rodham Clinton, I can say that Chapter 12, "Charge
of the Light Brigade," is quite factual and accurate. In fact, this
chapter is one of the most accurate accounts I have seen published to date
on the specifics of the Health Care Task Force headed by Hillary Clinton
during the great health care debate of 1993-1994. Although the chapter isn't
complete, it does provide a factual account of how the Health Care Task
Force operated behind closed doors against the best interest of the American
people and how the Association of American Physicians and Surgeons (AAPS)
played a pivotal role in derailing this flagrant attempt at establishing
fully socialized medicine in America. Although for many of us it became
obvious that many of the private participants in the Health Care Task Force
had a vested interest in establishing a monopolistic health care cartel
protected by the federal government, Brock provides another piece to this
puzzle. Why would private entities such as the Robert Wood Johnson Foundation,
a non-profit organization and a major stockholder of Johnson and Johnson,
Inc., want to participate in this takeover of the health care system? Brock
uncovers, "The company serves as an exclusive contractor of medical
supplies to several major nations with single payer plans like Canada's
and would have benefited substantially from a deal with the government-operated
health care system." Moreover, "Johnson and Johnson was represented
in Washington by the Wexler Group, a lobbying company headed by Clinton
associate Ann Wexler, who hired Betsy Wright as a lobbyist." For those
interested in health care policy this chapter alone may be worth the price
of this softcover edition.
This edition of News Capsules was compiled by Miguel A. Faria, Jr., M.D., Editor-in-Chief of the Medical Sentinel of the AAPS. It appeared in the Medical Sentinel 2000;5(2):36-41. Copyright©2000 Association of American Physicians and Surgeons.