Sunday, August 31, 2008

Medical Ethics and Health Policy - A Year in the Blogosphere

Here's what I wrote in my first posting when I started this blog a year ago today:
Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

Organizational ethics is what this blog is all about.

In the blog I will talk about how organizations engage with the ethical dimensions of their work. I will look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate. I encourage readers to present their own perspectives.
One year and almost 150 posts later, I feel that I'm starting to get the hang of the blogosphere. It's new learning for me. My modality for writing has been journal articles and books, and I'm among the rare Neanderthals who do not carry a cellphone or a blackberry.

Here are four of the main lessons I've learned:

1. I feel even more strongly than a year ago that the fundamental premise of the blog is sound. Health care is personal. It ultimately comes down to interactions within dyads - patient/doctor, patient/nurse... But as important as the temperament and personal ethics of the individual clinician are, the ethical quality of the setting(s) - hospital, clinic, community, and the wider health system - are almost always in the room with the patient/clinician dyad. The organization and system determine a substantial component of what we as individuals experience in our health care.

2. I've found myself paying attention to a much wider range of phenomena than I'd anticipated. I expected to focus on the organizations we're familiar with - hospitals, group practices, health plans, and the like. But as I've thought more about the factors outside the dyad of care that shape the ethical quality of the patient's experience, I've found myself including media, politics, and the elusive topic of the public mind(s) as well. Health care is about human finitude and death. Our explicit and implicit philosophies of life shape the way we think about health care and deal with our cockeyed health care system.

3. When I started the blog I envisioned a virtual meeting place, where folks with a shared interest in the ethical dimensions of health organizations and the health system would meet and talk. That was naive. There are many excellent health blogs that touch on the area I marked out. People are too busy to focus on any one blog for a long time. I've appreciated the opportunity to talk on the blog with those who make comments, but comments have been sparser than I'd (naively) anticipated. A year ago I'd never heard the term "lurker." I know from the statistics I get that the blog has lots of lurkers. I'm no longer surprised by this - I'm a lurker myself at blogs I find interesting and read regularly. Life is short, and lurking is efficient!

4. Blogging has been psychotherapy for my perfectionism. In writing articles and books, I've agonized over getting things just right. That kind of obsessional dilly-dallying doesn't work in the blogosphere. Readers don't spend a lot of time on blogs. They want to be engaged and shown something - quickly. I'm the same when I read blogs. My daughter-in-law Emily Bazelon blogs on the XX factor blog. When we were watching Michelle Obama's talk on Monday night Emily was on line with her laptop, writing as we listened. When we debated some of the points she made she said "that's what makes the blog interesting - someone else will take up the argument." I haven't gotten that free yet, but maybe it will happen in year 2.

I want to celebrate the one year birthday of the blog by thanking those who have given feedback on the blog, by email, and in person. And I make a special request to readers to tell me what they'd like me to concentrate on next year, and how to make the blog more interesting and useful to them.

(In July the Kaiser Family Foundation hosted an interesting conference on "The Health Blogosphere: What it Means for Policy Debates and Journalism." A video and a transcript are available here.)

Wednesday, August 27, 2008

Drug Trials in India

India is developing drug trials as a budding industrial sector. It is predicted that trials outsourced from the U.S. and Europe will bring $1 billion to India by 2010. But unless institutional review boards and ethics committees get their act together quickly, what may happen instead is a series of political scandals.

Drug trials in India cost 40% - 60% less than in the U.S. or Europe. India offers an enormous, diverse population. Regulation of drug trials are much looser than in the U.S., and expectations about informed consent are not the same.

In 1989, on my first visit to India, I spent a day with a skillful, caring psychiatrist at Banaras Hindu University. He had the patients he saw who could speak English talk with me. After I had spent a half hour (a long time in his fast paced clinic session) talking with a family I asked my host if it would be acceptable to ask the family if I could take their picture. My kindly host, a genuinely compassionate man, said - "Don't ask, just take the picture!"

Earlier this month the World Health Organization Bulletin warned of the potential for an ethical crisis in the outsourcing of drug trials to India. The bulletin quoted Dr Ambujam Nair Kapoor, a senior scientist of the Indian Council of Medical Research, as saying: “Unless we put in place systems that ensure safety of patients and good quality of trials, people will get away with whatever they can get away with.”

It didn't take long for the WHO warning to hit the fan. The Uday Foundation for Congenital Defects and Rare Blood Groups, one of India's huge number of NGOs, obtained information suggesting that 49 infants at the All India Institute of Medical Sciences, a public hospital in Delhi, had died in the course of drug trials.

The report has become a hot political issue. The communist party (not a fringe group in India) has seized on the story as an example of capitalist exploitation of the poor (see here). The ruling Congress party (see here) demanded an independent investigation of the All India Institute of Medical Sciences drug trial situation.

I don't have an independent view of the rights and wrongs of the All India Institute situation. But I can see from the political reaction that public trust of the drug trial industry is fragile at best. India, and drug companies, are incurring a tremendous risk. Regulation in India is limited. The potential for major ethical lapses is large. Lots of money is at stake. Happily, the NGO sector is strong, and will be vigilant in monitoring what happens.

As Maurice Sendak wrote in "Where the Wild Things Are" - "Let the wild rumpus start!"

Monday, August 25, 2008

Health Insurance and Health Care Cost - a personal experience

Charlie Baker, CEO at Harvard Pilgrim Health Care, where I direct the ethics program, has a valuable posting about "Bending the Health Care Cost Trend" on his "Let's Talk Health Care" blog.

Five years ago Harvard Pilgrim made three large changes in the way it provided insurance to employees. First, and most significantly, it moved from providing a fixed percentage (80%) of the cost of each health insurance option to a fixed contribution (80% of the cost of the mid price plan). Second, it provided all kinds of tools, including a cost estimator, to help employees compare the different choices. Finally, it eliminated the option of automatic rollover. If we didn't explicitly choose a plan we wouldn't be insured.

Until that time I had subscribed to the "point of service" plan. Although I had all of my care at the Harvard Vanguard medical group, I thought of the POS plan as a source of flexibility or an escape clause. I thought that if I needed a specialized procedure, such as a joint replacement, I could shop around for alternatives, and the POS plan would pay most of the cost.

When Harvard Pilgrim started making a fixed contribution towards our health insurance, the cost of the POS plan got much more personal. It cost something like $1,750 more than the HMO plan with a $1,000 deductible, and Harvard Pilgrim paid 1/2 of the deductible for those who chose that plan.

The change led me to think through how much the flexibility the POS plan was worth to me. After I spoke with my primary care physician and some others I trusted I concluded that the care options Harvard Vanguard provided met my needs. So for me it didn't make sense to shell out the additional money for the POS plan.

Choosing the HMO with a deductible was a carefully thought out decision. But my experience with the deductible has been altogether different. Policy types like to invoke the importance of "skin in the game," but when I had what turned out to be a fungal infection of the face or, another time, bronchitis with a fever, shopping for a different dermatologist or less costly bronchitis care wasn't feasible (where would I get the information) or desirable (when you're sick one doesn't want to shop). For me, the choice of which form of insurance to adopt involved deliberation about value (cost and quality), but deductible was simply a matter of my paying more of the cost of my care - it didn't involve me in deliberation about what was worthwhile to me and what wasn't.

From talking with colleagues, my impression is that their experiences are similar to mine. Virtually all thought carefully about the type of insurance they chose for themselves and their families. But very few experienced the deductible as a catalyst for value-oriented thinking about the components of their care.

Harvard Pilgrim's approach has been well accepted by employees. And, at the same time, it has slowed the company's health insurance bill to a 6% annual increase in a region where 10% and more is the norm. There appears to be widespread agreement that it is fair to expect employees who want costlier forms of insurance to pay more, and for those who choose a plan less costly than the mid-priced option to pay less.

Harvard Pilgrim's experience shows how employers can engage employees in meaningful reflection about health insurance and health care costs, and that the effort can have a positive effect on consumer understanding and the cost trend.

(If you're interested, Harvard Pilgrim's 2003 annual report describes its approach to employee health insurance in detail.)

Thursday, August 21, 2008

Harry, Louise, and Medical Ethics

Good news! Harry and Louise are back. And they've changed a lot since they deep-sixed the Clinton health plan in 1994.

Their big concern now is cost and access. Harry has the morning paper at breakfast, and tells Louise "Health care costs are up again. Small companies are being forced to cut their plans.” She's not surprised to hear this - her friend Lisa's husband has gotten a cancer diagnosis, but couldn't afford the coverage available through the start up he works with. Harry and Louise sigh, and agree that "too many people are falling through the cracks."

Louise makes their final pitch this way: "Whoever the next president is, health care should be at the top of his agenda. Bring everyone to the table, and make it happen!"

Wonky blogs like this one don't move public opinion, but Harry and Louise might. In 1994 they were effective in scaring us about government involvement in health care. This time they're out to scare us about rising costs and reduced access - not just for the unemployed poor, but for folks like Lisa's husband as well.

They're pushing a process, not a solution. Louise gets it right - without educative leadership from the political sector, and without getting consumers, clinicians, health organizations (hospitals, PhRMA, etc), and public/private insurers actively involved, the continued deterioration in affordability and access will stay on automatic pilot.

You can visit with Harry and Louise here. I hope that Harry reads more articles about how rising costs injure patients and the public. He and Louise could play a constructive role in health system reform.

Wednesday, August 20, 2008

Shakespeare and Medical Ethics

In Act V of Romeo and Juliet, Romeo, heartbroken by his (mistaken) belief that Juliet is dead, offers an apothecary 40 ducats for "a dram of poison" that will end his life. When the apothecary replies that Mantua's law forbids dispensing poison Romeo plays upon his poverty:
Art thou so bare, and full of wretchedness,
And fear’st to die? famine is in thy cheeks,
Need and oppression starveth in thine eyes,
Contempt and beggary hang upon thy back;
The world is not thy friend nor the world’s law:
The world affords no law to make thee rich;
Then be not poor, but break it, and take this.
Romeo's reasoning does the job. The apothecary replies with a familiar distinction between ethics and business:
My poverty, but not my will, consents.
Romeo reinforces the distinction, hands over the 40 ducats, and goes off with the poison:
I pay thy poverty, and not thy will.
If I'd received 40 ducats for every class or consultation in which someone said "ethics is fine - now let's get realistic about business..." I would never have to fear "contempt and beggary" again. Bottom line considerations should be part of ethical deliberation. Sometimes they deserve to be given the greatest weight in the moral reasoning process. Sometimes other values will and should prevail.

Thinking of "business" and "ethics" as separate and unconnected realms contributes to our national paralysis in dealing with health care costs. The split tempts clinicians to see the finance folks as uncaring bean counters, while those attuned to finance can see physicians as naive idealists.

This distinction got personal for me shortly after I joined the practice at the Harvard Community Health, a not-for-profit clinician managed HMO, in 1975. A young patient of mine with alcoholism had been admitted to a nearby psychiatric hospital after cutting his wrists while intoxicated. While negotiating by telephone with the attending psychiatrist for what I believed was a prudent discharge to outpatient care, I was chagrined to hear him call out to the chief of service - who had taught me as a resident 7 years earlier - "I have Sabin on the line...he used to care about patients...but now he cares about money!"

Mother Theresa and Albert Schweitzer could set the psychiatrist straight about caring about patients and caring about money. They understood that without a financial margin, they couldn't pursue their mission. They would have told us that devoted caretakers don't put "ethics" in one bucket and "business" in another.

(My friend Russell Teagarden brought Shakespeare's 400 year old insight into the pernicious impact of splitting business and ethics to my attention via an excellent article in the American Journal of Pharmaceutical Education." For those who want to delve further into how to bring care and cost together in pharmaceutical ethics, see also "An Ethical Template for Pharmacy Benefits," by Daniels, Teagarden, and Sabin.)

Monday, August 18, 2008

West Virginia's Medicaid Redesign and the Ethics of Personal Responsibility

Two years ago, West Virginia launched a Medicaid redesign based on the premise that beneficiaries should be expected to play an active role in managing their own health. As a condition of eligibility for an expanded portfolio of benefits, beneficiaries were asked to sign a document of "member responsibilities and rights," which included taking medications regularly, keeping appointments, and avoiding unnecessary emergency room visits.

If you were a Medicaid commissioner responsible for a budget-busting program or a hard-pressed taxpayer supporting it, these expectations would seem eminently reasonable. Adult patients aren't children. It is condescending for clinicians to expect too little from patients. A patient of mine with significant substance abuse problems brought this home to me some years ago:

Patient: "You remember the time a few months ago when you said I looked strung out and asked me if I was using? I told you I wasn't, but I had taken cocaine earlier that morning."

Me: "That's what gets called 'denial' in the substance abuse world."

Patient: "Not denial...LYING."

In my view, the impetus for West Virginia's redesign was understandable and inherently admirable. The question at the time of implementation was whether a blunt instrument like member responsibility agreement could really work.

This month a Georgetown University evaluation of the program gave the answer. It doesn't work.

So far 85% of those who are affected by the changes are children. Almost all children on Medicaid (93%) have had their benefits restricted. This isn't because their parents have failed to do their part in the care process - it's because the documents never got signed in the first place. It isn't that parents have been reading the documents, deliberating about whether to sign, and then saying "no." The process has been so confusing and poorly implemented that non-signing of the documents is virtually inevitable.

Children make up 50% of West Virginia's Medicaid enrollees but only 22% of the cost of the program. The elderly and disabled make up 36% of the enrollees but account for 70% of the cost. The program evaluation does not document any impact of the redesign on these populations.

I hope West Virginia's failure doesn't stifle efforts to bring patients and families into more active collaboration in the effort to improve health and control costs. We won't make progress on these fronts unless patients, providers, and payers work together. West Virginia's experience tells us that bureaucratic fiat won't do the job. If I were the Medicaid commissioner there I would bring Medicaid recipients and medical leaders together to learn from the first two years of experience and plan for next steps.

All around us we see efforts to get a grip on health care costs and quality. Unfortunately, most of these efforts are based on wishful thinking about magic bullets. In West Virginia the magic bullet was a written contract for care. In private insurance the magic bullet is high deductibles. But gimmicks like contracts and deductibles won't do the difficult job for us without a concomitant shift in the values by which we govern our health care non-system.
(The Georgetown evaluation can be found here. New England Journal of Medicine articles about West Virginia's Medicaid redesign are here and here.)

Thursday, August 14, 2008

PhRMA Stops Sabre Rattling in Massachusetts

Three days ago I criticized PhRMA's heavy-handed attack on the relatively mild restrictions Massachusetts Senate Bill 2863 imposes on drug and device manufacturers. Here's what I suggested PhRMA should have said:
We at the Pharmaceutical Research and Manufacturers of America disagree with much of Senate Bill 2863. But we understand that Massachusetts must control health care costs for its important reform process to succeed.

Our interests as business entities are not always aligned with the interests of the state. Sellers want to maximize profits. Buyers want to minimize costs. But we share a commitment to the health of the population and to ensuring that our industry can continue to draw on the many talented scientists in Massachusetts in pursuing research and development in the state.

To that end we propose that Massachusetts and the Pharmaceutical Research and Manufacturers of America work together to advance our shared interests, and to ensure that where our interests diverge we work as collaboratively as possible...
Happily, PhRMA appears to have come to its senses. Yesterday's Boston Globe reported that several Massachusetts companies, including Wyeth, which has 2,700 employees in the state, are proposing to work with the state to craft regulations that serve the interests of Senate Bill 2863 and recognize the interests of the local drug and device companies as well.

Too bad PhRMA didn't start out this way. Instead of reinforcing negative public perceptions of the industry, it could have endorsed the ethical appropriateness of the state's first tentative steps towards cost containment and defined itself as part of the solution, not the source of the problem.

Wednesday, August 13, 2008

The Rule of Rescue in the British National Health Service

Today's Daily Telegraph (here and here) bitterly attacks NICE (the National Institute for Health and Clinical Excellence) for not adopting the rule of rescue. Here's the gist of the attack (put together from the two articles):
[NICE] has now rejected the so-called "rule of rescue" which stipulates that people facing death should be treated regardless of the costs. The rule is based on the natural impulse to aid individuals in trouble.

Surely its latest pronouncement to the effect that patients should not expect the NHS to save their lives if the treatment required to do so would be too expensive, must be designed to be so outrageously offensive as to deliberately discredit the whole principle of healthcare funded through taxation.

No? Then what on earth could its members have been thinking when they laid down a ruling that doctors and nurses were to defy the most fundamental moral inclination, not only of the medical professions, but of the human community: to do whatever is necessary to save an individual life in one's care?
The Telegraph's reaction is psychologically understandable, but logically preposterous.

I've been attacked in the same way almost every time I've discussed rationing. Physicians like to say - "with my patients, the only thing for me to consider is providing what my patients need."

My response to this kind of feel-good nonsense is often - "Doctor, that's admirable! I suppose it means that if your patient needs a heart transplant, and you are the only good match, you will donate your heart. Did I understand you right?"

As societies, we must learn how to recognize that life is a blessing, invaluable to each of us, but in economic terms life isn't priceless. In the U.S., our inability (thus far) to achieve this maturity of perspective is the major impediment to controlling our runaway health care costs.

If working people had been able to put into the bank the difference between per capita health care costs in the U.S. compared to the next costliest developed country, many of those losing their homes to foreclosure would be able to pay there mortgages. The smug moralising about NICE that we see in today's Telegraph (which is more characteristic in U.S. than U.K. political discourse) may make the moralist feel virtuous, but the end result is deeply injurious to the population.

In "Setting Limits Fairly: Learning to Share Resources for Health," Norman Daniels and I discuss these issues at much greater length (232 pages). But I think the basic point can be said in eight words: "life is a blessing, but blessings aren't priceless."

I'll discuss "Social Value Judgements: Principles for the development of NICE guidance" (the document the Telegraph is attacking) and the excellent NICE Citizens Council Report "Rule of Rescue" at greater length in the next couple of weeks.

Monday, August 11, 2008

PhRMA Shoots Itself in the Foot in Massachusetts

Yesterday Massachusetts Governal Deval Patrick signed Senate Bill 2863, "An Act to promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care."

The most controversial aspect of the bill is Section 14 - new regulations for "Pharmaceutical and Medical Device Manufacturer Conduct." PhRMA lobbied hard against this section. (See here, here and here.) I think the industry misjudged its own long term interests and shot itself in the foot.

Here's part of what Ken Johnson, PhRMA Senior Vice President, had to say about the Massachusetts bill:
We believe the compromise language passed by the Massachusetts legislature could have grave consequences on both the future of clinical research in the state of Massachusetts and patient health in general.

Massachusetts is a hub of valuable health information and medical discovery. Physicians and other healthcare professionals in the commonwealth are at the nexus of both groundbreaking clinical research and quality patient care.

As written, Section 14 (Chapter 111N), which would require public disclosure of payments (valued at $50 or more) between pharmaceutical research companies and healthcare providers, could chill ongoing clinical research in the commonwealth.

Massachusetts has many academic medicine centers with healthcare providers who provide patient care, but who also conduct research in partnership with pharmaceutical companies. Physicians and other healthcare providers who do not want such personal information disclosed may decide to no longer work with the pharmaceutical research companies sponsoring the clinical studies.

Public disclosure of a pharmaceutical company’s arrangements with the principal investigators of its clinical trials also would reveal sensitive, proprietary business information to a company’s competitors. This could erode the independent decision-making of companies trying to bring science from research facilities to patient care settings.
Here's what I would have advised him to say:
We at the Pharmaceutical Research and Manufacturers of America disagree with much of Senate Bill 2863. But we understand that Massachusetts must control health care costs for its important reform process to succeed.

Our interests as business entities are not always aligned with the interests of the state. Sellers want to maximize profits. Buyers want to minimize costs. But we share a commitment to the health of the population and to ensuring that our industry can continue to draw on the many talented scientists in Massachusetts in pursuing research and development in the state.

To that end we propose that Massachusetts and the Pharmaceutical Research and Manufacturers of America work together to advance our shared interests, and to ensure that where our interests diverge we work as collaboratively as possible...
I would have explained that the handwriting is on the wall with regard to (a) understanding the impact of pharmaceuticals and medical devices on the cost trend, (b) the need to minimize conflicts of interest through new regulations, and (c) the need to strengthen trust through greater transparency. And I would have pointed out that Massachusetts would not, and should not, be sympathetic with "physicians and other healthcare providers who do not want [payments] disclosed..."

If PhRMA had persuaded the legislature or governor to squash Senate Bill 2863 it would have provoked a tremendous backlash that would have overwhelmed whatever value a short term "victory" provided.

In War and Peace, Tolstoy tells us how Mikhail Kutusov, the great Russian general, guided his troops - he observed which way the tide of war was going and then advised his army to go with it.

That's what PhRMA should have done. Health care costs are so destructively out of control, and wasteful care is so rampant, that the kind of stonewalling it attempted simply won't work over time. General Kutusov let Napoleon capture Moscow without a fight, and simply waited for winter to drive the French back.

PhRMA blew a good chance to ally itself with the future.

Sunday, August 10, 2008

Hospital Ethics

On reason "ethics" has a bad name is the gap between espoused principles and the behavior of individuals and organizations. Highfalutin talk is one thing. Action on the ground is another.

Think of all the aphorisms. "Talk is cheap." "Actions speak louder than words." "You can talk the talk, but can you walk the walk?" When I teach ethics I often distinguish between analysis ("What is the right thing to do?"), advocacy ("Do the right thing!"), and administration ("Let's run things so we reliably do the right thing in the right way"). To be worthy of attention, the discipline of ethics requires attention to all three components. In organizations, the administrative component is necessary to make values real.

An article in today's Boston Globe told about a surgeon at North Shore Medical Center in Massachusetts who blew up when a scissors cut poorly and threw them, barely missing one of the nurses. In the past, outbursts of this kind have been overlooked, especially for busy surgeons who brought a lot of patients to the hospital. But in this instance the scissor-tossing surgeon was disciplined. Many other hospitals are doing the same. Operating room teams are being trained in teamwork, and policies are calling for "civility and respect."

Since this was always the right thing to do, what's changed? The change appears to be recognition of the link between civil behavior among team members and patient safety. When the ethical calculus involved weighing respectful team behavior against potentially angering a high-producing surgeon, hospital administrators tilted towards ignoring bad behavior. But when research showed that team conflict increased medical errors, the scales tilted towards confronting the behavior.

There are two important lessons here.

First, it's easy to say that abusive behavior in an operating room team is disrespectful, and therefore wrong. But on its own, that argument accomplished nothing. Administrators felt the risk of alienating surgeons and losing their business outweighed respectful team behavior. Their conclusion is understandable. If the hospital didn't have patients to care for it would go down the tubes. No margin, no mission.

Demonstrating the link between team cohesiveness and patient safety made the equation come out differently. Medicine is about results. It is a very consequentialist field. The principle of "civility and respect" took on more weight when eruptive operating room behavior came to be seen as a cause of worse outcomes.

Second, North Shore Community Center took the administrative side of ethics seriously. It didn't just send out a memo saying "we should treat each other with civility and respect..." It followed through, with training and discipline. Without this kind of administrative follow through, staff become cynical about moral pronouncements and "ethics."

To be worth its salt, organizational ethics needs to bring analysis, advocacy, and administration together. We physicians often badmouth administration, but without it professional ideals are just words.

Wednesday, August 6, 2008

Prostate Cancer Screening

In organizational and health system ethics, the public is a key stakeholder. I've thought for a long time that widely held public values impede our ability to get a grip on health care costs. So the question of how public values change is a big one for me.

The best opportunity for our coming to see health care cost containment as an ethical responsibility - not a moral abomination - will come from a combination of perceived crisis and effective leadership. As I've written (most recently here), the looming crisis is Medicare going broke. We're seeing that a $1 increase in gas prices is making Al Gore seem more like a wise prophet than a kook to a wide swath of the public, but whether real leadership about cost containment or Godot will come first is anyone's guess.

The alternative to the big bang approach (crisis + leadership) to changing public values is a "chipping away" strategy. Publicity about the U.S. Preventive Services Task Force recommendation that men over 75 should not be screened for prostate cancer is just the type of story that can nudge a bit of values change.

The Task Force concluded that PSA testing of asymptomatic men over 75 is likelier to cause harm than benefit. Prostate cancer that has caused no symptoms and is not detectable on clinical examination grows so slowly that elderly men typically die of other causes before the nascent prostate cancer acts up. Since treatment has many negative effects (quite apart from what it costs), a "don't ask, don't tell" non-screening approach makes most sense.

But most of the stories about the Task Force recommendations emphasized that men who want to be tested will and should have the test paid for. Over time I hope this proves wrong. If I want to have a PSA test when I'm over 75, despite learning that it's likelier to cause harm than to provide benefit, why should you pay for it? From an ethical perspective, it seems right that I should have access to the test, but should be expected to bear (more of) the financial burden myself.

This is the basic concept of value based insurance design (see here). Having a PSA test when I'm an asymptomatic 80 year old may serve my values. But the allocation of public funds should be driven by public values, not by each individual's choices. That's not where our dominant public values are at present, but it's where we have to get to if we truly want to control health care spending.

(A New York Times article about the Task Force report is available here. See here for an Annals of Internal Medicine article summarizing the Task Force's research.)

Monday, August 4, 2008

Immigrants, Refugees, and Medical Ethics

After I wrote yesterday's post about refugees and asylum seekers in the British National Health Service, I read a remarkable article in the New York Times about Luis Alberto Jimenez.

Eight years ago, Mr. Jimenez, an illegal immigrant working as a gardener in Florida, was hit by a drunk driver, resulting in severe traumatic brain injury. Martin Memorial Hospital provided care. Given that no insurance coverage was available, Martin was unable to find a rehabilitation placement for Mr. Jimenez. They kept him in the acute hospital, accumulating a bill of $1.5 million. In the midst of litigation about returning him to Guatemala, which his U.S. guardian was resisting, the hospital hired an air ambulance and flew him back.

While accurate figures aren't available, hospital initiated deportations are not uncommon. Advocates for Mr. Jimenez accuse Martin Hospital of "dumping," but it is hard to see how an individual hospital can be expected to provide open-ended financing in circumstances like that of Mr. Jimenez.

An article in this month's Bulletin of the World Health Organization puts Mr. Jimenez's situation into a global context. 200 million or more people are living outside of their country of birth. Access to health care and the question of who will pay is a problem everywhere.

What we're seeing now is the way ethical problems roll downhill when wider societies choose to ignore them. In the U.K., GPs are asked to violate their most fundamental ethical commitments by refusing to treat undocumented immigrants. In Florida, Martin Hospital is asked to finance Mr. Jimenez's care in an open-ended way. Neither request is ethically justifiable.

The U.S., U.K., and every country that receives legal and illegal immigrants need to address the issues openly. International organizations like the WHO are crucial for helping to establish shared expectations and a broad ethical framework. The rehabilitation hospital in Guatemala that Mr. Jimenez was initially transferred to has an annual budget of $400,000, but appeared to provide excellent care. Rather than saddle Martin Hospital with a $1.5 million bill for inappropriate acute care, all parties would have been better served by a U.S.-Guatamala plan for augmenting services in Guatemala.

GP resistance to making them the agents for a National Health Service problem helps to push the complex ethical issues up to where they belong. In the hospital sphere, the American Hospital Association should do the same, so that hospitals like Martin are not forced to choose between financial ruin and spiriting patients out of the country in James Bond fashion.

Sunday, August 3, 2008

British GPs Demand Right to Treat Refugees

In January I wrote (here) about GP resistance to a proposed National Health Service directive that they not treat asylum seekers or undocumented migrants. I concluded:
[W]e should cheer for the petition signers. Refusing to care for sick people – whatever their status – violates fundamental medical, and human, values. A policy that orders health professionals to abandon their historical commitment to provide care is not acceptable.
Since then a British physician friend told me that many doctors are simply ignoring the NHS policy.

An article in today's Guardian reported that the Department of Health has not revealed the extent of advice it has received criticizing the policy. Typically these advisories are made public shortly after submission. The Global Health Advocacy Project obtained a list of those who had submitted comments and obtained most of the materials. (available here) Among these, the submission from Ken Livingstone, the former Mayor of London is especially interesting. Livingstone agrees that well-to-do foreigners who come to the U.K. to seek free NHS treatment can legitimately be charged for care, but argues that asylum seekers and undocumented migrants should be eligible on the basis of medical ethics and public health concerns.

The intersection of globalization and health care will create ever more ethical challenges. Developed countries are siphoning health professionals from poorer locations. In this situation, the rights of individual health professionals to pursue their own interests clash with the health needs of the home countries. Medical tourists from wealthy countries are travelling for care to all sectors of the globe. In that situation, their rights as individuals to seek care where they want it is distorting access to care in the countries they visit.

The British GPs are right in resisting the NHS policy. While it is understandable that local taxpayers, whether in the U.K., U.S., or elsewhere, are reluctant to subsidize care for foreigners, asking nurses, doctors, and others, to act as immigration police, risks undermining the integrity of our own health systems and health care.