Category: Health Care

Stealing from another is not compassionate to the robbed.

I didn’t watch the debate on Wed. night, so I have little background to understand the context of Senator McCain’s discussion of abortion beyond what I read from various people who live-blogged the debate. That is admittedly incomplete. From what I can piece together, this blog entry at Flotsam (link via Dooce) is an excellent rebuttal to McCain’s attitude. But I wish to point out one flaw in the entry:

McCain states that he would deal with the issue of abortion with “courage and compassion.” I quote: “the courage of a pregnant mother to bring her child into the world and the compassion of civil society to meet her needs and those of her newborn baby.” As if terminating my pregnancy would be the easy way out, the way not requiring his precious “courage.” As if dictating my medical care based upon his religious beliefs is compassionate. And I find it interesting to note that his “compassion” for this newborn does not extend to guaranteeing it health insurance.

First, McCain is pandering on abortion. I do not believe he cares. He’s trying to secure the Republican base with a few well-rehearsed lies. That makes him a scumbag, but for his pandering, not his position.

More importantly, the issue at stake is the right to control one’s own body, an issue I care deeply about. As much as I personally do not like abortion, I recognize that this is the issue involved. That matters as a principle of individual liberty. I believe it’s incomplete as an absolute when considering abortion, but not in a self-evident, attack-proof manner. It’s a complicated issue that will never be clear enough for a definitive policy. Therefore, we must err on the side of the individual with the clearer claim. Restrictions based on science are not abhorrent, but abortion should be legal, generally.

I do not get how that right to control one’s own body creates a right to have someone else provide material support (i.e. money for medical insurance) to care for the child. If a woman and her partner make the choice to have a child, it’s their obligation to support the child. In not guaranteeing health insurance, McCain is correct. His stated position is more logically consistent in that he’s saying people choosing to have children are responsible for everything involved, from start to finish, which is different from this blogger’s apparent belief that individual’s are responsible for the good (children, yay!), while society is responsible for at least some of the bad (health care expenses, boo!). No. This is a cheap straw man.

McCain is wrong on abortion. Attack that. He is cruel because he uses air quotes where compassion and understanding are necessary. Attack that. But he is not cruel because he won’t offer “free” health insurance.

Government can and will break its own rules.

When I say that the introduction of single-payer healthcare would not lead to the en – or even a significant reduction in – the circumcision of infant males in the United States, I do not hope I’m right. But I still see no reason to think I’m wrong. My analysis includes the evidence that countries with nationalized healthcare don’t pay for ritual/cultural circumcision. I also understand that claiming any particular market is somehow different is dangerous. But it’s quite clear that Americans have an irrational affinity for cutting the genitals of male children. That is a political rather than economic factor in this debate. Our politicians have never shown an ability to say “no” when confronted with a choice of excessive spending or the potential loss of votes. Wrap in religion and it’s a perfect combination for everyone to ignore facts (and the child).

There is one fact in the above narrative that is not accurate. If you’ve guessed that countries with nationalized healhtcare pay for ritual circumcision, congratulations, you understand politics at the expense of economics. From England:

… medical opinion has swung against it, and the procedure is now mainly carried out here for religious reasons.

As such, according to NHS guidelines, it should only be carried out, and paid for, privately.

But an investigation by More4 News has found an increasing number of health trusts are bowing to pressure, and offering circumcisions free on the NHS.

I’d normally embed the video here. I do not like the still image presented before the video plays. You can find it at the link above, or directly here.

Take note that no one in the report mentions what the boys might want. It’s a religious requirement for the parents to impose on their children. That’s enough for everyone to ignore the obvious questions beyond the cost, even though unnecessary circumcision is unjust, both morally and legally. But even in a culture like England that generally does not circumcise, mix the parents’ religion with an inability to pay and the state pays. America will be different how?

The bit about “unscrupulous circumcision practitioners” is particularly fascinating. The doctor interviewed in the beginning of the report operates in a glass house. No, he’s not a mechanic circumcising an infant with a soldering iron. Yet, he is a professional sworn to an oath placing the patient’s health as his first priority. As long as his child patients are healthy when he mutilates them, he is nothing more than an unscrupulous circumcision practitioner with training. The physical results may be less troublesome, but those children will still carry the mark of his criminal lack of ethics for the rest of their lives.

Post Script: I still detest the idea of single-payer healthcare because of the inevitable deterioration in health and care before we get to any discussion of rights.

But I want it. Isn’t that enough?

As if I needed more reasons to not vote for Sen. Obama, here’s another:

“If I were designing a system from scratch, I would probably go ahead with a single-payer system,” Obama told some 1,800 people at a town-hall meeting on the economy in
Albuquerque, New Mexico.

I suspect this is nothing more than pandering, that Sen. Obama understands how ineffective – stupid, really – a single-payer system would be. He even concedes as much in the same event.

But Obama repeated that he rejects an immediate shift to a single-payer system. “Given that a lot of people work for insurance companies, a lot of people work for HMOs. You’ve got a whole system of institutions that have been set up,” he said at a roundtable discussion with women Monday morning after a voter asked, “Why not single payer?”

All of that is an inconvenient hurdle. And it would be too easy to acknowledge that the government influenced or directly caused a significant part of the twisted, dysfunctional system that employs many people. And presumably serves many people, not all of whom are dissatisfied with what the private insurers do, or what they would do if freed from meddling. So, yeah, it’s a responsible to suppress the urge play central planner, even if it’s just pandering. Especially if it’s just pandering.

More:

His new marketplace would create a new government-run plan, like Medicare, to compete against the private plans.

The government should never compete with the private market. It is too easy, too inevitable that government will rig the game in its favor. There may be a claim of benevolent public good. We should have so little bad luck in a government market. More likely, politicians will reward naked rent-seeking for their own personal gain. Do we need to tally the examples?

As long as Sen. Obama pursues rhetoric like this, Sen. McCain’s possible strength in Virginia will not sway me into voting Democrat.

Link via Kevin, M.D.

There is no free in prevention.

This article about serious side effects possibly related to Gardasil is mostly speculation. Point conceded, so I won’t use it as fact. Instead, it’s worth considering the ethical questions. The (doctor) father of one teen believes Gardasil caused the medical problems his daughter now faces. (Correlation is not causation, of course.) He said:

One thing that’s different about Amanda’s case than some of the others is that both of her parents medical doctors who didn’t think twice about having their daughter get the shot – but are now second-guessing themselves. They call their daughter’s illness after Gardasil “a very sobering experience.” Amanda’s dad says, “as the father of three girls, I’ve had to ask myself why I let my eldest one get an unproven vaccine against a few strains of a nonlethal virus that can be dealt with in many more effective ways. It’s not like they are at high risk. It was the regrettable acceptance of the vaccine party line that [mis]led me.”

Don’t get distracted by “unproven vaccine” or “nonlethal virus”. They’re important in both the medical and ethical evaluation, but “can be dealt with in many more effective ways” should be the focus.

Merck, which makes the vaccine, the CDC and the FDA all say it is safe, effective, and important. Speaking of more than 8,000 adverse event reports and more than a dozen deaths, the CDC told CBS News, “we have found no connection between these deaths” and Gardasil. “We still recommend the vaccine and feel it is an important vaccine for the health of women. There are about 20 million people currently infected with HPV. Women have an 80 percent chance of developing HPV by the time they are 50. HPV is most common in people in their late teens and early 20s. Because the vaccine is a preventative and not a cure, it is important that the vaccine be given prior to beginning sexual activity. About 11,000 women will be diagnosed with cervical cancer and 3,600 will die. This vaccine prevents four viruses that account for about 70 percent of cervical cancers.” [emphasis added]

The CDC ignores the necessary caveats. It is important to give the vaccine prior to beginning sexual activity if the female will engage in risky sexual behavior and/or weighs the risk of infection greater than the risk of possible adverse reactions to Gardasil, among many factors in the decision. Parents can’t know the answers. They can assume, but assuming involves risk greater than they should impose. The threat of HPV is serious but infection is neither automatic nor inevitably deadly. Waiting involves additional risk. But risk involves rights. That can’t be forgotten.

Do a child’s eyes belong to the child’s parents?

As a thought experiment, consider:

LASIK surgery in children.

AIMS: To report success in the treatment of high myopia in children with LASIK. To report the visual results, complications and postoperative management of children with high myopia. METHODS: Six children (seven eyes) with high myopia were included in this series. Preoperative and postoperative refraction, visual acuity, and pachymetry were compared. RESULTS: Six children with high myopia ranging from -5.00DS to -16DS were treated. There were three males and three females. Five children had improved refraction and visual acuity post-LASIK. Age ranged from 2 to 12 years. Five of the children had unilateral amblyopia preoperatively. One had bilateral high myopia. CONCLUSION: High myopia in children may be treated safely and effectively with LASIK.

Now consider this story, via Amy Alkon:

Most Lasik recipients do walk away with crisper vision, and the American Society for Cataract and Refractive Surgery reviewed studies showing about 95 percent of patients say they’re satisfied with their outcome.

But not everyone’s a good candidate, and an unlucky fraction do suffer life-changing side effects: poor vision even with glasses, painful dry eyes, glare or inability to see or drive at night.

How big are the risks? The FDA agrees that about 5 percent of patients are dissatisfied with Lasik. How many struggle daily with side effects? How many are less harmed but unhappy that they couldn’t completely ditch their glasses? The range of effects on patients’ quality of life is a big unknown — and the reason the FDA help a public hearing Friday as part of its new move.

“Clearly there is a group who are not satisfied and do not get the kind of results they expect,” said Dr. Daniel Schultz, the FDA medical device chief. The study should “help us predict who those patients might be before they have the procedure.”
…

Doctors advise against Lasik for one in four people who seek the surgery, said Dr. Kerry Solomon of the Medical University of South Carolina, who led a review of Lasik’s safety for the ASCRS. Their pupils may be too large or corneas too thin or they may have some other condition that can increase the risk of a poor outcome.

Solomon estimates that fewer than 1 percent of patients have severe complications that leave poor vision.

Should parents have an unchallenged option to choose Lasik surgery for their children for any reason?

Bonus question: Should they have that unchallenged option for only their children of one gender, with the exclusion based on a societal belief such as the (non-)desirability of glasses?

Tax incentives are the problem, not the fruitless search for the correct incentive.

I still have no intention of voting for him, but Senator McCain makes the most sense offers the least bad suggestion on health insurance reform:

In a speech at a cancer research center here, McCain dismissed his rivals’ proposals for universal health care as riddled with “inefficiency, irrationality and uncontrolled costs.” He said the 47 million uninsured Americans will get coverage only when they are freed from the shackles of the current employer-dominated system.

McCain’s prescription would seek to lure workers away from their company health plans with a $5,000 family tax credit and a promise that, left to their own devices, they would be able to find cheaper insurance that is more tailored to their health-care needs and not tied to a particular job.

Under McCain’s plan, $3.6 trillion worth of tax breaks over a decade that would have gone to businesses for coverage of their employees would be redirected to individuals, regardless of whether they are covered by a company plan.

“Insurance companies could no longer take your business for granted, offering narrow plans with escalating costs,” McCain said. “It would help change the whole dynamic of the current system, putting individuals and families back in charge, and forcing companies to respond with better service at lower cost.”

Unfortunately the inaccurate 47 million uninsured number seems to now be accepted as fact. Moving on.

The details will be important. If he’s proposing that Congress remove the tax incentive from employers to provide health insurance, then he’s possibly on solid ground. I disagree with filling the tax code with incentives. The current employer-provided health insurance should be ample proof that this distorts markets. But we’re dealing with least bad, not optimal. Even though people can be expected to protect themselves when they must shoulder the risk by purchasing insurance on their own, without incentive, if there must be an incentive until some foggy date in the future when we figure out the foolishness of the political game, offer it to individuals.

If he’s proposing additional tax breaks without removing the employer incentive, I don’t see how his plan succeeds unless the individual incentive gives more free money than the employer incentive. Such a free money scheme would be stupid, but with equal competing incentives, employed individuals will be likely to let their employer’s HR department handle the task of securing an insurance plan. Nothing changes.

This calls for a little bit of research. And the answer is:

John McCain Will Reform The Tax Code To Offer More Choices Beyond Employer-Based Health Insurance Coverage. While still having the option of employer-based coverage, every family will also have the option of receiving a direct refundable tax credit – effectively cash – of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider. Those obtaining innovative insurance that costs less than the credit can deposit the remainder in expanded Health Savings Accounts.

The devil really is in the details, no? The employer-based incentive stays in place, which I assume means the incentive. If we take away the incentive, maybe employers will still offer insurance instead of cash. I doubt it, but let them if they want and employees agree. But to subsidize it is stupid, because then it requires “effectively cash” (i.e. free money). Behold the power of the government.

I realize this has a lower chance of becoming law than the plan proposed by Senator Obama. And that doesn’t factor the likely difference in electoral chances between Senators McCain and Obama in November once Senator Clinton gets pushed over the Party cliff figures out she has no chance.

It’s like legislating that puppies are cute.

Congress, protecting you from the world they built:

Lawmakers have agreed to make it illegal for employers and insurance companies to deny applicants jobs and health care coverage because DNA tests show they are genetically disposed to a disease.
…

It also makes clear that, while individuals are protected from discrimination based on genetic predisposition, insurance companies still have the right to base coverage and pricing on the actual presence of a disease.

Here’s an idea: eliminate the favorable incentive that irrationally ties health insurance in America to employment. If employers are no longer in the insurance business, they’ll have no opportunity to discriminate on the basis of future health care expense. Instead, Congress leaves the underlying problem that permits possible discrimination and codifies “discrimination is bad, mmmkay.” Never mind that politicians discriminate against the unemployed, under-employed, and self-employed.

Naturally Congress misses the point that discrimination is not inherently evil. It is often used for reasons we don’t like, so we’ve attached an exclusively pejorative interpretation to it. But I discriminate against meat when I choose vegetables instead. I discriminate against Ford when I drive a MINI. The Phillies discriminated against a local player when they traded him for a player they value more. Politicians discriminate against one expenditure when they vote for another. Sometimes, discrimination is just about making choices in a world with limitations.

I’m playing semantics right now. Conceded. But semantics matter, as this shows:

[Senator Olympia] Snowe noted that nearly 32 percent of women offered a genetic test for breast cancer risk by the National Institutes of Health declined because of concerns about health insurance discrimination.

I’m not advocating mandatory screening against a person’s wishes. But I’m also against prohibiting insurance companies from pricing risk more precisely by requiring genetic information through the voluntary application process. (Is that the inevitable future from this legislation?) Yet, just as an insurance provider may require the test, no applicant is forced to accept that condition. Competition breeds options where it is permitted. To a significant extent, it is not permitted while insurance is tied to employment, so we get further legislation.

Although it’s not explicit, I think the sponsors of this legislation are more content with the collective outcome of this. Insurance providers are good at knowing their business. They understand risk and how to price it based on statistics. Congress seems to be saying that pricing it better – to the individual, based on the individual – is discriminatory. Perhaps. But the risk will be priced. The only question for discussion is who pays. Is it shared across the insurance pool or paid by each according to his risk?

Legislation like this, as opposed to the more logical solution that removes the faulty incentive, clarifies the political mandate: genetic luck, just like financial “luck”, increases one’s responsibility to the unlucky.

This “flexible and compassionate” is misdirected.

This article appeared in the Boston Globe last week. It’s a discussion of efforts to train new mohels in Massachusetts. Two particular passages are relevant to my focus. First:

Be flexible and compassionate, [Dr. Bob] Levenson told the doctors. … Gently tell the truth when a tearful, post-partum mother asks if babies can feel pain. (The answer is “yes, but I’ll be as quick as possible”). And it is perfectly OK – recommended, even – to anesthetize the infant with a little kosher wine dabbed on the lips.

Beyond wanting to see evidence that wine dabbed on the lips of an infant male will anesthetize him from the pain of surgery, this issue raises a large ethical red flag. There must be an objective reason to inflict pain on another, particularly a child who can’t offer (his) consent. And does the infant male’s soon-to-be-removed foreskin serve a purpose? The answer is “yes,” no parenthesis necessary or appropriate.

Second:

But for doctors, the work is not considered particularly lucrative. Mohels must secure their own malpractice insurance, spend significant time counseling families, travel, perform the ceremony on the eighth day of a child’s [sic – male] life, all for a fee of $350 or $400.

If a religious observation requires medical malpractice insurance, it is only legitimate to perform on consenting adults. The individual right of minors to be free from (medically unnecessary) harm must remain the exclusive standard, superior to any religious requirements, because risk is objectively inherent. The evaluation of that medically unnecessary risk against unverifiable religious benefits is subjective. The conclusion is only legitimate from the individual giving up his foreskin.

Two Voluntary Participants

On an interesting concept among plastic surgeons:

“No, Judith. Just … no.”

Lee A. Gibstein, M.D., a plastic surgeon with offices in New York City and Miami, crumpled up the photo of the shiny, preternaturally line-free celebrity I’d brought with me and tossed it over his shoulder. “Oh, c’mon. Why not?” I whined.

“Because you’re a walking advertisement for me, and I don’t want my patients looking as if they belong in Madame Tussauds,” Dr. Gibstein said, setting down his syringe.

Doctors can reject a patient’s request for cosmetic surgery? Who knew? (Me.) If only other doctors might consider other examples of cosmetic surgery that demand a “no” in 100% of cases. And wouldn’t it be nice if they rejected such requests for ethical concerns rather than (the appropriate for the linked example) marketing concerns?

Link via Kevin, M.D.

Will Doctor Corps be voluntary?

Kevin, M.D. makes a key point today in the discussion about the reality of implementing universal/single-payer health care in the United States:

2) My take on Massachusetts’ Commonwealth Care considering cutting physician reimbursements: it demonstrates a profound of lack of insight by the politicians trying to fix health care. Unbelievably, this plan proposes year-to-year reimbursement increases that lag even Medicaid. Good luck finding any doctor accepting Commonwealth Care, once again making universal coverage useless without physician access.

Since the laws of economics cannot be altered, the only long-term solutions to the inevitable physician shortage from socialized medicine are forced-service or higher taxes to provide physicians with reimbursements close enough to a market wage for these intelligent, skilled individuals to choose to remain in medicine. Since the former solution requires either a violation or revocation of the 13th Amendment, I’m guessing politicians will rely on the latter. (Not a given, though.) That leaves only the latter, higher taxes. Inevitably, some politician(s) will suggest imposing user fees on patients (i.e. taxpayers), but that only begs the question of why not leave the entire system to the market to more efficiently and effectively allocate limited resources. Neither ignorance is justifiable as policy.

When politicians offer their rainbows and puppies version of single-payer financing, they lie.