--- Ronn! Blankenship <[EMAIL PROTECTED]>
wrote:
> At 02:15 PM 1/9/03 -0800, Deborah Harrell wrote:
<snip>
> >Doctors and nurses have struggled for years with
the
> >question of futile care. "Quality vs. quantity"...
>
> >In the past, decisions were often made by one
> >individual, acting in what they thought was the
best
> >interest of the family/patient; ethics comittees,
> >which have been around at many teaching hospitals
> >since the 80s, are an attempt to remove that power
> and
> >responsibility from a single person. Whether such
> >committees are a step towards greater transparency
> and
> >accountability, or towards 'star chamber' style
> >authoritarianism depends - like any governing body
> - on the rules/articles of its foundation and upon
> the integrity of most of the persons comprising it.
> >
> >One facet of taking care of critically/terminally
> ill patients has been to help the family know that
it
> is alright to let go, to accept that Mama or Papa is
> >*dying*, and all we can do is prolong that process
> - not bring them back to a life...
> >
>...so far Americans have not been willing to deal
with
> the reality of rationed healthcare...
>
>
> I think that at the heart of the problem is that
> when the so-called
> "bottom-line" is so heavily emphasized (as it has
> been since the advent of
> HMOs), the family *cannot be sure* any more that the
> doctor is telling them the truth... [or decided] "we
> might as well let them
> die and 'decrease the surplus population'."
I have not met _any_ doctor or nurse who would approve
of a 'Logan's Run'-style cut-off to "decrease the
surplus population." [Withholding all but
comfort-care from some of the murderous thugs that
land on the ER doorstep, yes -- but that is another
kettle of fish entirely, conflicting with the "make no
judgement" ethic; I don't know (and haven't personally
heard of) anyone who actually did more than snarl in
private about 'saving a vicious murderer's life when
those resources could have gone to help some innocent
but poor sick person.']
> IOW, can medicine be both a 'calling' AND a
> _business_? If not, which one will it actually be?
Only with great difficulty and personal sacrifice
(time, money or compromised ideals#) now; if medical
interventions could be made significantly cheaper, if
people would take responsibility for their own health
(lifestyle choices), if clinicians would demand what
is right and not merely expedient -- then maybe.
{#frex, choosing the needs of the profession over the
needs of one's family}
[Next 3 paragraphs are entirely my opinion/impressions
about what led to the current state of affairs; I'm
sure there are books out there which have more erudite
conclusions, but this is my "from the trenches" view:]
Historically, that is not an entirely new issue; the
elite/rich have always had access to the best a
society had to offer - the big difference now is that
"the best" really _can_ bring back life from the brink
of death, whereas, frex, "the best" Revolutionary
society had to offer George Washington was repeated
(and ultimately fatal) blood-letting.
Docs in the first quarter of the last century had only
marginally improved knowledge/interventions (I still
shake my head at the 1905 text that stated 'for
control of female fertility, relations should only
occur in the two weeks furthest removed from her
cycle; this is how the early Hewbrews were able to
keep their population managable'), and they did not
expect to be fabulously wealthy. (A good thing, as
payment was frequently a chicken or a sack of wheat.)
The social programs of the 60s, though initiated with
the best of intentions, were seen as a cash cow by the
unscrupulous, and suddenly to be a doctor was a way to
**get rich**. Nearly everybody was happy (from a
health standpoint; I'm ignoring Vietnam etc.) - many
people got 'free' (or nearly so) care, the government
(and business) was popular with the voters for being
caring and progessive, doctors were in the black
financially -- until the spending and the dissociation
between actions and consequences started to catch up
with Reality. Finger-pointing, fist-shaking and
near-panic ensued. Then came HMOs...
When I graduated from med school (1988), I was
expected to be my patient's advocate in all things
medical and health-related. I was not trained to be a
"gatekeeper" (HMO term for primary care clinicians -
they are expected to keep patients from seeing
specialists 'too frequently,' from getting 'too many'
expensive interventions, and thus to keep costs down).
I was trained to do the best for each patient.
During residency, cost was still a secondary issue,
but to be considered in a the sense that one should
not order an MRI if an X-ray would yield the same
diagnosis (say pneumonia, as an extreme frex), or
choose an expensive drug if a cheaper one would do the
job as well. Transition began from "doing everything
possible" as one did at a public teaching hospital, to
considering if a patient should be a DNR (Do Not
Resuscitate) because s/he was going to die very soon
no matter what was done; could the information gained
from placing a right-heart catheter be ethically
justified when it was essentially certain that this
85-year-old with multiple myeloma, renal failure,
heart failure and septic shock would die?
>how to restore the public's trust in the
profession...
<sigh>
Take it back.
But that is far, far easier said than done. Without a
united front or coherent vision, individuals defy or
trick the current system (frex, in one which paid only
for a mammogram if the clinician notes an abnormality
on physical exam, s/he 'finds' a lump); some have in
fact banded together and 'gone on strike' as in recent
posts (although I'm not sure people see _that_ as a
positive). And as long as people want their doctors
to "do everything" for them, it will be impossible -
we simply do not have those kinds of resources.
Bob, Dee - ?
Tangent: interesting review of the Hippocratic Oath
from NOVA (a PBS program):
http://www.pbs.org/wgbh/nova/doctors/oath_today.html
While I was in residency and early practice, I kept a
version of a Healer's Oath (from Katherine Kurtz'
Deryni series) posted on the inside of my front door
(it got packed for the last move, so I still have
it...somewhere! ;P ).
Now I Have A Dreadful Headache Maru :(
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