Morality — Not Costs — As the Proper Basis for Health Care Reform

John David Lewis died January 3rd after a heroic battle against cancer. He was a relentless advocate of healthcare freedom and the morality of the free market.



(HT Freedom and Individual rights in Medicine)

The Benevolence of Inequality

If we accepted inequality in health care, instead of insisting on instant equal access for everyone to the newest, best and most expensive treatments, where would health care be today? It's impossible to even imagine what treatments and cures would be available and affordable.

A multi-tiered healthcare system which respects individual property rights (instead of violating them through coercive wealth redistribution ) is not only the right thing to do, but we would all be better off in the long run.


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The Changing Character of Medicine: Are We Headed in the Right Direction?

As our country moves from being a nation of small business owners to a nation of employees, we are losing an important avenue for understanding the benefits and benevolence of capitalism.  This trend makes it all the more important to speak up on the morality of profits, private property and voluntary exchange to counter the loss of the direct, concrete experience gained by self-employment.

Physicians are no different. As the quality and integrity of our medical care depends upon free and independent thinking, in medicine,  it's even more directly a matter of life or death.

Read more:

The Changing Character of Medicine: Are We Headed in the Right Direction?

PJ Media June9, 2011

Book Review: In Defiance of Death

In Defiance of Death: Exposing the Real costs of End-of-Life Care
by Kenneth Fisher, MD with Lindsey Rockwell, DO and Missy Scott


End-of-life care has tragically been lumped together with the bruha over "death panels." Given the dire need to reign in the rising costs Medicare, and the looming threats of rationing under the auspices of "comparative effectiveness" and cost-control via the Independent Payment Advisory Board, these concerns are understandable but misplaced. But, assuring that people have humane and appropriate end-of-life care in line with their own wishes should have nothing to do with government rationing and everything to do with good medicine.


Drs. Fisher and Rockwell along with free-lance writer Scott  have written a compassionate, extensively researched appeal for rational end-of-life care. Their long over due discussion has the potential to improve the quality of medical care, while at the same time help eliminate wasting our wealth on futile treatments.

We spend a very large proportion of our health care dollars at the end of our lives. The reasons for this are multiple, but include an inadequate legal definition of death, the shifting of decision-making away from medicine and into the legal realm, lack of adequate communication between patient and medical care-takers about end-of-life wishes and realities (aggravated in part by the Patient Self-Determination Act), unrealistic expectations of what medical science can accomplish, and the divorcing of medical decisions from economic considerations. 

Dr. Fisher offers some very intriguing solutions which are worth further discussion. 

Death should be defined not as "absence of all brain activity" but the absence of cerebral cortex functioning. This would clarify the futility of continuing to keep bodies alive when the person who once inhabited them no longer exists. 

Hospitals could form Appropriate Care Committees to assist families and physicians provide the best possible care for individual patients. We must actually apply what we already know about which interventions are futile in which contexts, and when further treatment is merely prolonging suffering and death. Where I part ways with Dr. Fisher is his recommendation that these committees extend into a government-managed hierarchy. I can see them as a selling point for hospitals ("We provide only the best, appropriate care.") but it frightens me to think of the government making those determinations. 

Another idea of Dr. Fisher's  is to eliminate CPR as the default action for cardiopulmonary arrest. Upon hospital admission, each patient fills out a fresh advance directive form (a good idea), and if CPR is desired, an order for its use would have to be expressly written. The danger, of course, is that the order for CPR could be absent due to oversight rather than as a true reflection of the patient's wishes--and potentially lead to an irreversible error. Dr. Fisher points out that CPR-as-default was instituted when most hospital patients had acute, reversible problems. That is no longer the case. A growing proportion of hospitalized patients are admitted with debilitating chronic illnesses and aggressive treatment is frequently not beneficial.  I am still not sure what to think on this issue--but it is a discussion which needs to occur. 

A useful clarification in the book is the differentiation between the absolute right of individuals to refuse any and all treatment and the non-existence of a right to demand treatment that is not medically indicated. The tricky part is who gets to define what is "medically indicated." Dr. Fisher recommends only limiting treatments which are not controversial (such as attmepting to keep an anencephalic infant alive via mechanical ventilation.) These non-controversially futile actions are where there is no right to demand treatment. 

Dr. Fisher also calls for more training of medical personal in end-of-life matters and palliative care. The goal is to do our best to assure patients do not pointlessly suffer by receiving futile treatments, and families do not deplete life savings for inappropriate care. I heartily agree that a deeper understanding of this aspect of medicine is sorely needed. 

In summary, I support the following improvements recommended by the author: 

1. Implement a mechanism to keep advance directives fresh and timely. 
2. Develop Appropriate Care Committees for hospitals and long-term care facilities. 
3. Alter medical education to emphasize continuity of care. 
4. Increase training in palliative care/end-of-life 
5. Redefine death to loss of cerebral cortex functioning. 
6. Consider changing CPR away from being the default action. 
7. Address the issue of a shortage in nurses through expansion of 2-year hospital-based nurse training programs.

Some of the recommendations with which I differ: 

1. Making the Appropriate Care Committees a government function. 
2. Create a central agency to mandate uniform insurance billing (with the rationale that it will decrease administrative costs.) This is properly a market function. 
3. Government support of primary care over specialists, or vice versa. Again, the balance of primary care to specialists needs to be a market discovery by free individuals choosing what is of value for themselves. 
4. Legally restricting or eliminating the direct advertising of drugs and medical devices. Yet again, this is an appropriate free market activity. 


These areas of disagreement in no way detract from the over all value of the book. Dr. Fisher presents much valuable information accompanied by a number of concrete practical actions we could take to address a very real and serious problem within our current health care system. This book is an excellent place to start several long over-due conversations.

In the end, the way for us to assure the most cost-effective use of resources is by doing what is best for the patient in his or her entire context: medically, psychologically and economically. This can not be achieved in the collectivized, centrally controlled system of a medical commons where treatment decisions are divorced from economic consequences. As physicians, we can do a better job by understanding and then communicating the limits of beneficial treatment. As a society, we need to return personal responsibly and a respect for property rights, which means accepting the consequences of living in a world of limited resources and limited life. 

There is a time to defy death, but in the end, no one gets out of here alive. And nothing in life, not even death, is free.

How to Defend Health Care Freedom

Last fall, I was invited to speak about the Black Ribbon Project at the annual meeting of the American Association of Physicians and Surgeons. I took the opportunity to share a few of my thoughts on the principles we need to promote to effectively defend health care freedom and the doctor-patient relationship. I am pleased with how much I was able to cover in just 25 minutes. Let me know what you think!

Social Justice and Medical Ethics

The AMA is actively working in conjunction with Association of American Medical Colleges to inculcate young physicians with the ethics of "social justice."

Since 2005, the "Initiative to Transform Medical Education" has been working to correct what it views as deficiencies in the current training of physicians. These include an over-emphasis on the ability to acquire knowledge and problem solve-- to the detriment of "caring." Traditionally, physicians have expected to be autonomous decision-makers--but according to the Initiative this clashes with "increasing requirements...to be more accountable to various constituencies, including...the public, payers and government." Although physicians are recognized as "prepared to do what they believe is best for individual patients... [t]hey are not...prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless." The solution proposed for allocating finite resources is John Rawls' principle of social or "distributive" justice.

"Social justice" is a euphemism for economic egalitarianism--and since people do not naturally come by equal wealth, "social justice" requires taking from some to give to others. "Social justice" is thus in direct conflict with the principles of equality before the law and the individual right to private property. "Social justice" also requires that a physician NOT advise his patients solely based on what is in the patients own best interest. He must instead somehow "balance" the patient's interests with those of the rest of society.

The concept of "social justice" has now been incorporated into several official statements of medical ethics. The Physician's Charter of the American College of Physicians now states:

[C]onsiderations of justice must inform the physician's role as citizen and clinical decisions about resource allocation. The principle of distributive justice requires that we seek to equitably distribute the life-enhancing opportunities afforded by health care. How to accomplish this distribution is the focus of intense debate. More than ever, concerns about justice challenge the traditional role of physician as patient advocate.

The Council of Medical Specialty Societies ethics statement includes the following:

The ethic of medicine must seek to balance the physicians' responsibility to each patient and the professional, collective obligation to all who need medical care.

Not only is this new ethic altering the curricula of medical schools to emphasize "social justice," but admission requirements will also be changed--deemphasizing a background in the sciences and MCAT scores. It is hoped that the selection of more "altruistic" and less competitively driven applicants will result in a larger number of residents opting for a less prestigious and less remunerative career in primary care.

This shift away from academic excellence and autonomy in the doctor-patient relationship toward serving the needs of society follows directly from centuries of medical ethics disavowing the legitimacy of physician self-interest. This error is compounded by a claim of moral superiority because "medicine is a profession not a business."

The distancing of medicine from business has done both a disservice. In claiming to be primarily an altruistic service, physicians have essentially invited the government to enforce this ideal while simultaneously denigrating the honorable occupations of production and trade. In failing to understand and defend the morality of profits, and the harmony of self-interest which characterize voluntary economic transactions, doctors have aided the enemies of freedom and capitalism-- who are now designing medical school curricula and admission requirements.

Capitalism is nothing more than the individual rights of life, liberty and property as applied to trade. Profits, in medicine as in any economic transaction, are not gained by exploiting patients or customers. Profits are simply the proper reward for successfully offering a value to others which is worth more to them than it costs to produce. In a system of free trade, self-interests are not in conflict--not even between a physician and a patient. In a direct-pay, fee-for-service relationship, it is in the best long term interest of the physician to offer advice and treatment based on the patient's best interest. And, it is in the best long term interest of the patient to only deal with a physician who does!

We can not defend patients' freedom without also defending the freedom of physicians. We can not protect the doctor-patient relationship without protecting the autonomy of both. Freedom of association and freedom to contract are interrelated principles fundamental to a free republic, to capitalism and to the ethical practice of medicine. "Social justice" requires that the individual be sacrificed to the collective. Such an act is as immoral in medicine as it is anywhere else.

"Social justice" claims to be what it isn't-- because true justice will never involve the violation of individual rights. The only way to assure justice and an ethical doctor-patient relationship is through the consistent, proud, principled defense of individual rights. The only way to assure justice and an ethical doctor-patient relationship is through the consistent, proud, principled defense of individual rights. In economics, that means capitalism. In medicine, that means the freedom of choice, not government mandates, for both doctors and patients.

Update 5-21-10 Two other articles on the training of physician to advocate for "health care reform"--by which is meant greater government control.

"Train physicians to participate in health care reform" by Sachiin Jain, Jordan Bolman in Skin & Allergy News, July 2010

"A Plea to Medical Students" by Joseph M Scherzer