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First they came for the communists,
but I was not a communist, so I did not speak out. Then they came for the socialists
and the trade unionists, but I was neither, so I did not speak out. Then they
came for the Jews, but I was not a Jew, so I did not speak out. And when they
came for me, there was no one left to speak out for me.
– Pastor Martin Niemoeller.
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|Mother of Health Care? - Thursday, July 22, 2010
Mother of Health Care?
Or Midwife of the Nanny State?
David C. Stolinsky, MD
In an overstatement of cosmic proportions, Vice President Joe Biden referred to Speaker Nancy Pelosi as “the mother of health care.” Did she found a new medical or nursing school? Did she discover a new treatment for a serious illness? Did she volunteer in a hospice?
No, she pushed through a 2000-plus page bill that will fundamentally alter how health care is delivered in this country − I believe for the worse. The bill is so complex that pundits cannot agree even on how many pages it occupies.
And, of course, it will be enforced by more thousands of pages of regulations, written by unelected, unaccountable, faceless bureaucrats. They, not Congress, and surely not you and your doctor, will decide what care you will receive…or not.
“Health insurance = health care.”
Besides grossly exaggerating Pelosi’s accomplishments, the vice president also perpetuated the confusion between health care and health insurance. Ideally, one should have both. But in this country, many people lack insurance and still can get care. On the other hand, in nations with socialized health care, one can have insurance and still lack care. Which alternative would you prefer?
The media tell us that there are 30 to 40 million Americans without health insurance. Granted, the figure includes most of the 10 to 20 million illegal aliens, who would not be entitled to free health care even in a socialist nation. Granted, the figure includes millions of younger Americans who prefer to spend their money elsewhere.
Still, those without insurance are less likely to receive optimum care. The trouble starts when politicians equate having no health insurance with having no health care. This error insults my whole professional life. Like millions of other physicians, nurses, paramedics, technicians and others, I devoted most of my career to caring for patients who could not pay for their care.
The effects of President Obama’s health-care plan are not yet apparent. He is on record favoring a single-payer plan − that is, government-controlled medical care. The “stimulus” bill mandates that care be “cost-effective” − as decided by unelected, unaccountable officials.
But what is “cost-effective” is a subjective judgment. What you think is reasonable a bureaucrat may decide is too expensive. How much is a year of life worth? How much is a year walking versus a year lying in bed worth? And since we all die eventually, any care could be called “not cost-effective” if that suited the whim of a bureaucrat. For example, Obama would allow pacemakers for the elderly only if it would “save money.”
“The last year of life.”
Proponents of rationing health care tell us that a large percent of costs occur in the last year of life. Yes, but so what? “The last year of life” is clear in retrospect, but can anyone predict what it will be? I can’t, and I spent 20 years practicing, teaching and doing research in medical oncology.
I can quote statistics for a given disease, but I can’t know whether they apply to a specific patient. Doctors treat patients, not statistics. At least they do now.
“The last year of life” can mean the peaceful end for old persons who were lucky to have lived that long. Or it can mean the tragic end for young or middle-aged persons who were struck down by illness or injury − but who might still have decades of useful life if they received expensive care. “The last year of life” for 45-year-old actress Natasha Richardson was determined by the Canadian government’s decision not to buy medevac helicopters. But think of the “cost savings.”
“The last year of life” can be a self-fulfilling prophecy. If we stop active treatment of a serious injury or illness, we can almost guarantee that it will be “the last year of life.” Death then becomes not a tragedy, but a bureaucratic decision.
We will then face the absurdity of a government so solicitous of terrorists captured in Afghanistan that gives them Miranda warnings, but a government so unconcerned with its own citizens that it sentences them to death if their illness or injury doesn’t fit rigid, bureaucratic guidelines.
When I was in medical school, the word “terminal” meant that the patient was in the actual process of dying. It didn’t mean that he was expected to die sometime in the future – everyone is. It didn’t mean that she was expected to die within some fixed time – no one could be sure.
All doctors have seen patients who seemed to be near the end, then recovered to live long lives. But now “terminal” has been redefined to mean “expected to die within six months,” or in the case of Obama’s grandmother, within nine months − or in the era of rationing, perhaps within five years.
It is dangerous to predict a bad outcome, when your prediction leads you to stop treatment and make the prediction come true. Then you never realize you made a mistake, and you make the same mistake again.
Doctors are often wrong in their predictions of life expectancy. (Click here and here.) Yet these inaccurate predictions are now the basis of declaring someone “terminal” – and therefore suitable to be taken off treatment.
“Removing life support.”
During a discussion of the Terri Schiavo case, a doctor described removing her feeding tube as “removing an impediment to death.” This doctor headed the ethics committee of a major hospital. He was used to dealing with patients who were at the point of death, and deciding whether to stop active treatment. Of course, pain medication, food and water, and nursing care should always continue.
This doctor was used to withdrawing advanced medical treatment, so it was only a small step to withdrawing food and water. He pointed out that unlike Terri Schiavo, we normally take nourishment by eating, not through a tube.
Yes, and we normally breathe unaided. Surely he wouldn’t take an inhaler away from an asthmatic patient. We normally move by walking. Surely he wouldn’t take a wheelchair away from a paraplegic patient. At least we hope he wouldn’t. The opposite of “normal” is “abnormal.” It isn’t “dead.” At least not yet.
Terri Schiavo wasn’t on “life support.” She was receiving water and food. Death wasn’t approaching. We can’t “remove an impediment” to what isn’t coming. She wasn’t “terminal” until we made her so. We killed her.
This term should refer to patients who want some control over the way they leave this world. The problem arises when we use it for people whose lives are not ending.
Articles about Terri Schiavo, and patients like her, refer to “end-of-life” issues. But her life was not ending until someone else decided to end it. She might have lived for many years.
That may, or may not, have been a good thing. But we needed to be clear about it. We needed to say plainly, “Terri has already lived like this for years. Should we allow her to live for more years, or should we kill her now?” That would have been blunt, but it would have been honest.
Terri wasn’t “brain dead.” She may not even have been in a “persistent vegetative state.” There was no “end-of-life” issue, until her estranged husband decided to end her life. We can’t think clearly about serious problems if we use confusing and inaccurate terminology.
We must not allow people to use elastic definitions that stretch to cover whatever they want. We must not allow people to push abandoning treatment, or even euthanasia, for a wider and wider group of patients. Who’s next? Homeless schizophrenics? Disabled people on Social Security? Autistic children?
Without drastic rationing, how can anyone hope to provide health care for everyone at lower cost − and at the same time allow unlimited immigration? This isn’t a logical plan on which to base national policy. This is an irrational fantasy with which to take control of an additional one-sixth of the economy, as well as to make life-and-death decisions affecting us and our loved ones − and thus make us totally subservient to federal bureaucrats.
Why does the “health-care” bill require coin dealers, and other small businesses, to fill out an Internal Revenue form every time they buy $600 worth of anything from an individual in a year? The “health-care” bill undoubtedly contains other intrusive, stifling regulations utterly unrelated to health care.
Is Nancy Pelosi the “mother of health care”? It seems more accurate to call her the midwife of the nanny state. But if we live in a nanny state, that downgrades us into dependent children who are not allowed to run their own lives.
You might think it was a typographical error to put “Is Nancy Pelosi the mother of health care?” under “End-of-life issues.” It wasn’t.
Dr. Stolinsky writes on political and social issues. Contact: firstname.lastname@example.org.