Dorothy Guellec
The
right of the patient to direct his or her medical care and health outcome, known
as patient autonomy, and the right of society to control and allocate
"limited resources", known as distributive justice will certainly
collide. In an ideal world, or in an egalitarian society all individuals would
have access to healthcare.
The
U.S. health system now takes into account the imperatives of corporate
management, shareholders, and the investment community in addition to the
patient’s interests. In past articles I have briefly mentioned the PSDA (Patient
Self Determination Act) and other Advance Care Directives. The real question is:
are they binding and if so upon whom? In March 1999 the AMA ‘s (American Medical
Association) Council on Ethical and Judicial Affairs published a paper in an
attempt to resolve conflicts. There were 5 items but 2 and 3 are really eye
opening. They stated, "Patients and surrogates should be made aware that
physicians are under no obligation to provide futile care. Futile or medically
inappropriate care should not be offered ‘theoretically’ with the expectation
that it will be refused". That means that Advance Directives have no legal
force at all, and patients, families and care givers would be wasting their time
and causing emotional grief to no avail since wishes do not have the force of
law.
In
the past, those who provided health care were presumed to be governed by beliefs
in a set of ethical and social responsibilities that took precedence over
economic concerns. This is no longer true. According to Hiller (1986), six
ethical principles are relevant for health care leaders. They are: beneficence,
non-malfeasance, respect for persons, justice, utility and truth telling. This
is all very theoretical. In the real world patients and their families have no
idea what really determines outcomes. Adding to the complexity of end-of-life
issues, some authors writing on bioethics have suggested and argued forcefully
that, if there is little chance for recovery, the physicians may refuse to
deliver life-sustaining care, even if requested by patients or surrogates. What
is a patient to do? The ideal answer is to trust one’s physician. In the absence
of this a family member or surrogate could be enlisted to enforce the patient’s
wishes but thorny problems can arise.
The
American system relies heavily on the substituted judgment standard. The system,
which is about 15 years old, seeks to identify a surrogate to make the decision
that the patient would have made – putting oneself in the patient’s shoes as it
were. It relies and falls on the premises that the surrogate knows something of
the patient’s preferences. Many studies have demonstrated the inability of
family members or others to predict the wishes of the patients. Even patients
themselves who complete advance directives when healthy, are very likely to
change their minds later, due to what Rebecca Dresser has called "the
Metaphysical Objection to Advance Directives." She argues that it is
important for the patients completing advance directives to understand the
medical circumstances to which they might later be subject. She says, "Such
understanding is important not to ensure the autonomy of the decision maker but
to ensure the autonomy of the incapacitated person. Legally these two persons
are the same (e.g. both Michael Martin), but they are very different ‘selves’
(e.g. Michael Martin before and Michael Martin after the accident). The radical
differences in values, attitudes, and similar attributes which individuals often
undergo when they become incompetent make the person at the later point in time
a different person." In other words, the person who wrote the advance
directive is a different "person" from the incompetent person bound by
it. The person actually facing death is not the same person as before. This
theory does not fit neatly with the way Western law treats individuals. Dresser
calls this "hard paternalism." And asks, "the later self’s best
interests are defined by that individual in an earlier point in time, rather
than by another party. Ought this to be sufficient to remove the ethical and
legal concerns paternalism elicits?" Healthy people might not think that
expensive wheelchairs and portable ventilators were important, because they felt
that the disabled quality of life was very low and could not be significantly
raised. Nevertheless, not surprisingly, once patients became ill, they were far
more likely to prefer a longer life with a disability than a short one without
it. Most persons completing advance directives underestimate the quality of life
with disability because individuals adapt to their disabilities. The real
problem is that individuals are making decisions for their future selves that
those future selves would not want made.
Recent
updates
This
week a startling report surfaced called "To err is Human" This 200+
page book lays out a comprehensive strategy for government, industry, consumers,
and health providers to reduce medical errors, and it calls on Congress to
create a national patient safety center to develop new tools and systems needed
to address persistent problems. I spoke with one of the committee members Dr.
Joseph Scherger, Associate Dean for Clinical Affairs, University of California
at Irvine College of Medicine. He said," Hospitals are dangerous places and
patients need advocates every step of the way." That struck me as quite an
admission. One major study found that medical errors kill about 44,000 people a
year in hospitals. Another puts the number much higher at 98,000. This may be
the tip of the iceberg due to all the incidents that were not reported. Even
using the lower estimate, more people die from medical mistakes each year than
from highway accidents, breast cancer, or AIDS. Patients in the hospital now are
kind of edgy. The headlines created by this study are making them nervous. Who
would blame them? The doctors are trying to blame the nurses who in turn are
trying to blame others, and round and round it goes. The press release from the
National Academy of Sciences and The Institute of Medicine who published the
report states "These stunningly high rates of medical errors – resulting in
deaths, permanent disability, and unnecessary suffering – are simply
unacceptable in a medical system that promises first to ‘do no harm.’
Managed
care news from the Web
1)
Should physician entrepreneurs be held to professional standards? This is about
Dr.Koop Surgeon General retired and Dr. Koop.com.
2)
Aetna may adopt United Health’s model to give doctors more say on treatment
(Wall St. Journal)
3)
Lawyer seeks public support for settlement with HMO’s (Wall St. Journal) High
profile lawyer Richard Scruggs has been trying to drum up interest in filing
class actions suits against HMO’s. He is the lawyer in the tobacco litigation.
4)
Providers leaving Aetna, voicing dissatisfaction. (Philadelphia Inquirer)
Hospitals and doctor groups scattered around the country have walked away from
millions of dollars in patient revenues from Aetna U.S. Healthcare in a series
of unusually public rifts with the managed-care insurer.
5)
Emboldened by a ‘guild,’ therapists to abandon managed care. Four years ago a
group of Connecticut psychotherapists made the riskiest move of their careers.
They severed ties with most insurance companies and formed an alliance of
independent practitioners.
6)
Feds pile on healthcare bankrupts – Reduced federal government reimbursements
have forced a number of healthcare companies to enter bankruptcy this year
7)
Pharmabid.com auctions blood, plasma, and medical products on Web (APW
Boston.com) Orange, Calif. Hospitals needing blood plasma or syringes have a new
source: an online auction where supplies ranging from vaccines to rubber gloves
are sold to the highest bidder.
What
is a "Hospitalist"?
A
hospitalist is a physician who specializes in inpatient medicine. The New
England Journal of Medicine in 1996 said that this specialty would burgeon for
several reasons. First, because of "cost pressures, managed-care
organizations will reward professionals who can provide efficient care." In
the out patient setting, the premium on efficiency requires that the physician
provide care for a large panel of patients and be available in the office to see
them promptly as required. There is no greater barrier to efficiency in
outpatient care than the need to go to the hospital to see an unpredictable
number of inpatients. The hospitalist trend is already visible at both teaching
and nonteaching hospitals in areas where managed care has taken root- almost
everywhere. Internists’ worst fears about the hospitalist movement appear to be
coming true in south Florida.
According
to the ACP-ASIM Observer May 1999 In February, Prudential HealthCare-South
Florida told its 3,000 physicians that it would soon require them to transfer
the acute care of their patients to hospitalists. Starting March 15, 1999
hospitalists began caring for Prudential members in nine hospitals and a dozen
sub-acute facilities. The Prudential program is one of the country’s most
far-reaching efforts to use mandatory hospitalists-it could affect 230,000
patients in one geographical area. What ever happened to the doctor patient
relationship through thick and thin? Many doctors were shocked by Prudential’s
news that they would have to hand over care of their hospitalized patients.
"We think it’s a further erosion of the patient-physician relationship and
promotes the further isolation of the physician."
There
are so many changes, almost daily that it is hard to keep up, but maybe we are
moving to a better model for healthcare.