The Danger of a New Medical Care "Bioethics"
The Patient Protection and Affordable Care Act (PPACA, ACA, or "Obamacare"), signed into law March 2011, in the near term creates more than 100 new health care bureaucracies, a large increase in taxes, and new government expenses of $500 billion. Most importantly, however, it will create an incentive and penalty regime for health care institutions and professionals that will compromise traditional professional medical ethics.
Embedded in PPACA is a system of mandates and incentives derivative of guidelines for efficient patient care that means some rationing. An example most often raising objections in the public discussion of PPACA is the Patient Centered Outcomes Research Institute, a part of the bill intended to address "end of life" resource utilization, but other entities created by the PPACA, such as the Independent Payment Advisory Board (IPAB), will promote care guidelines intended to reduce resource utilization or withhold care for patients based on guidelines composed for promoting resource efficiency.
The basis for the claims that Medicare costs will be reduced by hundreds of billions for the next decade is driven by the research of Jack Wennberg, M.D. of Dartmouth called the "Small Areas Analysis" that compares medical care in different parts of America to identify the least expensive practice patterns.
PPACA introduces a heavy emphasis on social engineering and state-imposed patterns for care and resource utilization. The major casualty will be the quality of the individual patient-physician relationship -- physicians will be incentivized and provided guidance and asked to become agents of a monolithic, centrally directed health care system to produce efficiencies in medical resource utilization -- that some would translate such developments as rationing.
American medical ethics traditionally has been Judeo-Christian and focused on the value of the individual with an emphasis on professionals' duty to the needs of the patient. The new ethics is, in contrast, utilitarian, the goal of utility measured in terms of societal, not individual benefit. The abstract concept of the good for society and for "utility" can often be in conflict with the ethical duty to the individual.
The new "bioethics" is a product of cultural shifts and is a postmodern development, articulated 40 years ago and since by many. Originally, however, the movement was pioneered a confirmed atheist and proponent of situational ethics named Joseph Fletcher. Fletcher was an Episcopal priest-turned-atheist philosopher and writer, and then the first professor of medical ethics at the University of Virginia. He was not alone in his advocacy of eugenics, euthanasia, and a proper consideration of the "qualities" of "human hood." Fletcher emphasized that quality is more important than length of life. He even wrote of distinguishing "truly human beings," measured in terms of their cognition and quality of life, from their lesser brothers and sisters.
Don Berwick, M.D., appointed this past year as the Obama administration's new director of the Centers for Medicare and Medicaid Services (CMS), and Zeke Emanuel, M.D., Ph.D., appointed as director of Clinical Bioethics for the National Institutes of Health, are certainly examples of prominent individuals who espouse the ideas of Fletcher. These two and others like them will influence, as much as they might in their positions of influence, the direction of medical ethics in the years to come.
Dr. Berwick declares his admiration for the British National Health Service (NHS) and its rationing project, the National Institute for Clinical Excellence (NICE). Berwick asserts, "Excellent health care is by definition redistributional." Dr. Emanuel has espoused an elaborate quality-of-life scoring system for determining which patients will receive medical care in a more frugal and resource-efficient health care system.
The PPACA provides opportunities to ration medical resources and influence patient care choices. Discretionary authority affecting medical care resource allocations is given to the secretary of Health and Human Services more than 25 times, and many bureaucracies are created by the bill, empowered to study, influence, guide, and control medical care decisions. Penalties and incentives will be a part of the reimbursement rules for institutions and physicians. PPACA creates Accountable Care Organizations (ACOs), a renewal of the Health Maintenance Organization (HMO) concept, with incentivized global budgeting and the local administrative structures intended to create efficiencies. Cost and resource containment as outlined would certainly appear to be rationing and would potentially violate the ethical duty of care for the individual patient.
The continued push for health care reform is based on a faulty claim of bad outcomes and deaths from lack of insurance. Many of the problems of the health care system are the result of loss of free-market incentives created by government interference. The $100 billion in uncompensated and uninsured care is pocket change for a prosperous America and should not be an excuse for a complete revamp of the 2-trillion-dollar-plus health care system, particularly if it compromises ethical standards of care.
Repeal of PPACA prevents the loss of ethical, individually focused medical care, the final step to creating socialized medicine that Ronald Reagan warned against as the step that would make America a socialist society.
Ethical, individually focused medical care in a free-market system is still a viable alternative.
Jerome Arnett, Jr., M.D. is a pulmonologist in Helvetia, WV. John Dale Dunn, M.D., J.D. is an emergency physician in Brownwood, TX.
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