by Dr. Lee Hieb
The magician distracts the audience by doing meaningless but fascinating
things with his right hand, while his left hand is doing the really
meaningful activity unnoticed by the crowd. The bigger the trick, the
bigger the distraction required.
Democrats and President Obama should make David Copperfield proud. With one
hand they are distracting the American people with a nonstop barrage of
bills and discussion: What will happen to the budget? How many are really
uninsured? Is the Congressional Budget Office to be believed?
And for the ultimate distraction, Mr. Obama paraded a group of “doctors” in
borrowed white coats for a great visual effect wholly devoid of substance.
For all we knew, these guys could have been a group of actuaries at a DC
convention bussed in as props for the day. (More likely they were doctors of
the government paid variety, like Rahm Emanuels’s physician brother Ezekiel,
sheltered in research institutions and teaching hospitals where they don’t
have to run their own small businesses.)
While this diversion is going on, the real issues are hidden from the public
-- the consequences of government funding of medical care on individual
liberty and our moral compass.
Government pay medicine -- under any name you give it -- is immoral for
patients/citizens, and for physicians. No citizen would consider it moral
to put a gun to his neighbor’s head and demand that he pay for his mother’s
medical care -- no matter how much she may need it. It is no more moral
when people use the government as intermediary. For the physician, it is
impossible to practice moral medicine in a government system, because
ultimately at some level a physician will have to choose between doing the
best for his patient or acquiescing to the requirements of the state.
The worst moral examples of course were the German doctors who were forced
to cooperate in death camp selections. At the other end of the spectrum the
moral tightrope has already started here with Medicare. Federal practice
guidelines have slowly become mandates. If you do not do what the
government has deemed the optimum pathway for care, the hospital will not
get paid. In my case, for the most part, the guidelines can be followed,
but the day is coming when I will have to choose.
There is no question that the risk of DVT -- deep venous thrombosis, and PE
(pulmonary embolism) goes up after some hip fractures. So, usually,
Orthopaedic Surgeons prescribe a form of blood thinner to prevent this
complication. But thinning someone’s blood comes with its own risks of
death and morbidity, and there are certainly people for whom the risk of
anticoagulation is greater than the risk of thrombosis after the fracture.
Without federal “guidelines” physicians used clinical judgment to cull out
those people who would do well without the risk of anticoagulation, e.g.
those who have a non-displaced fracture, who undergo minimally invasive
pinning, and who are mobilized within hours of the fracture. This is not
uncommon in small hospitals where these patients can be treated promptly.
But the government is telling us we must anticoagulate all patients -- as if
all patients and all circumstances were the same. Although there are
recognized exceptions to the blood thinning protocol, judgment of relative
risk by the surgeon is not one the government accepts. So surgeons are in
the position of doing what is best for their patient, or what is prescribed
by the state wielding a financial mallet.
In between these two extremes is the Canadian physician who must prioritize
patients in a system with too little resources. Dr. Leo Kurisko is a
radiologist who left Canada to practice in the US (as have 11% of practicing
Canadian doctors). At a recent medical meeting, he related the moral
problem of practicing radiology in Canada. Because the system is
chronically short of functioning CT scanners, at his regional hospital there
was a three month waiting list for a CT. Dr. Kurisko would review the
requests for testing, and would then triage which patients went to the front
and which to the back of the queue. After the scans were finally completed,
he reviewed the studies and began to recognize patients with life
threatening tumors whom he had prioritized to the back of the line. Faced
with this Canadian version of “death camp selection” he quit. He has
documented the evils of government medicine in a new book, Health Reform:
The End of the American Revolution?
Consider the Netherlands, where the number one reason for the death of
children under the age of ten is murder by their doctor. Oh, of course they
do not call it that, but it is what it is. Because the Netherlands pays for
medical care, they choose whom to support. And severely disabled children
and the infirm elderly are not high on their priorities.
The Dutch doctors practicing thus are the children and grandchildren of
physicians who went to the death camps themselves rather than participate in
the Nazi killing machine. So how did this happen? It happened through the
moral incrementalism of becoming state doctors--of putting the good of the
state above the good of the individual patient.
Medicare has been an assault on freedom since its inception. Americans who
turn 65, may think they are still free but they are not. You are not free
to opt out unless you are willing to forgo your social security payment.
Even people who see Social Security as part of the problem are not willing
to give up an entitlement they have paid into all their lives. And once
enrolled in Medicare, you cannot pay for services outside the system unless
these services are not offered at all by Medicare, or unless you find that
rare physician who runs a cash practice totally off the grid.
Physicians who see any Medicare patients at all are not free to bill outside
the Medicare system for services which they cannot afford to offer at
Medicare rates. For example, if an active 65 year old patient wants to have
a special high tech knee implant that was designed for the more active
younger patient, he cannot pay the difference between the regular implant
and the latest development. If Medicare offers “the service” at any level
you cannot buy the service on the free market.
In this way, rationing by diminishing the supply of specialists has already
started by diminishing the options open to Medicare recipients. Physicians
are not that different from Starbucks -- they are not going to pay you for
the privilege of serving you.
Although, for a while, Oncologists did just that. In the last few years, as
Medicare cut the reimbursement for some newer types of chemotherapy,
Oncologists would suck up the cost because they wanted to do the best for
their patients. But now, as Medicare has ratcheted back payment even more,
they have reverted to older drugs. And because there is no free market, the
patient cannot simply pay the difference to get the latest scientific
So ignoring the smoke and magic mirror tricks, government payment for
medicine must be rejected, not on practical financial grounds, but by people
who value their freedom and their moral lives. As recognized by our
founders, but ignored by the current crop of politicos, the most unhealthy
immoral force in human history has been overly powerful central
governments. Charley Reese put it best when he said, “It is an eternal
shame to give up one’s freedom for a filled bowl of oatmeal and the promise
of security from liars”.
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