Atul Gawande on Cost and the Soul of American Medicine

Atul Gawande's superb article - "The Cost Conundrum" - in the June 1 issue of the New Yorker magazine is long (7500 words) but brilliantly written and researched. It won't teach anything new to policy wonks like me who've been fulminating about health care costs ad infinitum, but Gawande makes his analysis wonderfully understandable and persuasive for non-wonks by developing it through beautifully realized stories. I especially recommend the piece to the 20% of the readers of this blog from outside of the U.S. - it's an embarrassingly revealing view of the pathology of our health care system.

Gawande's core argument is that we are largely paying for health care as individual piece work, and rarely provide support for coordinated, population-based care. He makes his point by comparing McAllen, Texas to the Mayo Clinic and Grand Junction, Colorado, which achieve superior results at 1/3 the cost. He quotes Dennis Cortese, CEO of Mayo:

When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing.

You also get better care, happier patients, and physicians who love their work!

Every doctor has stories to support this point. I think of an experience at the Harvard Community Health Plan HMO 25 years ago. A primary care physician was seeing a patient who described intense sensations she called "anxiety" and who feared she was "going crazy." He asked me, as a psychiatrist, to see her. After we had spoken for some time I said - "I don't know what you have - but I do know what you don't have - it's not anxiety and you're not going crazy." I called a neurologist colleague. He was in his office. I walked my patient over and we sat together.

The diagnosis was ultimately not a happy one - an unusual brain tumor. I was able to spend more time with her in the next few weeks. She helped us understand her. An adult child who had had a turbulent life had gone back to school and was getting a college degree at age 45. My patient said "Before the graduation I want everything done so I can be there to celebrate. After the graduation I just want to be comfortable." Everyone involved with her care understood what mattered to her and we could see her through to the end of her life the way she wanted.

Gawande's article made me think of another patient as well - a woman who was going through a particularly difficult phase of a severe psychiatric ailment that involved depression, psychosis and alcoholism. The alcohol problem had gotten worse and was intensifying her other symptoms like a blowtorch. During a two week period she was seen by nine clinicians at various emergency sites. Between an electronic medical record that linked most of the sites, and telephonic communication with the others, everyone had a common understanding and shared plan. At the end of the two weeks my patient said, with some pleasure - "I've seen nine people and they all said the same thing - maybe there's a point to what you've been saying about AA!"

Gawande's argument is that simply achieving universal insurance - whether it's a public single payer plan or a mix of private and public programs - costs will continue to run amok if we don't foster coordinated care for populations instead of giving physicians incentives to flog patients with unnecessary and often harmful treatments. Here's Gawande's final paragraph:

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.

I hope every public leader involved with health care reads the piece!

Abortion and Conscience

Here's the assignment I developed for today's section of Harvard Medical School's required first year course on "Medical Ethics and Professionalism":

Drawing on the articles by May and Aulisio ["Personal Morality and Professional Obligations] and Curlin ["Religion, Conscience, and Controversial Clinical Practices"], discuss how you would respond to a respected colleague who is strongly against abortion and feels he cannot in good conscience refer a patient to a potential abortion provider and should discuss his moral perspective with his patients.

All 13 students (and I) believed that abortion should be legal, available and safe. My aim for the class was not to have yet another repetitive discussion of abortion ethics, but to engage with the question of whether and how our divided society can reduce the level of rancorous conflict and collaborate despite deep moral differences.

We conducted a segment of the class as a dialogue/role play. One student and I took the role of the anti-abortion physician envisioned in the assignment. The rest of the group was assigned the role of chief of the practice. Here's a summary of the dialogue, written as if it occurred between two people:

Chief: I've been told that you are refusing to refer patients for potential abortion services and are telling them about your personal moral outlook. Is that true?

Physician: It is. I know that abortion is legal and that a majority of the population believes it should be. But it seems so clear to me that abortion is killing a baby-in-the-making that there's no way of not seeing it as a profound wrong. I can't possibly support that - even by referring a patient to someone else.

Chief: Medical ethics is built around patient autonomy - that people have a right to make their own medical choices among legal alternatives. People can refuse life-saving treatment, and two states allow physician assisted suicide!

Physician: I know what the law says. In the country I came from female circumcision was legal and widely practiced, but I refused to do it or refer for it because I saw it as a deep moral wrong. The fact that the law allows abortion or female circumcision doesn't make these practices right or morally acceptable.

Chief: If you can't bring yourself to provide information patients are entitled to maybe you should have gone into a different profession!

Physician: I love medicine, and the feedback we get shows that my patients feel respected and well treated by me. Abortion is the one area where there's a problem for me in the practice.

Chief: It would be better to steer patients who want to consider abortion away from you in the first place.

Physician: That's a good idea.

Chief: Another thing. When you talk with patients about your views, we don't want you using terms like "evil" or "murder." You're entitled to your own views. But people who I regard as just as morally serious as you - including myself - disagree. You can say what you want in a political discussion, but not when you're a doctor dealing with patients.

Physician: I can live with that...

My aim in the class was to challenge us to respect a colleague we deeply disagreed with and not to demonize him because John Salvi and James Kopp felt called upon to murder abortion providers.

As I wrote in a post a few weeks ago, I think the best we can hope for is a gradual reduction of the virulence of the pro and anti abortion debate. (I don't like to use "pro life" and "pro choice" - all decent human beings value both life and choice!) President Obama has made a promising start with the working group he convened and his speech at Notre Dame (see here). And versions of the class experience my students and I had today - if repeated in a few million settings - may make a difference as well.

Public and Expert Beliefs about Health Care Reform

Readers who have not made use of the superb information provided by the Kaiser Family Foundation are missing a national treasure. Director Drew Altman's recent two page analysis of the ways in which expert and public views of health care reform differ is a must read. President Obama and his health care team will use it to guide their advocacy messages, and the Republican opposition will use it to encourage fear about what the Democrats propose.

Here are some of the key points that Altman draws from the Kaiser Family Foundation surveys:

1. Experts believe that up to 30% of the medical care provided is unnecessary, but 2/3 of the public believes that Americans don't get the tests and treatments they need - in other words, that too little care is the problem.


2. Experts believe that patients should be - and could be - prudent consumers of health care, but only 1/5 of the public has ever inquired about the cost of care.


3. Experts believe there are big differences in the quality of health care, but 70% of the public believe there are no major quality differences among doctors in their area.


4. Experts believe that health care consumes too much of the GDP but only 14% of the public has this as a major concern.


5. Experts attribute the ever escalating cost trend to expensive new technologies and treatments and to limited public understanding of quality and cost. The public sees the major cost drivers as waste,fraud and greedy drug and insurance companies.

We already see demagogic use of public (mis)understanding in the Republican campaign against comparative effectiveness research. If - as virtually every practicing clinician knows - our knowledge of which treatments work better and worse is much too skimpy, comparative effectiveness research is crucial for health care reform. But 55% of the public say that insurance should pay for whatever their doctor recommends, whether it is known to be more effective than alternatives or not. Republicans portray comparative effectiveness research as a ploy to allow "government bureaucrats to tell your doctors what they can and can't prescribe, no matter what your doctor thinks."

Our outlook on health and the health system is driven by emotion at least as much as by rationality. Except for those of us who fall into the "young invincible" category we are vulnerable beings, afraid of illness and mortality, eager to rely on a protective, healing power. That's why we place so much reliance on the opinions of our friends and family - the people we trust - rather than on the grail of evidence based medicine.

It's much easier to visualize demagogic attack on the way experts would reform the health system than it is to picture an equally emotionally alive form of advocacy for the experts' views. I believe that the President himself will have to take the role of an Everyman who (1) wants his doctor to be guided by good information, (2) understands that in the absence of good information, well-intentioned physicians prescribe large amounts of unnecessary and potentially harmful care, and (3) recognizes that runaway health spending actually reduces the overall health of the nation by hijacking funds from other health-promoting social benefits, one of which is higher wages! And we will need a new version of Harry and Louise who endorse evidence based medicine and see constraining our health expenditures as an admirable moral enterprise.

Desperately Seeking Health Insurance

I spent the weekend in rural New Hampshire, and had occasion to talk with a friend about his elusive quest for affordable health insurance.

My friend has worked hard all his adult life. He is self employed. Shortly before his 60th birthday he had a joint replacement. When he went to renew his health insurance for himself and his wife he was told that his monthly premium would double - from $1,200/month (bad enough) to $2,400/month (impossible). If he took coverage with a $10,000 family deductible he could keep the premium at $1,200/month. He was told that the 100% rate hike was due to having had a joint replacement prior to turning 60.

In our market-based health system self-employed people seeking insurance as individuals are up the creek. The basic nature of insurance requires companies to assess the risk they are taking on. If I chose to go uninsured until I am diagnosed with cancer it's fair to make me pay a hefty premium to make up for all the years I didn't contribute to the insurance pool. But what about my friend in New Hampshire?

It could be that an actuarial algorithm predicts that a person who has had a joint replacement before 60 becomes twice as risky to insure. But even if that's the case my friend has not been a free rider - he's been paying his part of the insurance pool year after year. A system that requires him to double his payment because of the treatment he needed is unjust, even if the insurance company and its actuarial practices are on the up and up.

Even if every insurer used actuarially fair methods to estimate risk it's simply wrong for individuals to have to pay more for their insurance because of their health status if they have maintained their insurance over time and were not simply waiting until a need for care arose. But I'm afraid that as our national discussion of health reform proceeds we'll fall into our familiar pattern of blaming individuals for not "putting enough skin into the game" or insurers for greed and profiteering.

Individuals and insurers both misbehave, but it's our system itself that's mistreating my friend. If we - the body politic - allow it to continue as it is, we'll have to point the finger of blame at ourselves.

Obama at Notre Dame

Dear readers - if, like me, you did not see President Obama's graduation speech at Notre Dame University yesterday, watch it now. I'll be surprised if it doesn't bring tears to at least some eyes. I'm still a bit teary. (See here for the text of his speech and a video.)

Obama spoke at length about the virulent way the abortion controversy has played out in the U.S. He acknowledged that ultimately the "pro life" and "pro choice" perspectives are irreconcilable. But with his remarkable rhetorical force he conveyed a small "c" catholic perspective of acceptance among those who hold different faiths, including no faith, which he referred to as "humanism."

For me, the most moving moment occurred when a heckler began to shout. The student audience drowned him out by chanting "yes we can," and gave the President a standing ovation.

Every religion, including "humanism," includes a hate-laden minority, eager to demonize, and sometimes to kill, those who don't share their convictions. Here's what the president had to say about that stance:

But remember too that the ultimate irony of faith is that it necessarily admits doubt. It is the belief in things not seen. It is beyond our capacity as human beings to know with certainty what God has planned for us or what He asks of us, and those of us who believe must trust that His wisdom is greater than our own.

This doubt should not push us away from our faith. But it should humble us. It should temper our passions, and cause us to be wary of self-righteousness. It should compel us to remain open, and curious, and eager to continue the moral and spiritual debate that began for so many of you within the walls of Notre Dame. And within our vast democracy, this doubt should remind us to persuade through reason, through an appeal whenever we can to universal rather than parochial principles, and most of all through an abiding example of good works, charity, kindness, and service that moves hearts and minds.

For if there is one law that we can be most certain of, it is the law that binds people of all faiths and no faith together. It is no coincidence that it exists in Christianity and Judaism; in Islam and Hinduism; in Buddhism and humanism. It is, of course, the Golden Rule - the call to treat one another as we wish to be treated. The call to love. To serve. To do what we can to make a difference in the lives of those with whom we share the same brief moment on this Earth.

The key thing here isn't the words, which are familiar, though eloquent. It's the fact that the President was speaking at one of the world's leading leading Catholic institutions. This kind of leadership won't persuade convinced haters, but it can and will make a difference in our public attitudes over time.

(Ten days ago I wrote a post about the working group on abortion the White House has convened. You may want to look at it as well.)

ALS, the Rule of Rescue, and the FDA

The opening paragraph in "Fighting for a Last Chance at Life" in today's New York Times led me to expect what the Brits call "hanging crepe" - using imminent death to blast insurers as uncaring, profit-seekers and the FDA as a callous bueaucracy:

As Lou Gehrig’s disease sapped Joshua Thompson of his ability to move and speak last fall, he consistently summoned one question from within the prison of his own body. “Iplex,” he asked, in a whisper that pierced his mother’s heart. “When?”

Joshua, a vigorous, athletic, married 34 year old father was diagnosed with Amyotrophic Lateral Sclerosis in 2007. Kathy Thompson, Joshua's mother went onto the web, and learned about Iplex, a drug containing an insulin-like growth factor that in 2006 had been reported to stimulate growth of the nerve cells involved in ALS (in tissue culture). The growth factor had been tested on ALS patients and was found to be ineffective, but Iplex combined the growth factor with a protein that might get it into the nervous system more effectively. The New York Times article describes in rich detail the campaign Kathy orchestrated to make Iplex available, despite the lack of FDA approval or evidence - other than anecdotes from Italy, where the government provides it - for its effectiveness.

There are currently no effective treatments for ALS. It is regarded as a uniformly fatal condition. The desperate effort on the part of ALS patients and their families to try any approach about which they have hope is totally understandable. The public policy challenge is - how should a health system respond to patients in a "last chance" situation who want medications (or other interventions) they regard as promising but which have not been shown to be effective?

It's possible that the medication may prove to do more harm than good, but I don't see that as a reason to forbid access. As Kathy Thompson said when safety concerns were invoked - "what, exactly, is safe about ALS?" Patients who are competent to make decisions and who are fully informed about the risks and benefits of a treatment are entitled to decide whether they want to bear the risks for the chance of the gain.

The core issue involves considerations of the common good. If unproven medications are made available, patients in last chance situations will want to try them. I know that I would. But when this happens it is impossible to find out whether the medication really works. In the 1990s many states mandated insurance coverage for high dose chemotherapy and bone marrow transplant for women with advanced breast cancer. The availability of the treatment made it almost impossible to test its effectiveness. When results finally came in it emerged that the treatment was no better than the existing interventions, and often worse. Hundreds of millions of dollars were spent for what, on a population basis, was a net decrement in health compared to alternatives. (The chemotherapy story is told in detail in False Hope.)

As I read the story I thought - the FDA should make the drug available for what is called "compassionate use," but only in the context of a clinical trial. To my surprise and pleasure, that's exactly what the FDA did in March of this year. Here are the key sections of the FDA statement:

FDA's Decision

The FDA and Insmed [the manufacturer of Iplex] have agreed that access to Iplex for investigational use in patients with ALS will occur in two ways under Investigational New Drug applications (INDs):
1. Single-patient INDs requesting “compassionate use” of Iplex for treatment of named patients with ALS, received and date-stamped by FDA’s document room by close of business on March 6, 2009, will be allowed to proceed, and Insmed has agreed to supply Iplex to those patients; and
2. The remaining supply of Iplex, which is very limited, will be used by Insmed to conduct a clinical trial under an IND in which other patients with ALS who are interested in receiving Iplex treatment will be randomly assigned to receive drug through a lottery system.
All patients who receive Iplex under either a single-patient IND or in the Insmed clinical trial must be adequately informed by their treating physician of the possible benefits and risks of the treatment...

Rationale for FDA's Decision

...FDA has attempted to balance the needs of individual patients who are desperately seeking treatment options for this devastating disease with the need to learn if the drug is in fact beneficial, or harmful, in treating patients with ALS. These considerations were weighed over the last few weeks by FDA scientists and physicians, who held a series of meetings with Insmed and internal meetings to discuss the best path forward.

Conclusion

The FDA understands that ALS is a fatal disease with limited to no treatment options. We are very sympathetic to the desperate situation of patients with this terrible disease, and their families, and we remain committed to facilitating the development of effective drugs to combat ALS. Sometimes therapies that appear promising in the preclinical phase (before studies in humans) do not lead to benefits in patients...

The FDA is mindful of the need to strike a balance between access to unproven therapies for patients with limited treatment options, and the ethics of subjecting those patients to drugs with unacceptable risks or unconfirmed benefits. Today we have chosen a means to provide access to Iplex to as many patients as possible, consistent with all of the considerations discussed earlier.

The FDA has done an impressive piece of ethical analysis with regard to Iplex and ALS. It recognizes the dire circumstances of people like Joshua Thompson in last chance situations, the intensity of society's wish to rescue identifiable victims, and the importance of rigorous evaluation of new treatments on behalf of the common good. Hat's off to the FDA!

Octomom, Ethics, and Health Care Limits

This morning I participated in the Massachusetts Association of Health Plans (MAHP) ethics forum. MAHP has been sponsoring 3-4 ethics forums each year since 2002, open to Massachusetts health plans and interested others. Our topic today was "The Octomom Case: Who Should Decide About Fertility Treatment?"

We used the well publicized case of Nadya Suleman ("Octomom") who gave birth to octuplets as a result of in vitro fertilization as an avenue into large issues of health system ethics. Here's how the invitation defined the topic:

There are many ethical dimensions presented in this case. The first is “limits” itself. Should there be enforceable limits to fertility treatments (as opposed to guidelines)? Are we willing to limit choice? And if so, how far are we willing to go? Few would endorse China’s policy of one child per couple, but we intuitively understand that in vitro fertilization resulting in 14 children is too many. Who should set the limit: the patient, the doctor, government or society – or health plan? And is it the same limit for everyone – or are there different limits for those who can afford to pay all costs themselves?

We had decided to open the forum with a mini-debate. I took the roles of Ms. Suleman and Dr. Kamrava, her fertility specialist. Although I've long argued that society and the health professions have a responsibility for stewardship of societal resources and that limits are an ethic ethical obligation, not a moral abomination, I was impressed with how readily I could enter into a role I do not endorse.

The argument I made as Ms. Suleman was based on (a) love of children, (b) not wanting to discard the six embryos that were implanted, (c) my fully informed consent to the procedure and (d) the high value we place on choice in the U.S. As Dr. Kamrava I argued that we ask physicians in the U.S. to respect the uniqueness of each patient. Ms. Suleman loved children, wished for more, and previously had had single births (and one set of twins) when I transferred six embryos to her. I directly responded to the criticism that I had not followed American Society for Reproductive Medicine guidelines by quoting the relevant passage:

For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transferring only a single embryo. All others in this age group should have no more than 2 embryos (cleavage-stage or blastocyst) transferred in the absence of extraordinary circumstances.

I argued that the intensity of Ms. Suleman's love for children and her commitment to not destroying the six remaining embryos, combined with our experience in her previous cycles, constituted "extraordinary circumstances."

The contrary position in the debate was amplified by the group's discussion.

• Individual preference ("patient autonomy") is very important, but it should not be allowed to trump all other values.
• Being part of a multiple birth increases risks for the unborn child. Even though our society allows abortion, it can legitimately decide to limit conception as a way of protecting child health. We protect children after they are born. Why not do so before they are conceived?
• Even if advances in technology eliminated the risks associated with multiple births, so that harm to the potential child would not be a consideration, our resources are not unlimited. Future costs to society should be part of the equation and can be a legitimate basis for establishing a limit.
• We can't expect physicians to be the limit setters. They are (and should be) sensitive to their patient's values and wishes. Many fertility specialists would welcome external limits set by society.

The forum discussion recognized how strongly we in the U.S. value "life, liberty, and the pursuit of happiness." There was some hope that the recession would help us add heightened concern for the commons to our portfolio of guiding values. The group took note of the fact that several European countries regulate the number of embryos that can be transferred - some to two and some to one. They also limit the number of eggs that can be fertilized, which avoids the issue Nadya Suleman invoked - the presence of multiple untransferred embryos.

At the very least, the Octomom case may have created public readiness to accept limits set by insurers on the basis of the American Society for Reproductive Medicine guidelines.

The Demise of Fee-for-Service in Massachusetts

A wonky-sounding component of the Massachusetts government - the Special Commission on the Health Care Payment System - is fomenting a quiet revolution.

On May 8 the Commission proposed taking down the hallowed system of fee-for-service reimbursement. If Massachusetts follows the recommendation the state will "transition to a payment system where global payments to provider networks are the predominant form of reimbursement."

The core concept in the Commission's recommendations is something we should all be taught in childhood - how to live within a budget. We in the U.S. have been notably lax about budgeting, as evidenced by our recent trend into negative levels of savings.

The Commission's proposals aren't new. What's important is that they are coming from a state commission in a state whose leadership is likely to follow its advice:

• The health system should be organized into “Accountable Care Organizations (ACOs), which include doctors, other community-based providers, and hospitals collectively capable of providing a full range of services. Relationships among providers can vary (ownership, virtual/contractual). "
• "Global payments should be adjusted for risk and other factors and incorporate common performance measures. "
• "Since some Massachusetts providers will face challenges moving away from fee-for-service, a careful transition must occur and offer adequate infrastructure support for providers. The transition will occur over a period not to exceed 5 years, though some providers may transition sooner. "

If Massachusetts proceeds with this plan - and I expect that it will - it could have significant national implications. The state has received a great deal of attention for its health care reform plan. To date, however, Massachusetts has succeeded in insuring most of its citizens, but has flopped in its efforts to contain costs. Unless Massachusetts gets a better grip on health care costs its reform program will die. Having gone this far the state doesn't want to see its efforts crash and burn. It has concluded - correctly - that fee-for-service reimbursement must go.

(For a previous posting on health care costs in Massachusetts see here)

Learning about Health Care Limits from the Recession

I've spent a lot of time over the years thinking about how we in the U.S. can come to understand and accept limits on the health care we provide. My heroes in this effort have been public leaders like former Oregon Governor John Kitzhaber and Michael Rawlins, Chairman of the National Institute of Health and Clinical Excellence (NICE) in the U.K.

But an article in this morning's New York Times headlined "Shift to Saving May be Downturn's Lasting Impact" suggests that the current recession may inadvertently teach useful lessons about health care quite apart from the impact of educative leaders like Kitzhaber and Rawlins. Here's the relevant quote:

Whether for reasons moral or otherwise, consumers are already thinking a bit differently about their long-term budgets. A recent Pew Research Center survey found that many more Americans had begun regarding products like microwave ovens as luxuries rather than necessities...

"People are realizing they can’t accumulate everything they want anymore, and they’ll have to prioritize more...That may be hard for a lot of brands — figuring out not only how to get considered by consumers, but put at the top of their list.”

...A recent Gallup poll found that most Americans who have recently increased their savings believe their budget adjustments represent a “new, normal pattern for years ahead.”

Until I read this article I hadn't connected the dots between the facts that (a) the U.S. has had the world's lowest levels of savings and (b) the world's highest per capita levels of health care spending. I may be slow but I've finally gotten the point - our ways of thinking about health care are part of our ways of thinking about the wider economy and whether it is possible to get all we want! And since our profligate health system achieves relatively poor results, we may find that increasing our savings is good for our health as well as for our personal budgets.

Good Politics and Good Ethics about Abortion

An article in yesterday's Wall Street Journal described how President Obama has convened a group of abortion rights opponents and supporters to help develop policies both sides can get behind.

This is probably smart politics. It may lead some pro lifers to see the President more favorably. But it's definitely good ethics.

Some years ago, when medical ethics was taught as an elective at Harvard Medical School (it's a required course now), my colleague & friend Lachlan Forrow (president of the Albert Schweitzer Fellowship) and I co-taught the course together. We didn't see how a course on ethics could avoid discussing abortion, but we feared that simply discussing it pro and con would get nowhere, since most people would just be repeating fixed opinions. We decided to approach the issue from the side, through discussing the pros and cons of "selective reduction" in triplet pregnancies, where reducing the pregnancy from three to two increases the likelihood of survival. We also discussed whether an OB/GYN program that included training in abortion should accept or turn down an otherwise well qualified candidate who opposed abortion and refused to participate.

In retrospect I wish we'd asked President Obama's question - how might we create some rapprochement between the pro life and pro choice camps? The issue of whether and how it is possible to promote constructive dialogue in intensely polarized situations should be part of ethics education.

The ideas being discussed in the White House process are constructive but predictable - reducing the frequency of unwanted pregnancies, as by making contraception more available and improving sex education, and making it easier for new mothers to keep their babies and making it easier to adopt.

But the most important outcome could be a greater readiness for the "camps" to appreciate each other's human decency.

Pro choicers should acknowledge that abortion does involve sacrificing a (pre natal) life. That's a deeply serious moral choice and a very sad event. They shouldn't see pro lifers in terms of the lunatic and criminal fringe of the movement. And the pro choice folks shouldn't be demonized as promiscuous baby killers. Comparing abortion to the Nazi gas chambers is preposterous logic and grotesque ethics.

But it's important to have realistic expectations about dialogues of the sort the White House has convened. In 1994, after John Salvi murdered Shannon Lowney, receptionist at Planned Parenthood, and Lee Ann Nichols, receptionist at Preterm (both in Boston), Governor Weld and Cardinal Law promoted talks between six prochoice and prolife leaders. The women, with two facilitators, met for more than 150 hours over the course of five years.

The talks did not lead the leaders to change their basic views, but they did promote a change in tone in the public debate. The "sides" came to see their "opponents" as as people of integrity and decency who held wrong views. But heightened recognition of each others' humanity in Massachusetts did not prevent James Kopp from murdering abortion provider Dr. Barnett Slepian in Buffalo in 1998. And if there is a Salvi/Kopp clone skulking about somewhere, the White House talks will not bring him to sanity.

The fact that even the deepest ethical dialogue has finite impact shouldn't dissuade us from promoting the process. For me one point of the Garden of Eden story is that even an omnipotent creator doesn't have full control over what our species will do!

Here's the final paragraph from a superb Boston Globe article written by the participants in the Massachusetts abortion dialogues:

We hope this account of our experience will encourage people everywhere to consider engaging in dialogues about abortion and other protracted disputes. In this world of polarizing conflicts, we have glimpsed a new possibility: a way in which people can disagree frankly and passionately, become clearer in heart and mind about their activism, and, at the same time, contribute to a more civil and compassionate society.

Ethical Challenges in Veterans Administration Healthcare Facilities

The April issue of the American Journal of Bioethics has a valuable piece of ethics research from the VHA.

To understand the challenges faced by Veterans Administration facilities, the authors conducted focus groups with patients (32) and managers (38), and semi-structured interviews with managers (31), clinicians (55) and ethics committee chairpersons (21). They found that all parties were deeply concerned about the ethics of the enterprise. There was no evidence whatsoever to support the common view held by clinicians that they are concerned with values while bureaucratic "beancounters" are concerned with business and the bottom line.

But the issues that most concerned the groups varied:

• Managers worried about how to distribute resources fairly among the different components of the facility and what kind of process to follow in doing this.



• Clinicians worried about providing high quality care with limited resources and balancing duty to patients with the obligation to be stewards of VA resources.



• Ethics committee chairs were most concerned with improving end-of-life care and ensuring that patient preferences were honored.



• Patients had as their top priorities receiving respectful and caring treatment from all staff and improving service quality.

The good news for those concerned with strengthening the culture of ethics at health care organizations is the fact that everyone saw health care as a value-driven mission. The bad news is the danger that health organizations could become Towers of Babel, with all groups speaking about ethics and values but unable to communicate with each other.

The VHA National Center for Ethics in Health Care has developed and is beginning to implement a very promising approach to the Tower of Babel danger - the IntegratedEthics program.

Anyone interested in the ethics of organizations should read the 15 page VHA report. Page 5 of the report has a useful picture of an "ethics iceberg." At the surface are the visible decisions and actions that are carried out every day - respecting/not respecting patient preferences, returning/not returning telephone calls, etc. Immediately under the surface are the organizational systems and processes that shape decisions and actions - such as ethics consultation, staff education and supervisory systems. At the deepest level, least directly observable but most powerful, is the ethical environment and culture of the organization.

What's most distinctive about the VHA approach is the way it links components of the organization that usually live in separate silos. In my teaching about ethics I've used the heuristic device of 3 "As" to describe the components of ethics in organizations. The VHA conception suggests a practical way to make them work together:

• Analysis (What's the right thing to do?) Ethics committees/ethics consultation concentrate on answering these analytical questions.



• Administration (How do we make it easier to do the right thing?) This is the responsibility of the various components of operations management.



• Advocacy (Let's make sure that we all embrace the same values and ideals.) This is the values leadership for which the CEO and her team are crucial.

The IntegratedEthics program envisions these ordinarily disparate functions being brought together in a managerially coordinated way. It's a smart, practical and promising approach to improving the ethics of organizations.

President Obama's Grandmother and the Ethics of Health Care Reform

I've written a number of posts about the need for presidential leadership for our country to come to grips with the issue of health care costs in a meaningful way. (See here, here, and here.) An interview published on line by the New York Times suggests that President Obama is starting to provide the kind of leadership that will be required:

When my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

...I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

The President has done two key things here. First, he has started to discuss resource allocation and rationing in down-to-earth, personal terms. The question of whether to do a hip replacement is a truly challenging clinical as well as ethical decision. This wasn't a situation of "flogging" his grandmother with a chemotherapy that offered a small chance of minor extension of life but at the cost of major side effects and high expenditures.If the President's grandmother had nine months of life in store and the hip replacement went well, the operation could have contributed to a significant improvement in quality of life for many months, but her heart condition and the cancer made the procedure riskier. What to do was a tough question.

A successful hip replacement might have let the President's grandmother go to her beloved grandson's inauguration. Insurance in a nation as wealthy as the U.S. should cover the procedure.

But an ethically guided health care system should consider costs, and every doctor and nurse who has dealt with end of life care knows that many of the interventions we make are, in balance, harmful and should not be done, and that others could, at best, provide tiny benefits at enormous cost, and should be questioned. These are among the issues we need to understand better and deliberate about.

The final paragraph in the quote suggests that the President and his advisers have thought about a public process designed to foster more informed political dialogue and to head off the kind of posturing and demagoguery we saw at the end of Terry Schiavo's life.

The interview touches on other important issues for health care reform - I'll probably write about these next week. But the President's words point in a promising direction!