We just did a fantastic interview with the legendary G. Keith Smith, MD, co-founder of the Surgery Center of Oklahoma.
Early in the interview, Dr. Smith speaks of the motivation that pushed him and his partner, Dr. Steven Lantier to divest themselves from the government-insurance-hospital system back in the late 1990s: They wanted to stop enabling what Smith identified as “financial serial killers,” so-called non-profit institutions that end up charging astronomical prices for healthcare yet have no qualms about bankrupting defenseless patients who are unable to pay those prices.Continue reading “How to rid medicine of its cronyism”
I was interviewed by Tom Woods on his great podcast. We talked about the Alfie Evans case and discussed in depth the question of “best interests” of the child, and the appalling reasoning by which the UK medical authorities and the court decided that he was better off dead. I think you’ll find the episode worth listening to.
In reading about the case I discovered that the UK judge presiding over the case was greatly offended by a comment made by Dr. Nikolaus Haas, the German physician who—along with the doctors from the Vatican’s Bambino Gesu Hospital—had offered to transport the baby out of the UK and provide the care that the parents requested, namely, placement of a tracheostomy and feeding tube so he could be cared for at home.
In his report to the court, Dr. Haas said the following, which the judge found “inflammatory and inappropriate:”
Because of our history in Germany, we’ve learned that there are some things you just don’t do with severely handicapped children. A society must be prepared to look after these severely handicapped children and not decide that life support has to be withdrawn against the will of the parents if there is uncertainty of the feelings of the child, as in this case.
In his judgment about Alfie Evans rendered February 20, 2018, Justice Hayden of the UK’s Royal Courts of London writes:
Crucial to the decision I am being asked to make is the need to ascertain, as accurately as it can be, the present level of Alfie’s awareness. Accordingly, I considered that an up-to-date MRI scan was a significant component in the broad sweep of evidence that was likely to inform this assessment.
Nowadays, it may seem obvious that an MRI should inform someone about another person’s level of consciousness because it is widely assumed that if consciousness is present, it must somehow be present “in the brain.”
I don’t have time now to discuss in detail why that view is not quite correct (you can sign up for my Philosophy of Nature and Man course if you have the urge to know!), but I am reminded of 2 amusing items.
Michael Cannon, director of health care policy at the Cato Institute, has just published a piece where he criticizes conservatives for being “all wrong” about the Alfie Evans case which, according to him “had almost nothing to do with socialized medicine.”
As hostile as libertarians are to government, even we believe government can legitimately order the withdrawal of life support, and prohibit parents from moving a child to obtain further treatment, when that treatment would fruitlessly prolong a child’s suffering – i.e., when further treatment would be akin to torture.
But the court’s decision to prevent Alfie’s parents from obtaining the free care offered by the Vatican had nothing to do with limiting the child’s suffering.
As Cannon himself concedes, neither the court nor the doctors had any way of knowing if the child was suffering or not. In fact, they were in agreement that the child was in a coma, without any awareness of the external environment (and certainly not subject to a treatment “akin to torture”).
What the court actually argued is that dying was in the child’s “best interests”—even absent pain and suffering. That specific stipulation comes from recent guidelines by the Royal College of Paediatrics (RCP), which essentially argue that state-employed doctors can, by fiat, assert that a child’s quality of life is poor enough that he or she should die—and must die.
Cannon’s thoughts on Alfie’s case are still “tentative,” he tells us, but not tentative enough to take issue—as a libertarian—with a health care system where a government can forcibly prevent loving parents from providing life sustaining treatment for a sick baby at no cost to the taxpayer. If the RCP’s guidelines are a perversion of medical ethics, Cannon’s position has got to be a perversion of libertarianism.
Meanwhile, if you would like a sane perspective on the insanity of the Alfie case, below is my latest video with Dr. Anish Koka, in which we discuss this at length.
In our latest video, Dr. Koka and I discuss a recent paper in JAMA that starts with the following opening paragraph.
Physicians and teaching hospitals in the United States receive approximately $7 billion from the pharmaceutical industry annually. These payments have been associated with higher-cost, brand-name pharmaceutical prescribing. Whether industry payments are associated with physician treatment choice in oncology is uncertain. We examined the association between oncologists’ receipt of payments from pharmaceutical manufacturers and drug selection in 2 situations where there are multiple treatment options.
Payments to doctors by the pharmaceutical industry are problematic, even if they amount to literally peanuts. But let’s not get distracted by the much greater and more pervasive conflicts of interest that affect implicate everyone in the health care system.
At the end of the clip, I offer my version of the kind of opening paragraph I would love to read in the medical literature (but never do):
Physicians in the United States receive approximately $700 billion from the government and insurance industry annually. These payments have been associated with higher-costs, over-utilization, over-treatment, and decreased quality. Whether government and insurance industry payments are associated with physician treatment choice is uncertain. We examined the association between physicians’ receipt of payments from the government and insurance industry with duration of office visits, quality of care as perceived by the patient, and with utilization of health care resources. The control group was composed of patients who do not accept government and insurance payment for services.
Kevin Malik writes in the New York Times in support of Charlie Gard’s parents, presenting a secular, utilitarian argument for the continuation of the child’s treatment.
In the article, Malik draws attention to a contradiction between the State’s position regarding Gard and its position regarding the wishes of a patient with a terminal neurological condition who wishes for assisted suicide.
The practice of withdrawal of care is often invoked in the debate over assisted suicide. Proponents of assisted suicide frequently make an “equal protection” argument: since we allow the death of patients by withdrawing intensive care, shouldn’t we also allow patients to commit assisted suicide?
A few years ago, Neil Garsuch wrote an excellent book examining the legal and moral arguments that bear on the question of assisted suicide. He discussed at length and with meticulous detail the question of withdrawal of care as it might relate to assisted suicide.
Opponents of assisted suicide sometimes argue that withdrawing care is not the same as assisting someone’s suicide because the former is an omission, while the latter is an “action.” Gorsuch explains that that argument is unsatisfactory.Continue reading “Charlie Gard, disproportionate care, and assisted suicide”
A 90-year-old mother is in the hospital for a stroke. Her son gave me the following details:
Two months ago, mom was admitted to the hospital for dehydration. At baseline she had mild dementia and chronic atrial fibrillation.
She recovered well. Before discharge, the primary care physician convinced the family to change her status to “hospice,” arguing that she would get better, more appropriate, and more comfortable care. Her blood thinner Eliquis was discontinued for being “too risky.”Continue reading “Compassionate care in 2017”
Laws that allow assisted suicide restrict the provision of “aid-in-dying” drugs to patients whose mental status is not impaired and who are capable of sound judgment.
Medscape recently featured a video interview of Timothy Quill, the palliative care specialist and long-term assisted suicide activist. He is interviewed by the ethicist Arthur Caplan, and the two discuss the psychological evaluation of terminally ill patients who request physician-assisted suicide (PAS).
Abigail Hall Blanco, a research fellow at the Independent Institute, recently wrote a piece entitled “Assisted suicide is a personal choice” in which she defends the position that assisted suicide should be legal in a free society.
Before discussing this piece, it is important to clarify what Blanco probably means when she asserts that assisted suicide is a “personal choice.” After all, the statement may seem like a triviality: all humans are persons, and therefore all human choices are personal choices.
I suspect that what Blanco means to say is that assisted suicide should be legal because it is a free choice that only affects the person making it. In that sense, the subject and object of the choice are both the same person: The choice begins with the person and the effect ends in the same person.
There is an interesting thread on Twitter generated by a BBC article relating the case of a British patient who was granted the right to have her pacemaker deactivated. Dr. Wes Fisher was interviewed in the article.
