Monday, October 26, 2009

Josh Marshall Explains the 'Opt-Out' Compromise.

Now that Reid has announced that his bill will include the public option with an "opt-out" for the states, we can start to get an idea of how this bill might work and how the "opt-out" has proven a helpful political tool. From TalkingPointsMemo:

And there's one other part to this -- momentum in the favor of full opt-in. Just as people rail against 'government health care' and love their Medicare, there's good reason to believe that the Public Option will have been a lot scarier as a GOP straw man and a Glenn Beck temper tantrum than it will as a real world option for people who can't get private coverage. And if the public option is available in North Carolina, just to pick a hypothetical, and not South Carolina, after a while, people in the South Carolina might start to wonder what the logic was of denying them a lower cost health insurance option. And if that's true, presumably, pressure will build in the opt-out states to opt-in. So even if a substantial number of people aren't covered at the start, there's good reason to believe that will change over time.

I think he's dead on with the need to give Republicans and moderate Democrats cover for voting for the bill. The rabid Republican base and the way this reform has been scorned in the media has made some senators wary of standing up against criticism. This just might be enough to garner 60 votes. And I can't wait to see how it plays out with the states.


Randy Stroup, Barbara Wagner and the Misconceptions Surrounding End of Life Care.

Many opposed to health care reform have grabbed with both hands the cases of Barbara Wagner and Randy Stroup as examples of how "government run" health care preys on the elderly, terminal, and infirm. Their fascination with these two cases comes in part from their occurrence in Oregon, a state where Death with Dignity has been law since 1994.

Death with Dignity has long been opposed by "pro-life" groups as removing jurisdiction over suffering from God. Only God, they contend, may decide when life ends. This requires their application of complicity with God to medicine and the state, when it is on their side (as in Montana where constitutional aid in dying is being contested before the Supreme Court).

Where the state supports end of life choice, opponents to health care reform and Death with Dignity have worked to undermine it. Back to Barbara Wagner and Randy Stroup. Both were denied expensive treatments by the Oregon Health Plan because the treatments promised less than 5% efficacy over 5 years. OHP is notoriously poor at delivering bad news - just as doctors are! - and have been deeply criticized for offering Wagner and Stroup other options: palliative care, Death with Dignity, and hospice care. (I address the case of Barbara Wagner in my latest article for AlterNet on rationing.)

Because few understand what palliative care is and associate hospice care with euthanasia or "giving up" on a patient, these two cases have been used to bolster the fear that the state is not competent to manage health care services.

Firebrand, though an opponent of Death with Dignity, takes RedState to task for their use of Stroup as an example of "The Barack Obama's America.

There is another point about Mr. Stroup’s experience that was not made clear at RedState or at the Fox story RedState linked. The Oregon Health Plan does not offer terminally ill patients a choice between no medical care and State-paid physician-assisted suicide. Rather it offers terminally ill patients “comfort/palliative care” and - despite the title of my post (taken from the Fox story) - comfort/palliative care is medical care.

And shoots down the misconception that "rationing" doesn't and shouldn't exist:
The Oregon Health Plan is attempting to conserve a scarce resource: tax dollars available to fund health care for the poor and uninsured. The government of Oregon realizes that if agrees to pay for very expensive treatments with very little chance of success it will have to do one of two things: provide care to fewer poor and uninsured people or raise more money for the Health Plan through higher taxes. By focusing on physician-assisted suicide and failing to consider the broader offer of palliative care, the RedState story insures that anyone who reads Mr. Stroup’s story will insist the State should have paid for Mr. Stroup’s chemotherapy - and that their failure to do so is a condemnation of government-run health insurance.

Yet this formulation obscures the issue that is really at the heart of this story: are we willing to spend whatever amount of money it takes to make sure that everyone gets every possible treatment?

Posts like Firebrand's should be spread far and wide. The conflation of "rationing" (as something only employed by government-run health care plans) and euthanasia, Death with Dignity, or even hospice, palliative care and end of life choice is a ploy by health care reform opponents. They have long underfunded palliative care because it doesn't pay like ICU or hospital care (see my prior post). Hospice organizations rely on volunteers and bake sales for their funding.

The religious right is being used by the corporate health care industry to railroad reform. For their own ideological purposes, they are more than happy to complicitly spread lies about the cases of Stroup and Wagner.

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Filling the Beds: ICU Usage Among Terminal Eight Times Higher Than in England.

England does a better job of offering elderly and terminal patients end of life choices. The November 1 issue of American Journal of Respiratory and Critical Care, published by the American Thoracic Society, reports on a new study by Dr. Hannah Wunsch at Columbia University:

Patients who die in the hospital in the United States are almost five times as likely to have spent part of their last hospital stay in the ICU than patients in England. What's more, over the age of 85, ICU usage among terminal patients is eight times higher in the U.S. than in England, according to new research from Columbia University that compared the two countries' use of intensive care services during final hospitalizations.

"Evaluating the use of intensive care services is particularly important because it is costly, resource intensive, and often traumatic for patients and families, especially for those at the end of life" said Hannah Wunsch, M.D., M.Sc., assistant professor of anesthesiology and critical care medicine, of Columbia University, lead author of the study. "We found far greater use of intensive care services in the United States during terminal hospitalizations, especially among medical patients and the elderly."

Among the statistics culled from the study:

They also found that hospital mortality among those who received intensive care was almost three times higher in England than in the U.S. (19.6 percent vs. 7.4 percent). But when examining deaths overall, only 10.6 of hospital deaths in England involved the ICU, whereas 47.1 in the U.S. did. Of those over 85, only 1.3 percent received ICU care in England vs. 11 percent in the U.S. But young adults and children received ICU services at similar rates in both countries. "These numbers need to be interpreted with caution," explains Dr. Wunsch, "as the differences in mortality for ICU patients likely reflect the higher severity of illness of patients admitted in the first place in England. The data do bring up the interesting question of how much intensive care is beneficial. Doing more may not always be better." (emphasis mine)

What is often called "rationing" in the US is actually a predatory medical industry paying for its equipment. The more beds you have the more you need to fill. The more services you offer, the more you need to sell. We live in a culture where natural death has become cost-ineffective. And our government has failed, as with so many other industries, to enforce ethical, humane regulation.

via FuturePundit.

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Need Something to Read?

From ReligionClause, a list of new books and articles:

From SSRN:

From SmartCILP and elsewhere:

Recent Books:

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Anti-Choicers Use Ebay to Raise Money for Dr. Tiller's Killer.

An Army of God manual. A prison cookbook compiled by a woman doing time for abortion clinic bombings and arsons. An autographed bullhorn.

These are among the items that abortion foes plan to auction on eBay and other Web sites in a fundraiser for Scott Roeder, the Kansas City man charged with killing Wichita abortion doctor George Tiller.

"This is unique," said Regina Dinwiddie, a Kansas City anti-abortion activist who will sign the bullhorn. "Nobody's ever done this before. The goal is that everybody makes money for Scott Roeder's defense."

One abortion-rights leader called the auction deplorable and said it could lead to more violence.

"The network of extremists promoting and defending the murder of doctors is contributing to escalating threats against clinics and doctors across the country," said Kathy Spillar, executive vice president of the Feminist Majority Foundation.

Roeder, charged with first-degree murder in the May 31 shooting of Tiller, is scheduled to go to trial in January.

Dave Leach, an Iowa abortion opponent who is organizing the auction effort, said he was aiming for a Nov. 1 launch.

From McClatchy, via Amanda Marcotte.

Brawling Bioethicists? How Health Care Reform is Creating a Schism in the Field of Bioethics.

From MercatorNet, an article on a developing schism among bioethicists. (I refer to this in my latest article for AlterNet on rationing of health care.) According to Michael Cook, the field is in crisis.

This was sparked by an address by Dr Emanuel to the annual conference of the ASBH [American Society for Bioethics and Humanities]. He argued that what bioethics needed was more statistics. Without a solid grounding in quantitative methods, bioethicists simply aren't much good. Ideally, aspiring bioethicists should study behavioral economics, psychology, decision theory or sociology. There should be less public discussion and more number-crunching. And, he implied, it is number-crunching bioethicists who will be getting the precious government funding which enables them to stay in business.

America's best-known bioethicist, Arthur Caplan, of the University of Pennsylvania, was so irritated that he almost immediately posted an open reply. He responded that a bioethicist must be a "moral diagnostician". "A crucial part of the bioethicist's role is to alert, engage and help to illuminate ethical problems and challenges both old and new in the health and life sciences." Empirical data are just one tool in the bioethical toolbox.

Emanuel's address has not been published on the internet yet. But this very public dust-up provides more ammunition for those who believe that the field of bioethics is in crisis. When the most quoted US bioethicist says that the philosophy of the most powerful US bioethicist is "narrow, misguided and wrong", what are laymen to think? It certainly gives them no confidence whatsoever that President Obama is getting the right bioethical advice.

And Cook goes on to explain the schism as a loss of philosophical reasoning in what has become a statistics-focused profession. To make his point, he starts with the definition of bioethics:

For so familiar a word, "bioethics" has a short history. It entered our dictionaries as late as the 1970s. The English word cobbles together the Greek words for life, Bios, and for moral character, or custom, Ethos. So huddled under the umbrella of a single term are two related but distinct intellectual disciplines, metaphysics and ethics. Bioethics is inexplicable without them, just as biochemistry is inexplicable without biology and chemistry.

Let's look at metaphysics first. The ancient Greek philosopher Aristotle coined the word. He wanted to investigate whatever underlies or lies beyond (meta) the physical world of what we can see and touch (physica). So metaphysics deals with the most fundamental questions of experience: what is reality? what does it mean to be? what does it mean to be a person? what is life? Bioethics "works" only if its metaphysics is correct, that is, if its understanding of life, humanity and personhood corresponds to reality. An astrophysicist who bases all of his calculations on the equation e=mc³ will ultimately reach the wrong conclusions, no matter how sophisticated his mathematics.

He concludes that the profession has lost credibility because many in it rely on statistical analysis to come to conclusions.

I humbly disagree. How one parses statistics requires an ethics. How many times do "pro-life" groups use skewed statistics to trumpet that approval of abortion has slipped in the US? Or that abortion is linked to cancers in women? Or that abortion has declined in the US because of their efforts? Statistics, of course, can be - and most often are - used for one's own purposes, in this case control of women's reproduction and role in society. (There are so many more examples of the use of skewed statistics but the "pro-lifers" are currently the most egregious.)

Bioethicists are getting push-back from their own for a number of reasons. No one wants to have their profession vilified in the public square. Many are wary of statistical (and ethical) support for "rationing" of health care. As I write in my latest article for AlterNet, "rationing" exists and will always exist because resources are finite. (I conclude that much of the expense of end of life care can be decreased by simply giving the elderly and terminal patient a choice in how they die.) How to best use those resources in an egalitarian and ethical way is what is at issue. Denial that "rationing" exists (or has to exist) is certainly easier than facing the harder questions of how to mitigate its effects.

The greatest detractors from such a discussion often rely on a faith system, a religious code; or a capitalistic assessment of medical resources. Either God or the free market should decide who gets what treatments, medicines and services. The former relies on a moral system that is dominant in our culture, that adhered to by Catholics and Evangelicals, but is not representative of all society. The latter relies on a cultural value held by fiscal conservatives fearful of a regulating government, the profit-motivated medical industry, and Republicans afraid of "the spread of socialism." Let private companies pick and choose what services individual patients get and the free market, this group says, will take care of the ethics.

For the bioethicist charged with finding an egalitarian way to deliver services, neither code works. The first discludes non-believers or other believers. The second favors the wealthy or entitled. Neither answers the over-all cost question.

Saying that neither of these dominant theories works is not popular nor easy. And this is root of the crisis in bioethics; not a loss of philosophy as Cook contends, but a profession trying to save itself from the criticisms it sustains when wading into a contested arena.

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