Bio-Ethicist, Ethics Blind

Socialism defined here.  Creeping socialism defined here.

What do the actions of a professional ethicist say of him when he calls Sarah Palin and 'her ilk' ignorant, nefarious, and just plain stupid?  Since I am of Sarah Palin's 'ilk,' I take offense at Dr. Nuland's summation of my principles, knowledge, understanding, and motives.  Allow me to demonstrate my ignorant, nefarious and just plain stupid concerns regarding the socialism of my liberties and freedom, my self reliance and desire to control what I have made or earned, my choices with regard to my own health care, wealth, and my participation in philanthropy.  

Dead Wrong, by Sherwin B. Nuland.

Sarah Palin, meet Hippocrates.

  As if you hadn't heard, a gaggle of American conservatives is stridently charging that pending healthcare reform legislation will institute a mechanism for euthanizing selected members of the handicapped and elderly populations.  That it would, in Sarah Palin's formulation, establish 'death panels.'  Its true that HR3200, the bill that will eventually come before the house of representatives, is still a work in progress.  It has already been amended by three separate house committees while two senate committees are working on drafts of their own.  All of the provisions to be included in the final bill are not yet known, but one thing is certain.  There is not a single statement in the voluminous number of pages under study that contains the slightest consideration, no matter its remoteness, of death panels, euthanasia, or any such fearsome concept.  In reality, the legislation simply calls for the reimbursement of physicians who council patients on 'end of life' decision making.  Counseling that is already required by a 1990 law that is now covered by many insurance plans.  

 

But the specifics of the present bill are irrelevant to the loony conversation the right has sparked during the August recess.  After all, even if there were some provision before congress that could conceivably be interpreted as establishing a 'death panel' centuries, if not millennia of established medical ethics, in addition to existing U.S. law, would prevent its actualization.  In the midst of this crucial debate on the future of health care, somehow, the proponents of the euthanasia talking point, seem to have forgotten everything we know about the practice of medicine in America.  Even putting aside the Judeo-Christian morality upon which the constitution and our nation's culture are based, the notion of forced euthanasia would contradict the long-held body of medical ethics to which all American doctors must adhere.  At times, morality can be dismissed as a matter of personal conscience no matter how wide-spread its acceptance.  Ethics, on the other hand, arises from societal or group commitments to principia of behavior, a formulated code of ethical precepts, whether philosophical, legal, or religious, is a statement of commitment that the group has a right to insist upon from its members, even to the point of punishing breaches.  

 

Since its origin, in the works authored by followers of Hippocratic teaching, the ethics of Western medicine have forbidden any action that might harm a patient, hence the famous injunction, "Have two special objects in view with regard to disease, namely to do good or to do no harm."  That principle has been re-iterated again and again through the ages.  As for example in the words of the Geneva Convention code of medical ethics adopted by the world medical association in 1949, which states in part, "The health of my patient will be my first consideration, and elsewhere I will maintain the utmost respect for human life.  I will not use my medical knowledge contrary to the laws of humanity."  I know of no source that permits anything else.  Moreover, as the modern discipline of bio-ethics has evolved since the 1960's, there has been universal acceptance among its authorities of four principles that are considered fundamental.  Autonomy, beneficence, non-malfeasance, and justice.  The principle of autonomy, which refers to the autonomy of the patient, directs that every individual has the free will authority to make well informed medical decisions for himself and that the physician must never dictate such decisions.  In the words of a highly regarded text book of bio-ethics, "This implies a respectful and broadly rational dialog between doctor and patient in order to combine the patient's values and the doctor's expertise to produce benefit.  For this to happen the patient and the doctor must be prepared to listen to each other, think about what is being said, and be responsible about their respective roles."  

 

As for beneficence, non-malfeasance, the 'do no harm' of antiquity, and justice, the words speak for themselves.  Death panels indeed, euthanasia indeed!  The growing professional disciplines of medical ethics and bio-ethics have had a profound impact on researchers, bed-side doctors, associations of physicians and government.  The president's council on bio-ethics, a carefully chosen committee of some of the field's most eminent members, was created to advise the executive branch on any and all issues for which guidance is needed.  Furthermore, the much maligned American medical association, a strong supporter of HR3200, has urged President Obama to publicly recognize the code of ethics that governs the actions of physicians.  Even if some wild-eyed legislator, special interest group, or purposeful trouble-maker were to ignore the personal ethical behavior that has long been among individual and organized medicine's strongest influences, no bill could legally include any deadly provision of the kind being bruted about.

 

In 1990, responding to several high profile court cases, notably those of Karen Ann Quinlan and Nancy Cruzan, two young women in deep and irreversible comas who were kept on life support for unconscionably long periods, even as their families petitioned for cessation month after month, congress mandated that any health care institution receiving Medicare or Medicaid funding, which means all but a very few acute and chronic care hospitals, must on admission provide patients with three statements.  One outlining their right to accept or refuse any type of treatment.  Another laying out their right to issue advance directives to ensure that their wishes about continuing life sustaining therapy be carried out.  And a third explaining any policies that govern the institution's withholding or withdrawal of life supporting treatments.  Though the purpose of the 1990 legislation was to ascertain that hospitalized patients would not be maintained on ultimately futile therapies such as ventilators or feeding tubes against their stated wishes, it also forbids anything resembling forced euthanasia, since the patient or in the case of incompetence his or her legally authorized surrogate, by definition would not have requested it.  Regardless, fulfilling such a request would be illegal if it were made in any of the 48 states that do not have an assisted suicide law, and even in the other two, Oregon and Washington, assisted suicide would certainly be viewed by the authorities as quite a different thing than forced euthanasia.  In order for patients to make knowledgeable decisions under the 1990 law, it is essential that they thoroughly discuss with their physicians the implications of the directives they are choosing such as 'do not resuscitate' orders.  HR3200 would for the first time legislate that the physician receive a fee for these discussions making it more likely that they will take place and that they will be of real substance.  From these provisions of the bill, the ignorant, the nefarious, and the just plain stupid have extrapolated that the purpose of the periodic consultations is really to determine life or death with government officials and even physicians heaven forfend, taking on the role of Dr. Menglen.

 

It is ironic that the very legislation designed to protect patient autonomy is that from which Sarah Palin and her ilk have derived the fantastical notion that her son, Trig who has Down Syndrome would be euthanized if HR3200 were passed.  Even if such a gruesome threat were real, the combination of morality, ethics, and the law would stop it early in its malodorous tracks.  The entire issue or non-issue, which it surely is, contains the ingredients of travesty unworthy not only of the attention of the bio-ethics committee, but of the general public as well.

 

Sherwin B. Nuland the author of "How We Die" is political professor of surgery at Yale University and a member of the executive committee of the Yale interdisciplinary center for bio-ethics.

 

Now that you've heard the ethics expert, lets consider the possible ramifications we've learned from history.  History this expert and the AMA and the Democrats are purposefully ignoring.  Doctors have been honored in this country for a very long time and rightly so in my estimation.  Lately, the AMA and other leading representative experts are not listening to their constituent groups, the doctors they supposedly represent.  The AMA may be on board the government option/universal health care plan but the majority of doctors are not because they understand that this is not about health care choice or even 100% coverage.  This is about centralizing power to the government.  The real result being rationed health care and worse compensation for the health care provider.  Rationed health care is the point at which we WILL see death panels.  Who decides what procedures will be funded, how many of them will be funded, and who they will be funded for.  Putting aside the grossly and notoriously underestimated costs of ANY government program often by literally 10,000% so that the current estimated costs of the government option at $1.2 to $1.5 trillion dollars winds up at more like $100 trillion.  Compare the original estimations of Medicare costs projection $9 billion to the current Medicare costs projection $6.4 trillion.  Missed it by "that" much! and so do the current guestimates for our government option health care insurance.  

 

That isn't even the issue which most concerns the Tea Parties and Sarah Palin's ilk.  What concerns us is this idea that a government bureaucrat pencil pushing bean counter will one day be sitting across the desk from us or some remote office discussing our net worth with regard to society when it comes to doling out resources to meet our health care needs or, as Sarah Palin in her address and the good Dr. referred to them in his article, death panels.  On top of that, our legislators are not inspiring any confidence that they are capable of understanding what they are doing to my liberty or that they care if they do.  We aren't guessing so much as looking at past government ethics in health care and how low they've sunk.  Barack Obama stood alone in the state senate in refusing to support a bill that would prescribe a doctor's care for an aborted fetus born alive.  There is no more radical individual in this nation than the president on matters of health ethics.  His crocodile tears for the health care of the poor don't stand at all against the backdrop of his stance toward a living human being just born allowed to suffer and die or in many cases strangled by the 'doctor' performing the abortion.  I can't imagine a more calloused heart than that.  The very fact that the abortion is legal, or that tax dollars are used to fund them, then that a doctor would take it upon himself to strangle the newborn infant refutes any high minded notion that medical, social, or legal ethics will prevent death panels' actualization.  Once again, the eggheads in our institutions of higher learning demonstrate their profound blindness to the evidence in history, especially recent history.  Or could it be that Dr. Nuland IS aware that this is possible and is engaging in obfuscation of the principles and facts?