I agree, this is getting ridiculous: our colloquy on the ethical and policy complexities of health care policy has created the first Ethics Alarms Comment of the Day on a Comment of the Day on a Comment of the Day. Nonetheless, John Billingsley’s COTD is deserving, as well as interesting and informative. Here it is, his comment on Comment Of The Day: “Comment Of The Day: ‘No, Insurance Companies Treating People With Pre-Existing Conditions Differently From Other Customers Is Not Discrimination’”—which in this case you really should read Charlie Green’s post that prompted it.
I have a few comments on specific points.
“New diseases like RLS”
RLS was first described in 1685 and the first detailed clinical description was in 1944 and it was shown in test recordings in 1962. Not really a new disease but a newly publicized disease. Once a medication was developed that was effective at relieving the symptoms, it became profitable for a pharmaceutical company to target it and raise awareness. The company was not being altruistic, but is it wrong to make money by informing someone that there is a way to relieve the distress they are experiencing? If you have ever talked to someone who really has this disorder, you know how much it disrupts their lives. Is it over diagnosed? Possibly, but polysomnography to make a firm diagnosis is expensive and it is a condition where the clinical symptoms are pretty reliable. Probably cheaper to just treat it.
“Because who’s still going to argue with your doc? Especially when he or she gets side benefits from giving in to the latest DTC ads on network news programs?”
I hate DTC ads. I would be good with a spot that just said, do you experience these symptoms (of RLS perhaps)? If you do, tell your doctor. I actually spent quite a bit of time telling patients why they did not need the newest, expensive drug they heard about on TV or in a magazine either because they didn’t meet the criteria for it or because I felt that the cheaper alternatives were just as effective and needed to be tried first. It was a hard sell, particularly when the patient would say, “but my insurance will cover it.” I, and I think most doctors, take being a good steward of the healthcare dollar seriously. In the past there were sometimes substantial “side benefits” from drug companies especially if you used really expensive things like artificial joints or pacemakers. The most I ever received was dinner in a restaurant and things like cheap pens and sticky note pads. These days there are no more cheap ballpoint pens and meals typically are take out from Newks or equivalent in the office during a presentation. Not something I am likely to sell my soul for although I understand the implications.
What about when a patient really needed the expensive spread but their insurance didn’t cover it? I was almost always able to ensure they received the medication. Sometimes it was by doing the work to get an authorization from their insurance, sometimes it was by getting vouchers from the drug company, and in some cases where there was no insurance coverage at all, the company just provided the medication free. I had patients who received thousands of dollars worth of medication a month totally without charge to them. I know the drug companies were not doing that purely out of the goodness of their heart but for that patient it made a huge difference in the quality of their life.
“The AMA limits the number of doctors.”
I would like your citation for this frequently bandied about statement. I replied to Alex’s comments about this but I think it is important enough to cover in more detail. Basically the AMA is the professional organization for doctors the same way the ABA is the professional organization for attorneys. They represent people who are doctors and medical students but they do not decide who becomes a doctor, license doctors, discipline doctors, test doctors, or decide how many doctors there are. Through lobbying they have influence on health care legislation but they do not make the laws or the regulations. By the way, there is also an American Osteopathic Association (AOA) that fulfills the same function for osteopathic physicians (DO) that the AMA fulfills for allopathic physicians (MD).
In the early 2000s, it was projected that there was going to be a doctor surplus. At that time efforts were made to decrease the number of doctors being trained. It later became apparent that there was going to be a deficit and the American Association of Medical Colleges set the goal of increasing the number of doctors. New schools were opened and the total number of graduates rose from 16.140 in 2007 to 18,938 in 2016. Don’t forget that there are also International Medical Graduates (IMG) who come to the US for residency training. I am not familiar with the rules that govern how many IMG are admitted and what the criteria are. In 2015 there were 12,397 IMG participating in the match for residency positions and 6,302 obtained a position.
The limiting factor in how many doctors can be produced is the number of residency positions available. A graduate of medical school can fulfill every other requirement but if they don’t get a residency they cannot complete training to practice medicine. The AMA does not control how many residencies there are. I think it is an important enough point that I will repeat what I said above; Dr. Bruce Koeppen explains, “Medicare covers the majority of the cost teaching hospitals spend on training medical residents, but the Balanced Budget Act of 1997 capped the number of residency slots the federal government would fund. The shortfall-what is not covered by the Federal government-is paid for by the hospitals where residents train. While it is possible to increase the number of residents they train, to do so, hospitals must fund the entire cost of those training positions.” That represents a lot of money that has to come from somewhere.
“Both parties don’t like to admit it, but there has to be what the GOP used to derisively call “death panels.””
Agree, but I think of them more as “who is gonna die sooner rather than later panels” since we all got to go some day. Health dollars can be spent various ways. A whole lot for a few, a lot for a moderate number, enough for the basics for everybody, or some combination of the above. Except for the basics for everybody the decision has to be made who gets what and who gets to decide who gets what. Clearly, decisions should be made on the basis of a cost benefit analysis but evaluating the benefit is going to be the sticky part. Just one example, a million dollar heart transplant for a young parent who may be able to return to work to support his or her family or a million dollars worth of care to a premature infant with Trisomy 21 and multiple congenital heart defects. Somebody is going to have to be willing to be seen as a really heartless bastard. Ethicists are going to earn their money.
Again, thank you for your insightful and thought-provoking comments.
Ethics Alarms 
Congrats to John; very well written and well-deserved.
“Thought provoking” but slanted to the left. One example: These evil pharmaceutical companies frequently provide patient assistance programs that cover expensive life saving drugs for low income folks. In some cases multiple companies develop treatments for the same disease. First to be approved by the FDA gets first prize for awhile. But they can lose their monopoly of treatment fairly quickly when equally efficacious drugs are approved.
“First to be approved by the FDA gets first prize for awhile. But they can lose their monopoly of treatment fairly quickly when equally efficacious drugs are approved.” True. The example I am most familiar with is Prozac and Zoloft. Prozac was marketed by Eli Lilly in 1987 while I was still in my residency. It was the first really new antidepressant and because it was as effective as the older medications and much safer it rapidly became the go to med becoming one of the most prescribed drugs at that time. It made a mint for Eli Lilly. Zoloft was marketed in 1991 by Pfizer. It is in the same class of drugs and is pretty much an equivalent medication with the same uses. Because doctors were familiar with using Prozac and insurance companies did not want to add another expensive medication to their formulary, it continued to be a market leader for quite a while even though it no longer held a monopoly on that class of medication. It is still a commonly used medication in generic form. 1987 was definitely a good time to own Lilly stock. Wish I had some.
If the people who need the care make their own decision based on what they can or can’t afford then they become their own heartless bastards.
I can’t afford to have a long expensive chronic medical condition or a short devastating one. My choice would be to go without medications that prolong life. I think this is selfless. I prefer to not leave debts for my family to deal with. When I express this people think I’m suicidal. I’m not at all. If I can have a long life with health and limited health care costs I’ll live long happily. If not, I’m happier to leave.
There are worse things than death.
“There are worse things than death.” Agreed. That is why my wife and I both have our living wills and our kids are well aware of our wishes and have been warned that we will haunt them if they don’t comply.
Reminds me of this article regarding how doctors choose to die:
http://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/
What profits a man to gain the world, but lose his soul?
Some ideas are not new 🙂
Given this discussion, I wonder how many of you would have answered Kohlberg’s Heinz Dilemma:
A woman was near death. There was one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman’s husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: “No, I discovered the drug and I’m going to make money from it.” So Heinz got desperate and broke into the man’s laboratory to steal the drug for his wife. Should Heinz have broken into the laboratory to steal the drug for his wife? Why or why not?
Should citizens break the law to benefit themselves or others? Of course you can’t have a societal standard that says you SHOULD do this. If so, then you SHOULD steal savings from the wealthy to feed yourself, or the poor. That anyone thinks this is a tough question is troubling. Episodes of Westerns in the 50s and 60s had variations of it almost weekly.
1. The druggist is unethical, but within his rights and protected by the Rule of Law. He has no duty to sacrifice to save someone else.
2. Heinz’s conduct fails Kantian ethical standards, fails the Golden Rule, but can be ethically justified by some utilitarian arguments.
3. If he does steal the stuff, then he has to submit himself for punishment and receive punishment. If a jury nullifies the crime, then theft has been validated by the society.
It’s the illegal immigration issue, essentially.
Not to mention it’s a silly hypothetical. If we really want to honestly use this as some sort of analogy, the town must be a closed universe… meaning that the only market available to the druggist is that man’s sick wife. The druggist will lower his price to sell something. Otherwise he makes NOTHING on his endeavor.
Thanks, Dr. John. Your comment brought to mind the old saw “If it ain’t broke, don’t fix it.” I was stunned when the first thing that happened after Obama was elected, the Dems went all in on health insurance. It wasn’t even an issue in the campaign. The left seems to consistently over draw negatives in the country. It gets a little (a lot?) tiring.
Health insurance was a HUGE issue in the 2008 campaign.
In the Oct. 23-26, 2008 Gallup Poll in which Americans were asked to rate the importance of 12 policy issues to their vote for president, health CARE (not health insurance) came in #6 out of 12. The economy was by far #1. The rest: The federal budget deficit (44% of those polled), terrorism (42%), energy/gas prices (41%), the situation in Iraq (41%), healthcare (41%), and taxes (40%).
I was referring to how much it was discussed by the various candidates, not necessarily how much Americans said it mattered. I remember the disagreements between Hillary and Obama over health insurance during the primary being especially significant to their campaigns.
“. . .a million dollars worth of care to a premature infant with Trisomy 21 with and multiple congenital heart defects.”
That precisely describes our identical twin sons whose hearts are repaired and are now 26 years old. The surgeons and pediatricians and my wife and I estimate their initial care to be about a million and a half dollars.
Will and Jamie will live independently from us and have their own jobs. They will be sustained through their earnings, public assistance and a specially tailored trust.
I have a good friend with a grandchild who has those problems and I have a grandniece with cerebral palsy. I want both of them to get all the care they need. I do believe that there will have to be decisions made about how to allocate healthcare dollars. There is just not enough money to pay for everything possible for everyone. I posed that particular scenario because it would be a very difficult and heartbreaking one but in reality I don’t think that is the type of question that is going to arise often if at all. I believe the decisions will be ones like how the money should be split up among various types of services. Decisions will also need to be made about how to rein in costs for treatments like end stage renal disease which cost Medicare 30.9 billion dollars in 2013 and chronic obstructive pulmonary disease which was estimated at 36 billion in 2014 and expected to rise to 49 billion dollars by 2020. The only way I can see that happening is rationing treatment in some fashion. I am happy to hear that your sons are doing well. I know from experience with my niece and talking to my friend and his family that there are many challenges but also rewards.
This brings back the point I made about the ACA in another thread. The program does not set limits but encourages efforts to provide more effective health care, through pilot studies, review boards and uniform medical reporting systems. Just to name a few. I keep stressing that if one understands even a little bit of the Act, one will realize that it’s intended to overhaul and improve the delivery of health care in the US. And it very well could.