By Peter Laird, MD
The debate over health care reform out of Washington DC is underscored by a new medical ethics that is seldom discussed and even fewer that understand it in the general public. It is called population based medicine. Harvard medical students recently protested the closing of their Primary Care Department and instituting instead the Department of Population Medicine as several other medical schools have already done previously. The ivory towers of Harvard were never the champions of primary care as evidenced by the meager $200,000 funding to their now defunct primary care department which is essentially the salary of one primary care physician and one primary care nurse.
My first profound experience with this new medical ethics came several years ago when I was reviewing a newly revised tuberculosis treatment guideline from the CDC. Isoniazid (INH) is the most often prescribed medication for latent TB which most would know simply as a positive PPD/TB test. For the majority of my medical career counseling patients on the risk, benefits and alternative treatment options of latent TB, I had followed a very standard risk protocol based on a 1978 study by Kopanoff finding significant risk based on increasing age:
In fact, the risk of INH treatment based on age listed above was exactly the information that I provided since 1993 to all of my patients with a positive TB test. Several patients chose not to take the prophylactic medication after coming to an understanding of the number of patients who will at some time develop active TB versus the number of patients that will possibly develop at times fatal INH induced hepatitis. However, current CDC latent TB treatment guidelines no longer mention INH risks in their treatment recommendations. The reason, we are now treating the herd in an attempt to eliminate or mitigate the effects of Tuberculosis in our entire population at the expense of a few individuals who may die from IHN induced hepatitis. The risks to the individual based on their age is now supplanted by the risks to the population. In other words, the CDC has switched from the ethics of treating the individual to the ethics of treating the population. This is only one of many examples of the new medical ethics that could be cited today.
The current debate on health care reform in America is simply the debate on completely changing from that of treating the individual to that of the population as a national choice. The healthcare systems of Canada and England have long since shed the medical ethics of Hippocrates (PDF link) in serving the individual patient to the maximum extent of the talents of the physicians to that of population based outcomes that often deny the individual treatments that could extend, prolong or improve their remaining life.
When I graduated Boston University School of Medicine, my class chose the Oath of Maimonides instead of the Hippocratic Oath. Staying true to this oath and having suffered myself in pain, it would behoove the American physician of today to truly recall the true calling of a physician to his individual patients.
The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
May I never see in the patient anything but a fellow creature in pain.
Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.
To understand this new medical ethics of population based outcomes is to understand what the true healthcare reform debate in Washington DC is all about. As evidenced by the example of the new latent TB treatment guidelines, the new medical ethics is already entrenched in our institutions and most especially, in all of the new medical school graduates. No wonder many patients wonder why they are not receiving the same care as they once did from those of us in the medical profession with much gray hair if we have any hair at all. As for me, I will always remember each time I self cannulate with a large 15 ga needle that I am simply a fellow creature in pain.
The healthcare systems of Canada and England have long since shed the medical ethics of Hippocrates(PDF link) in serving the individual patient to the maximum extent of the talents of the physicians to that of population based outcomes that often deny the individual treatments that could extend, prolong or improve their remaining life.
Peter do you have an example of this? It seems to me that compared to the US model of insurance based healthcare the Europeans are closer to the Hippocratic ideal.
If a Briton walks into an NIH facility their ailment is treated per medical guidelines. In the US a person is treated per insurance guidelines. The ethics of US medicine are more business then anything else.
Posted by: Bill Peckham | August 06, 2009 at 10:45 PM
Dear Bill, thank you as always for your comments.
I was quite fortunate to have the work situation where yes, I did have guidelines, but I could exceed them and do what I felt in my best judgement was best for the patient. The insurance guidelines did not constrain me. I have heard many accounts where physicians in Britain do not have the authority to go beyond the guidelines even when effective treatments are known but not approved in the guidelines such as some of the new treatments for RCCA specifically as is hopefully never a need that you will ever have personally but in England they are fighting for this still despite the known benefit.
http://www.kidneycancerresource.com/index.php/Kidney_Cancer_Support_Group_Oxford_27-Jan-09
http://scienceblog.cancerresearchuk.org/2008/08/06/nice-decision-on-kidney-cancer-drugs-have-your-say/
The issue is whether the doctor is able to use all of his abilities or are they restricted by guidelines set at a national level. A diligent physician here in America still has the ability to overcome the financial constraints of the insurance company when they are able to document the risk, benefit and alternatives in a dramatic fashion. The biggest issue is that of malpractice in America where the insurance companies are held to a higher standard if care is withheld that could have benefited the patient that the physician sought.
Under a NHS type of system, the NHS will set the standards of care instead of the current community standard of care we have in America. In that system, the lawyers will not be able to sue if the doctors act in accordance with government mandated population based outcomes. There is still checks and balances in our system even with all of the financial incentives of insurance companies to avoid expensive care.
Fortunately, my entire career has been devoid of personal financial incentives on any patient care. I never felt hindered by what I could offer the patient other than the limitations of our knowledge. I believe that is in keeping with the Hippocratic tradition where limiting care on a national level by approved guidelines has potential conflicts of interest at the level of the individual.
Posted by: Peter Laird, MD | August 07, 2009 at 12:30 AM
Peter you didn't see anyone unless they were in the Kaiser system. The problems in America addressed by the current legislation are problems with insurance - people getting dumped when they get sick, policies that don't actually give people the coverage they need, insurance costs that increase 40% a year.
Right now I and many others who have chronic illnesses are not employable by small businesses or able start a business because of insurance issues. It has nothing to do with the skills we could bring to a job, it is only about the our cost under existing insurance schemes.
Talking about an NHS system isn't relevant - there is no proposal for the US government to buy the hospitals and employ the docs. That's just not on the table or even down the road.
The issues that I see being debated in Congress are all around insurance and pharmaceuticals. The current system is expensive and ineffective. Keeping things as they are is not an appealing option.
Posted by: Bill Peckham | August 07, 2009 at 10:41 AM
Bill, I believe at the heart of my comments is the ethical change occurring with in my profession. Unfortunately as you have correctly pointed out, American medicine has long since slipped away from being a profession to being a big business. There are many of us old timers that decry the change in the ethics of individual patient care to that of population based outcomes. It is a movement away from the traditional doctor-patient bedside decisions.
At Kaiser, since I did not have to obtain prior approval for medical tests and treatments that I ordered, I still had the freedom to act upon my personal medical ethics framed in the Oath of Maimonides and Hippocretes of devotion to the individual before you. For myself, it was quite easy since I have suffered my own medical issues. From what I have read about the Canadian and English system, it is unlikely that I would have been able to operate within my own old fashioned medical ethics. I simply would not be able to order the tests or the treatments that went beyond the guidelines as I was able to do at Kaiser.
That is at the heart of my objection to the new medical ethics that is already entrenched in American medicine.
Posted by: Peter Laird, MD | August 07, 2009 at 03:36 PM