Global Health Unequal Distribution:The Need For Active Moral Imagination (2)

 

Towards the Delineation of a Moral Framework

The increasing magnitude of global health inequalities demands an urgent plan of actions both at the national and the international level. This plan of action should be grounded in the ethical values associated with health and the moral fundamental anthropological understanding of human beings. I would suggest that bioethicists should be more actively involved in the imagination of moral frameworks that contribute to the identification of principles of action guiding national and international policies. The elucidation of the moral implications of global health inequalities presupposes the explanation of the reasons why they are morally disturbing and why efforts to reduce them are morally justified. The utilitarian, contractarian and neo-liberal theories maintain that global health inequalities do not possess any ethical valence that would support the moral obligation of eliminating them: societal welfare, collective security and self-interest constitute the only reasons urging their reduction. Overall, the utility value underpinning the current dominant approach to public health does not attribute any overarching value to the health of the individual person, especially when individual rights conflict with community’s health.

On the contrary, a theory of health ethics that integrates Aristotle’s political theory with Amartya Sen’s capability theory, considers individuals as the central moral unit of justice and emphasizes the instrumental value of health for human flourishing. In light of these presuppositions every society has the moral obligation to equally guarantee to each person the capability of achieving good health and being free from preventable morbidity and mortality. Therefore, health inequalities are morally troubling because they reduce the individual capabilities for properly functioning and flourishing. In a similar vein, a personalist view of health that rests on the personal nature of human beings acknowledges the instrumental value of health for the development and the fulfillment of the multiple dimensions of personal life.

A Personalist Understanding of Health

Personalism is a philosophical and ethical theory based on the notion of person as the ultimate criterion for defining all other ethical concepts: what is good for the human person.  Among the different versions of personalism that have been elaborated since the early 19th century, “realistic personalism”  supports an objective view of human health. The central tenet of realistic personalism is the commonly shared ontological value of the being and the dignity of the human person, regardless of any external recognition. Nevertheless, the notion of human person includes not only the commonly shared human nature, but also the subjective experiences of each individual person. From this notion of the human person stems the inviolability of human life that has to be respected in all its manifestations through the promotion of the basic human rights. The respect for the life of every human being does not justify the sacrifice of the interest of a individual for the advantage of the collectivity. These personalist presuppositions parallel the second principle of ethical practice of Public Health issued by the American Public Health Association in the year 2000 that states that “Public health should achieve community health in a way that respects the rights of individuals in the community” (#2). In addition, the personalist respect of the human freedom presupposes a more articulated concept of freedom than “the principle of authonomy” that characterizes bioethical principalism: it entails the reasonable use of one’s power of self-determination in accord with the objective moral order known through reason. A personalist view of health is based on the value of the absolute respect for the multidimensional nature of every person from which the following three principles emerge: 1. the principle of subsidiarity; 2. the principle of solidarity; and 3. the principle of justice.

Principles of Action

According to the principle of subsidiarity, rooted in Christian social ethics as well as in political philosophy, public health policies should always rely on public education rather than on constriction and prohibition. These policies should not be imposed by the nation-state or by global political authorities when they can be freely and responsibly chosen by individuals. In particular, this principle recognizes the central role of local communities and promotes respect for cultural differences.

In comparison to a centralized authority, smaller structures and communities can more effectively solve health problems by promoting human creativity and the development of less bureaucratized relations. However, the encouragement of individual and professional groups’ initiatives is not intended to foster individualism or particularism. In reality, subsidiarity alone does not guarantee the good and appropriate functioning of health care policies if personal choices do not care for the needs of the other members of the community. Therefore, the principle of subsidiarity has to be balanced with the principle of solidarity.

Through public education personalism encourages individuals to become responsible both for themselves as well as for the community in which they live and to promote the integral good that combines healthy personal lifestyles with a sustainable community life. On a global scale health can be promoted through a combination of responsible personal and communitarian choices.

The third principle of justice emerges as a consequence of the fact that for personalism the maximization of personal health benefits, namely the principle of subsidiarity, has to be balanced with the principle of solidarity. The principle of justice entails that global health interventions must fairly distribute risks and benefits among the population by promoting access to healthcare systems to all members of the community. In his theory of distributive justice that employs geometric proportion to support equal shares for equal needs and unequal shares for unequal needs, Aristotle introduced the concept of “disproportionate effort” that aims to bring disadvantaged people close to a threshold level of functioning within the limits of that person circumstances. Therefore, priority should be given to people who suffer from a gap between their health status and the threshold status they should achieve, provided that such efforts do not reduce the health functioning of the general population below the minimally acceptable levels.

A Moral Foundation for Global Health Care Policies

Based upon the recognition of health as an instrumental value to the respect of the dignity of every human being and the definition of the three principles of action, nation-states and international institutions and organizations like the WHO, the World Bank along with communities, non-governmental organizations (NGOs), families and individuals are called to cooperate for the reduction of global health injustices. Guided by the principles of subsidiarity, solidarity and justice, nation-states should create the adequate conditions for promoting individuals’ capability of being healthy, for guaranteeing equitable healthcare access, and for implementing participatory reforms and social services.

In summary, an interpretation of human health based on the commonly shared personal nature of every human being provides an appropriate moral framework grounding the obligation to reduce global health inequalities through the application of the principles of subsidiarity, solidarity and justice at a national and international levels. These principles, however, do not provide clear-cut answers to specific health issues, but they leave room for case-by-case ethical discussions

 

Though this ethical strategy grounded in the Western tradition of respect of the dignity of every human being might not be accepted in different cultural and religious contexts, it, however, can serve as a theoretical and operational paradigm for addressing global health issues. This model includes the following four sequential steps:

  1. The assessment of global health inequalities and their economic, political and social determinants.
  2. The identification of the basic moral value(s) about health and its distribution
  3. The development of principles of action that should guide international and national policies
  4. Finally, the coordination of the nation-state efforts with the supportive interventions of international institutions and organizations could reduce health inequalities and promote promoting health equity on a global scale.

At the same time the acknowledgment that moral discourse, narratives and commitments assume different connotations in relation to particular cultures and traditions calls into question the possibility of developing a global ethics, namely a common universal moral code, in a morally pluralistic world. Nevertheless, in the present multicultural context, an increasing respect of the richness and diversity of human values and moralities should foster a continuing moral dialogue on global health issues. This dialogue should be engrained in the right of each person to participate in global discussions about health and in his/her duty of living responsibly in a global diverse community.

 

Recommended articles

  1. Ruger JP. Ethics and governance of global health inequalities. J Epidemiol Community Health 2006; 60: 998-1003

 

  1. Petrini C, Gainotti S. A personalist approach to public health ethics. Bulletin of the World Health Organization 2008; 86: 624-9

 

  1. Wolff J. Global justice and health: the basis of the global health duty. Pages 78-101 in Global Justice and Bioethics/ Edited by Millum J. and Emanuel EJ. Oxford University Press: New York, NY, 2012

 

  1. Sgreccia E. The Human Person and His Body. Pages 105-49 in Personalist Bioethics Foundations and Applications . Translated by J. A. Di Camillo and M.J. Miller. The National Catholic Bioethics Center: Philadelphia, 2012

 

Global Health Unequal Distribution: The Need For Active Moral Imagination (Part 1)

Key Facts

The discovery of the structure of the DNA, in 1953, was the landmark of a new era that about fifty years later, Francis Collins, the director of the Human Genome Project, called the “genomic era” that has been affecting almost every aspect of human life. One of the most striking features of this new era has been an increasing awareness of the unequal distribution of wealth and health around the globe. In effect, during the last century, despite the tremendous explosion of knowledge and investment in science and technology, disparities in wealth and health within and between nations have been progressively widening.

Although the global economy has increased 7-fold since 1950, the disparity per capita gross domestic product (GPD) between the 20 richest and the 20 poorest nations has more than doubled. The global pyramid of wealth from 1997 to 2007 has showed that the inflation-adjusted incomes of the top 0.1% of the wage earners increased 390% in comparison with an increase of just 5% of the incomes of the bottom 99% of the earners.

In spite of unprecedented advances in science, technology and medicine, marked disparities in the distribution of global health are currently very apparent as some global health parameters eloquently indicate. Although worldwide life-expectancy has improved dramatically during the 20th century, recently this trend has been reversed in the poorest countries. In 2011 life expectancy was 80 years in Canada and in high-income countries, whereas in some sub-Saharan countries it was only 40 years. In addition, in 2004 South-East Asia and Africa together bore 54% of the total global burden of disease as measured by the disability-adjusted life year (DALYs) rate. In particular, premature mortality rates and years lost due to disability rates were respectively seven and eighty times higher in Africa than in high-income countries. Global infant mortality rate has decreased from 61 deaths per 1000 live births in 1990 to 37 in 2011. However, the risk of a child dying before completing the first year of age was about 6 times higher in the World Health Organization (WHO) African region than in the correspondent European one. In 2012 the maternal mortality ratio in developing countries is 240 per 100 000 births versus 16 per 100 000 births in developed countries. Ninety-nine percent of all maternal deaths occur in developing countries, in low-resource settings due to medical problems that could be easily prevented by providing access to antenatal and perinatal care and skilled care during childbirth. Within countries maternal mortality presents large variation between women with high and low income and between women living in rural and urban areas.

Due to modern advances in medical technology, in many industrialized countries the total expenditure in health as percentage of the GDP has been escalating rapidly. The United States alone spends more than 50% of the global health care expenditure for a population that accounts only for 5% of the world population. However, in some developing countries, especially in Sub-Saharan Africa, the proportion of GDP spent on health care has significantly decreased over the past 20 years.

Global Health

Due to the great variability of health distribution across and between countries global health has recently emerged as an important area of study, research and practice that addresses transnational health issues by identifying their determinants and suggesting workable solutions. In reality the notion of health across countries emerged in the 16th century in Europe when nation-states began to cooperate to control the spreading of epidemics, especially of plague. In the 19th century, during the European colonization period, the term “international health” was coined to indicate the ill conditions of the people living in the developing countries that could pose a serious medical threat to the European colonizers.

Then, in the 20th century the foundation of the major international institutions of health, the discovery of the impact of the social factors on individual and public health contributed to the broadening of the global health topics that have become increasingly interdisciplinary. In this respect, it is still under debate whether global health is to be equated to public health or whether it constitutes an autonomous entity. Some researchers argue that global health corresponds to the notion of public health since its main purpose consists of reducing the global burden of disease through the combination of population prevention policies and individual clinical care with a particular attention to the improvement of the health population in the developing countries. Harvey Fineberg and David Hunter in their recent editorial on the January issue of the New England Journal of Medicine have defined global health as “the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities and deaths”. This goal can be achieved by the combination of clinical care at the level of the individual person with health promoting and preventive population-based programs. On the other hand, an increasing consensus has gathered around the idea that global health aims not simply to reduce the worldwide disease burden, but also to improve the social, political and economic dimensions of human life. Therefore, global health has been progressively relying on the contribution of various disciplines outside biomedicine and public health that identify the causes of the current global economic, political, social and ecological instabilities. Increasing evidence has confirmed that one of the main factors implicated in the current world economic instability is the disjunction between a massive economic growth and a just distribution of economic and social benefits. This disjunction has been associated with the fact that the developed countries have valued global economic growth as an end in itself. In addition, wealthy nations have been continuously extracted financial, human and material resources from developing countries and have contributed to maintain the debt of poor countries at unbearable levels through trade protectionism and farming subsidies. Global political and social instabilities have been associated with wars, ethnic conflicts, genocides, large scale disruption of communities and people displacements, international terrorism, fragmentation of social services. From the human rights standpoint, both global political authorities and single nation-states have failed to guarantee the respect of political and civil rights along with the promotion of economic and social rights.

Finally, global ecological instability and unsustainability have been directly associated with environmental degradation, global warming, and loss of biodiversity that have contributed to the development of new infections and of a growing burden of chronic diseases in numerous countries. In short, the current dominant understanding of global health acknowledges that the global economic, political, social and environmental processes unequivocally impact health and healthcare and that various disciplines are to cooperate in the identification of workable solutions across the world.

Despite the lack of an unanimous definition of global health, many strategies have been designed for improving the health of all. They have been classified into

four main categories: 1. philanthropy from individuals, foundations and organizations; 2. long-term aid from affluent countries; 3. emergency humanitarian interventions and 4. expansion of the ethical discourse on global health.

The last category mainly appeals to moral imagination based on the assumptions that health inequalities pose ethical challenges to the global community and national and international responses should stem from the appreciation of the ethical aspects of human health. Ethical values, then, can assist to delineate principles, duties and responsibilities and to hold international and national institutions morally accountable for promoting the global common good. Though the reduction of global health inequalities has been directly associated with the promotion of global justice, the more fundamental challenge currently facing the national and international political and economic authorities is the configuration of a moral and anthropological framework compelling a more equitable distribution of health and health services between and within countries.

 

Recommended articles

 

  1. Fineberg HV, Hunter DJ.  A global view of health – An unfolding series. N Eng J Med 2013; 368: 78-79    

2.   World Health Organization. Data and statistics    http://www.who.int/research/en/  (accessed on 3-24-2013)

3.   Muray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med 2013; 369: 448-457

4.   Benatar S, Upshur R. What is global health?  Pages 13-23 in Global Health and Global Health Ethics. Edited by Benatar S. and Brock G. Cambridge University Press: Cambridge, UK, 2011   

5.    Benatar SR, Gill S, Bakker I. Global health and the global economic crisis. Am J Public Health 2011;101:646-653

6.     Daniels N. International health inequalities and global justice: toward a middle ground. Pages 97-107 in Global Health and Global Health Ethics. Edited by Benatar S. and Brock G. Cambridge University Press: Cambridge, UK, 2011

 

Doctor Patient Relationship, Part II: Theoretical Models and Clinical Reality

Theoretical Models

In 1972 Robert Veach postulated four models of the doctor-patient relationship: (1) Priestly, (2) Engineering, (3) Collegial and (4) Contractual. The Priestly Model dates back to the Hippocratic tradition: “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”. In other words, the physician makes all decisions regarding medical care of the patient based on his medical expertise and assessment of the patient’s best interests, without consulting the patient. The Hippocratic, priestly physician operates on the medical model, which treats patients as illnesses, not as persons. The priestly physician does not take into account a patient’s value system which includes a broad range of considerations beyond illness that might impact decision making. The paternalistic, Priestly Model of the doctor-patient relationship remained dominant from the time of Hippocrates (4th century B.C.) until the 1970s when Veach first wrote on the subject.

The Engineering Model switches the locus of decision making from physician to patient. The physician becomes a “hired gun” who relays the medical facts to the patient who then has full authority to select whichever treatment option he thinks is most consistent with his needs and desires, and then the physician implements the patient’s decision. In this model, the physician is like a plumber who, hired by a client, uses the skills of his trade to make repairs and flush out clogged pipes. He is a reservoir of scientific knowledge and dispenser of medical facts, presenting options to the patient without sharing his personal recommendations.

In the Priestly Model the patient relinquishes his moral authority and puts full decision-making responsibility in the hands of the physician; contrariwise, in the Engineering Model the physician abdicates his moral authority, reduces his role to that of a scientific expert who presents medical findings in a factual, value-free way and then places the full responsibility of decision-making in the hands of the patient.

Over the past 4 decades the once dominant Priestly Model with its centuries-old Hippocratic ethic has lost ground to the Engineering Model which better describes the dominant physician-patient dynamic in the modern medical marketplace. The movement from primary care to specialization in the medical profession, with emphasis shifting from conversation with patients to performance of procedures, is one manifestation of its emergent influence. Another is the growing perception that medical care is a commodity to be bought and sold at a competitive price. Physicians are referred to as health care providers, not health care professionals; patients are consumers of a health product.

From the times of Hippocrates until the 1970s, physicians were guided by the principle of beneficence to the extreme of paternalism (looking out for the good of the patient as they understood it and acting unilaterally in decision making). Beginning in the 1970s the doctor-patient dynamic began to change dramatically with a growing recognition of the importance of patient autonomy in decision making. The newer models of the doctor-patient relationship reflect a trend toward more interaction and dialogue between patient and physician in a collaborative process to discern the health care decision that is not only “medically indicated” but also most aligned with patient values.

A strong advocate of patient autonomy and critic of the Hippocratic tradition, Robert Veach in 1972 was the first to postulate a collaborative model of the physician patient relationship. In the Contractual Model of collaboration, physician and patient forge a mutually agreeable contract, more like biblical covenant than legal construct. There is true sharing of decision making in such a way that both physician and patient can be confident of retaining their moral integrity. The basic principles of autonomy, fidelity, voracity, avoiding killing and justice are essential to their contractual relationship. Physician and patient, through open discussion and exchange of views, establish a mutually agreeable value framework for medical decision making. In this way the physician is able to make the myriad decisions regarding medical care on a daily basis without consulting the patient on every detail.

Twenty years after Veach, Ezekiel Emanuel and Linda Emanuel proposed 4 Models of the physician-patient relationship. The first two are very similar to Veach’s: Paternal Model (like Priestly) and Informative Model (like Engineering). However, their two collaborative models (Interpretative and Deliberative) spell out the role of the physician in greater detail than Veach.

In the Interpretative Model, the physician acts like a counselor whose role is to elucidate and interpret the patient’s values, and then to assist him in determining the medical interventions which would best realize the specified values. It presumes that people are often unclear about their values and that discussion with another would help them apply their value system to clinical situations. The counselor physician acts as a facilitator in the process and does not introduce his value structure into the discussion. He helps the patient reconstruct his goals and aspirations, his character and life commitments. Once the physician understands the patient’s value system, he determines which tests and treatments would best realize these values. This final step resembles Veach’s Contractual Model since it’s not necessary that patients be involved in every detail of decision-making once the patient’s value structure is established. Yet in both models, the patient is the center of decision-making and has full moral authority.

In the Deliberative Model, the physician takes a much more active role in the collaborative dynamic. He presumes that the patient’s values are open to development and revision through moral discussion. He articulates and persuades the patient of the most admirable values. Like a teacher he explains what course of action in his judgment is not only “medically indicated” (Informative Model) but also most noble. Thus, the physician presents his medical and moral judgment up front in the discussion and uses his skills of persuasion based on clinical experience and firm opinion, yet ultimately he leaves the final decision to the patient.

It seems to me that none of the models apply in all clinical circumstances. In an emergency, clearly the Priestly/Paternalistic Model would apply since there is no time for discussion about values and preferences. It may also apply in some agrarian, third world cultures where the patient traditionally places all decisions in the hands of the physician and defers to his family all discussion with the physician. But in our modern pluralistic society, it would be foolish to presume physician and patient would espouse similar values and views of what constitutes a benefit, thus this paternalistic model would rarely apply now. The Engineering/Informative Model would be operative when medical facts are all that’s needed, e.g. when a specialist is consulted for a second opinion to confirm a diagnosis. But it erodes the virtue of caring so integral to the medical profession by reducing the role of a physician to a medical technician, disengaged from any meaningful relationship with his patient. It seems to me that both physician and society bear responsibility for the rising influence of this model. Doctors may be reluctant to make firm recommendations for fear of litigation if their opinion leads to a bad patient outcome. And in a consumer society, medical goods are like other commodities that can be bought and sold at the marketplace. Doctors need to be more courageous and society needs to regain its moral bearings.

Under most day to day circumstances, I would advocate discussion and collaboration between physician and patient. And like the Emanuels, I prefer the deliberative model, which requires alignment of medical decisions with the patient’s value system and, at the same time, engages the physician more directly and integrally in the process of working out the best decision. It encourages the physician to state frankly and directly his specific treatment recommendation and to explain how the decision is consistent with the patient’s most noble values. It seems to me this depth of deliberation is rarely possible in one visit, but rather requires a history of ongoing relationship. A primary care physician who sees a patient over a long period of time is in a perfect position to use the deliberative dynamic without much difficulty. And in the context of intensive care, an intensivist who sees patient and family at least daily can use the deliberative dynamic more easily than with a specialist who sees the patient only once or twice.

Clinical Reality

Theoretical models are helpful for discussion but do they apply in real life clinical medicine? In a provocative article entitled “No more models: just ask the patient”, Clark et al argue that the common theoretical models of “preferred” decision making relationships do not correspond well with clinical experience. The theoretical models of doctor patient relationship treat the patient alone outside of his or her family and social context. Yet typically the patient does not want to make decisions alone. Most patients prefer family or friends to be involved and they want advice from a spouse, son or daughter before they make a final decision. And at times they delegate decisions to someone they think has better judgment or a better grasp of the facts. As long as the physician patient model is that of an individual autonomous patient and a single physician in a decision making context, the preferences of such patients would be ignored. In short, there appears to be considerable variety in patients’ preferences for decision models, so the search for a single best model is based on a misguided assumption that one protocol fits all.

Physicians will be guided in the right direction, and will actively take into account the differences between individual patients, if they begin the process by asking the patient a few simple questions: (1) how do you want communication and decision-making to be handled?, (2) who do you want to be present for support and advice when the physician discusses treatment options with you?, (3) how much information about the case do you want the doctor to tell you?, and (4) in which of the many clinical decisions do you want to participate? The answer to these questions would set parameters for the collaborative process of decision making within the family and social context of the patient’s life. Given the variety of patient desires concerning communication, it seems unreasonable to believe that any one model of decision-making will fit all patients.

______________________________________

i Veach R. “Models for ethical medicine in a revolutionary age“. Hastings Center Report: 1972 (June): 2(3)

ii Emanuel EJ and Emanuel L “Four Models of the Physician-Patient Relationship”. Journal of the American Medical Association 1992: 267 (16); 2221

iii Clarke G, Hall RT and Rosencrance G. “Physician-Patient Relations: No More Models”. The American Journal of Bioethics 2004: 4(2), 16- 19.

 

The Doctor Patient Relationship Part I

Observations of a Physician

During the course of my medical career I’ve observed momentous changes in the way patients and physicians interact with each other. During my medical school days in the early 1970s I observed how patients would look up to their doctors with great respect as the trusted expert who knew best how to take care of them. Typically they would entrust all aspects of their medical care to the judgment of the physician. For their part, physicians would follow the routine S.O.A.P. Protocol: (1) Subjective – history taking, (2) Objective – physical examination and laboratory testing, (3) Assessment – diagnosis of illness, and (4) Plan: treatment plan. The patient’s simple contribution to this protocol would be to answer questions about his present, past, family and social history. The physician did the rest. And I noticed that patients did not seem to object to the protocol. They made their simple contribution to the process and willingly followed whatever doctor thought best.

As an intern in Internal Medicine in the middle 1970s, we would have sign out rounds to the night shift when we finished our daily duties in the late afternoon. As we signed out our patients from the intensive care unit, we’d describe their diagnoses and treatment plans in great detail and end briefly by designating for each patient a code status so that the night shift intern would know how aggressively to treat a patient if s(he) were called for a code. One might say, Mr. X is “full code” (do everything) or Mr. Y is “DNR” (do not resuscitate). And we made these designations without consulting the family. That was standard procedure in those years. By today’s standards, our sign out protocol of designating code status without consulting family members would be illegal, if not immoral, but the issue was not so clear in those days. After all, the Karen Quinlan case was being argued at this precise time. That historic decision of the NJ Supreme Court in 1976 forever changed the way interns sign out the code status of their patients.

From ancient times until the 1970s, physicians were guided by the principle of beneficence (looking out for the good of the patient as they understood it and acting unilaterally in decision making). Indeed, physicians practiced beneficence to the point of paternalism. Doctors focused on the patient’s illness, and since she had the expertise to know the best course of treatment for that illness, she thought it best for the patient to act upon that knowledge without worrying the patient.

In the 1970s the doctor patient dynamic began to change dramatically with a growing recognition of the importance of patient autonomy in decision making. Instead of being the passive recipient of the medical care administered by their physicians, patients became active participants in the doctor patient relationship. In their beneficence doctors may strongly recommend a specific treatment plan but the patient has the right to be informed of the therapeutic options and the right to make the final decision. Autonomy requires the informed consent of the patient, which includes full disclosure of information in a way he understands and to which he fully consents without any outside constraint.

Edmund Pellegrino postulates several reasons for the ascendancy of patient autonomy in the doctor patient relationship:  participatory democracy, increasing moral pluralism, weakening of religion as the ultimate source of morality, better public education, general mistrust of authority, reaction against expansion of medical technologies, and entry of professional philosophy in the study of medical ethics. Perhaps the last two reasons are of special importance. With advances in modern technologies (in-vitro fertilization, organ transplantation, genomics, etc.) came a broad range of ethical dilemmas that transformed what was previously called medical ethics into a wider field we now call bioethics. One might say that theologians and physicians in past days were the key players in medical ethics, whereas in our day of rapid technological innovation philosophers and scientists have greater influence in the broader discipline of bioethics. And liberty which is the core principle of the liberal philosophical tradition is precursor of the principle of autonomy.

The ascendancy of respect for patient autonomy is but one of the many factors which have impacted the doctor patient relationship over the past four decades, yet it’s a very important and healthy development. The principle of autonomy serves as a fundamental critique to the Medical Model which physicians are taught. A Patient is not an Illness. Physicians need to incorporate the whole person with her unique value structure into a process of shared decision making.

Part II posted in July will explore various models of the doctor patient relationship.

Is Intracytoplasmic Sperm Injection (ICSI) ethical according to the teachings of the Catholic Church?

First, the ICSI procedure needs to be explained.

ICSI – Intracytoplasmic sperm Injection

ICSI or Intracytoplasmic sperm Injection is offered to a couple when the semen sample does not fall within ‘normal’ parameters. This can be due to:

  • Oligozoospermia – Low number of sperm in the ejaculate
  • Athenzoospermia – Poor progression or movement of the sperm
  • Teratzoospemia – High numbers of abnormally formed sperm

Other couples that might be offered ICSI are those who have unexplained fertility, who have had an IVF cycle which has resulted in low or no fertilisation.

ICSI Treatment Stage 1

The first stage of treatment involves taking a nasal spray or subcutaneous injection of GnRH or Gonandotrophin releasing Hormone analogue. This drug temporarily stops the normal activity of the ovary so that ovulation does not occur when the ovaries are being stimulated. It shuts down the ‘normal’ ovarian function. Some women may experience side effects from the nasal spray or injection. These can be headaches, hot flushes or mood swings. The symptoms can be similar to that of PMT. The nasal spray or injection is taken for approximately two weeks. An ultra sound scan will then be performed to ensure that the ovaries are inactive.

ICSI Treatment Stage 2

Following the scan and confirmation that the nasal spray or injection has worked, the second drug will be introduced. These are administered by subcutaneous injection. These drugs are known as FSH or Follicle Stimulating Hormones. These will be administered on a daily basis and a scan will
be scheduled between D6-D9 to check the response. FSH stimulates the ovaries to produce multiple follicles. The progress will be assessed by ultra sound scans. There can also be some side effects with these drugs such as tiredness, feeling bloated or breast tenderness.

ICSI Treatment Stage 3

The scan will be checking the response to the FSH injections. The follicles will be counted and measured. When the follicles are a certain size approximately 18mm, this indicates that there may be a mature egg present (unfortunately not all follicles will contain eggs). At this stage, depending on the number and size of the follicles will determine when the egg collection will be scheduled. If the ovaries have responded well to the FSH injections then another injection called HCG or Human Chorionic Gonadotrophin will be advised to be administered. This injection helps to mature the eggs present and to release the eggs in the follicles for the egg collection. It is advised that this injection is taken approximately 36 hours prior to the scheduled procedure. Normally after this injection all other drugs are stopped.

Blog 1

ICSI Treatment Stage 4- The Egg Collection

The egg collection or oocyte retrieval can be performed either under General Anaesthetic or sedation. It involves a vaginal probe, similar to the one that have been used in the vaginal scans, with a needle guide attached to it. The needle then, under ultra sound guidance, is passed through the vaginal wall into each ovary. The follicles are then individually drained and an embryologist checks the follicular fluid for eggs.

Blog 2

It is in the laboratory following egg collection that it differs. Instead of the sperm being placed with an egg for natural fertilisation to occur, ICSI involves a selected single sperm injected directly into a mature egg. The eggs will then be placed in an incubator and checked the following day for fertilisation rates. The embryos are checked on day 2/3 of development. If they are progressing as expected then it may be recommended to aim for a blastocyst transfer on day 5. This can increase chances of a pregnancy.

Blog 3

ICSI Treatment Stage 5-Embryo Replacement

It is at the embryo transfer that the discussion of the number of and quality of embryos to be replaced will take place. The embryo replacement normally takes place with no sedation. It is similar to a smear test in that a speculum is passed into the vagina. The vagina is then cleaned whilst the embryologist loads the catheter containing the embryos. A fine caterer containing the embryo/ embryos is passed through the cervix and into the uterus. The embryo’s are deposited in the uterus. This is performed under ultra sound guidance. A pregnancy test should be performed 14 days after Embryo transfer.

Ethical Analysis:

According to Instruction Dignitas Personae : On Certain Bioethical Questions issued by the Congregation for the Doctrine of the Church:

17. Among the recent techniques of artificial fertilization which have gradually assumed a particular importance is intracytoplasmic sperm injection.[32]  This technique is used with increasing frequency given its effectiveness in overcoming various forms of male infertility.[33]

Just as in general with in vitro fertilization, of which it is a variety, ICSI is intrinsically illicit:  it causes a complete separation between procreation and the conjugal act. Indeed ICSI takes place “outside the bodies of the couple through actions of third parties whose competence and technical activity determine the success of the procedure. Such fertilization entrusts the life and identity of the embryo into the power of doctors and biologists and establishes the domination of technology over the origin and destiny of the human person. Such a relationship of domination is in itself contrary to the dignity and equality that must be common to parents and children. Conception in vitro is the result of the technical action which presides over fertilization. Such fertilization is neither in fact achieved nor positively willed as the expression and fruit of a specific act of the conjugal union”.[34]

[32] Intracytoplasmic sperm injection is similar in almost every respect to other forms of in vitro fertilization with the difference that in this procedure fertilization in the test tube does not take place on its own, but rather by means of the injection into the oocyte of a single sperm, selected earlier, or by the injection of immature germ cells taken from the man.

[33] There is ongoing discussion among specialists regarding the health risks which this method may pose for children conceived in this way.

[34] Congregation for the Doctrine of the Faith, Instruction Donum vitae, II, B, 5: AAS 80 (1988), 93.

 

 

Question: Is Concierge Medicine Ethical?

“Concierge medicine,” “retainer medicine,” “platinum medicine,” or what some refer to as “executive health programs” is a new concept but one that is here to stay. The basic concept entails a situation whereby a patient pays a set annual fee for “special medical services.” The cost of such membership ranges from $1,500 to $20,000 depending on the services that are provided, as well as the age and health of the patient. As stated above, there are numerous benefits and disadvantages to this new alternative medical practice. The main ethical issues focuses on whether concierge medicine will result in a two-tiered medical system based upon economics; is this a form of patient abandonment; and how does this new form of medical practice address the age old notion that physicians have a professional obligation to provide care for all those in need, especially the most vulnerable of patients? To determine if concierge medicine is ethical it will be evaluated by the basic ethical principles of respect for persons, beneficence, nonmaleficence and justice47.

Respect for persons incorporates two ethical convictions: first, individuals should be treated as autonomous agents; and second, persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy48. The physician-patient relationship is a covenant that is based on mutual trust. It is a fiduciary relationship that is based on honesty. Ethicists Edmund Pellegrino and David Thomasma, who have written extensively in this area, argue that among the obligations that arise from the physician-patient relationship is technical competence: the act of the medical professional is inauthentic and a lie unless it fulfills the expectation of technical competence49. This means that patients can expect their physicians to offer the same standard of diagnostic and therapeutic services to all patients.  The American Medical Association is quite clear regarding this issue:

Concern for quality of care the patient receives should be the physician’s first consideration. However, it is
important that a retainer contract not be promoted as a promise for more or better diagnostic and therapeutic
services. Physicians must always ensure that medical care is provided only on the basis of scientific evidence,
sound medical judgment,relevant professional guidelines,and concern for economic prudence.50

Autonomy gives physicians the right to offer concierge care and patients the right to take advantage of these exclusive services. Many concierge physicians argue that this type if medicine is not only in the best interest of the patient but also in the best interest of the physician. Physicians can practice more personalized medicine without being constrained by time and income issues. Having more time to spend with patients will allow physicians to focus not only on treating diseases and injuries but also preventing them. Preventive medicine has been proven to save patients money and suffering.  The problem area that arises is the issue of patient abandonment.  The cost of concierge medicine can eliminate a number of patients from a physician’s practice as was discussed earlier in the paper. Critics argue that this could be seen as a form of patient abandonment. Advocates respond to this criticism by arguing that as long as physicians have a careful transition process that assists patients in finding new physicians and allows for continuity of care then this objection can be negated. The American Medical Association offers a strict guideline on this matter which was referred to on page thirteen.  Abandonment of patients violates their basic human right of respect for persons, because they are not being treated with dignity and respect. If a patient is abandoned for economic reasons this patient can be considered vulnerable because their medical conditions are being untreated and their quality of life suffers. This violates the principle of respect for persons because we are failing to protect those individuals with diminished autonomy.

Another area that relates directly to the principle of respect for persons is the issue of informed consent. Most commonly, informed consent refers to surgical procedures and operations.  However, in this paper, informed consent also refers to the legal contract between patient and physician.  Patients have a right to be informed about the services that are covered and not covered as well as the retainer fees for their medical care.  This contract should also provide termination language. Patients have every right to be informed about the duration of the contract and renewal arrangements. Physicians need to be very careful in following all the rules and regulations regarding opting out of Medicare and/or other third-party payers and patients need to be informed about these arrangements and their payment responsibilities. Patients cannot give informed consent unless they have adequate knowledge about their options.  One of the basic aspects of the principle of respect for persons is that a person should never be treated simply as a means, but always as an end. Failure to treat a patient because of economic issues or failure to inform a patient of the cost and extent of contracted medical services is to use patients as a means rather than an end. However, if concierge physicians have a plan of continuity of care with other physicians in the community that provide adequate notice and appropriate referrals, do not leave patients in an unstable condition and the concierge contract is clearly understood, then this objection of using a patient as a means to an end can be eliminated. Respect for persons entails giving patients the right to select their physicians and to be treated with dignity and respect.  Following the guidelines outlined by the American Medical Association regarding retainer contracts would provide the needed safeguards for patients that would show a basic respect that all human persons deserve.

Beneficence involves the obligation to prevent and remove harms and to promote the good of the person by minimizing possible harms and maximizing possible benefits. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others. In medical ethics this principle has been closely associated with the maxim Primum non nocere: Above all do no harm51. Advocates argue that concierge medicine is in the best interest of the patient. Patients receive special medical services that are not now provided by most primary care physicians. They receive priority same day or guaranteed next day appointments, 24/7 access to physicians, house calls, preventive care, enhanced yearly health exams, telephone and e-mail consultations, etc. Having immediate access to a physician gives many patients a special peace of mind. It also allows a physician to be proactive with patients focusing on wellness and preventive care.  Concierge medicine allows physicians to intervene early before medical issues become problematic. “Patients undergo a comprehensive yearly exam that goes well beyond the typical physical, with chest x-rays, extensive blood work, and electrocardiograms, among other tests. With the information gathered from these extensive checkups, each patient gets a unique ‘wellness plan’4.” According to recent studies, patients in a concierge practice had 61.3% fewer hospitalizations compared with similar patients in commercial insurance plans, and 74% fewer hospitalizations compared with Medicare patients of similar age, gender, and disease risk. Practicing medicine in this manner is not practicing better medicine but it is giving better care. It is maximizing medical benefits and minimizing medical harms.

Concierge medicine is also in the best interest of the physician. As stated above, many primary care physicians feel overworked, underpaid and under appreciated in their current medical practices. Due to time and financial constraints placed upon them, physicians believe they are not providing the treatment that their patients deserve. As a result, many physicians in family practice are contemplating leaving the medical field and many medical students are not opting for family practice residencies.  Concierge medicine maximizes benefits for physicians by allowing them to have a reasonable number of patients and a salary that approaches the salaries of specialty physicians. It also minimizes harms by sustaining physicians who might otherwise abandon the medical field and encourages new physicians to seek family practice as a viable professional option.

Critics argue that concierge medicine violates the principle of nonmaleficence because it could cause more harm and even injury to patients.   These critics argue that with 47 million people uninsured and with the new Patient Protection and Affordable Care Act set to be initiated, if we continue to drain the healthcare system of qualified physicians then who will care for the majority of Americans who need primary care?  It is true that concierge medicine does benefit patients in these practices and is in their best interest medically. However, critics argue that instead of concentrating on a minority of individuals why not spend this time and money on reforming a deeply flawed healthcare system.  Concierge medicine does offer the patient, who is a consumer, a choice. Those who can afford concierge medicine have the right to exclusive medical services, because medicine is now a consumer driven market. This may be true but unlike other consumer goods, physicians should be held to a higher standard than other ordinary drivers in the marketplace.  Physicians are professionals and have an obligation to provide the “gold standard” of medicine to all patients equally. Failure to do so could inflict harm, injury and even death on the most vulnerable in society, especially minority patients, Medicare patients, and those with chronic diseases.

Advocates argue that this new sense of competition between traditional and concierge medicine may be in the best interest of patients, physicians and society as a whole. The high renewal rates in concierge practices, even in this economy, demonstrate how dissatisfied many patients are with the standard medical practice in the United States. In order to maintain their patients, concierge practices might be setting a new standard for medical practice or may be returning to a standard that once existed in medicine.  Emphasis on preventive medicine may become the new standard of care. This is not better medicine but it is better care. If studies continue to prove that taking the time to listen to patients causes physicians to order fewer expensive tests because their physical exam would have told them what they need to know and preventive medicine keeps patients out of hospitals and emergency rooms, then the cost of healthcare will decrease. If the government and insurers begin reimbursing physicians more for their time and clinical services and offered salaries comparable to specialists, then the shortage of physicians could be averted and more medical students would be attracted to primary care residencies. Instead of being accused of draining the healthcare system of primary care physicians, concierge medicine could maximize medical benefits by bringing a new sense of excitement to the field of primary care both medically and financially. The result might be that “doctors in traditional practices could offer more boutique-like services without the boutique prices4.” It is possible that concierge medicine could fail not only the test of beneficence, but also fail the test of nonmaleficence if proper safeguards are not imposed by the medical profession. However, with these safeguards in place, concierge medicine could also raise the standard of patient care to a level that is in the best interest of patients, physicians and society as a whole. As a result, prevention and wellness could become mainstream and affordable, healthcare costs could decline, physicians contemplating leaving the medical field may extend their careers, and medical students may be lured into family practice if salaries approach those of specialty care. This would satisfy the tests of both beneficence and nonmaleficence by maximizing benefits and minimizing harms.

Finally, the principle of justice recognizes that each person should be treated fairly, equitably, and be given his or her due. Justice also pertains to distributive justice, which concerns the fair and equitable allocation of resources, benefits and burdens, according to a just standard. Inequality concerning access to medical care is a well-documented fact52. To allow some patients, in similar situations, to have better access to physicians and medical treatments is an egregious violation of the principle of justice.  Justice dictates that patients should be treated in a similar manner if at all possible. If there are medical treatments that are good for concierge patients, and these are prescribed for some but not others, then failure to treat all equally violates the basic tenet of justice, that is, to treat all people fairly and equitably. The principle of justice can be applied to the problem under discussion in two ways.

First, critics argue that concierge medicine is only affordable for the wealthy.  Having discussed the annual fees, it is clear that one would pay at least one thousand dollars for this practice.  These critics argue that concierge medicine threatens access to care especially for the poor and the uninsured.  Studies have shown that concierge practices see fewer African-Americans, Hispanics and Medicaid/Medicare patients33. This contributes to the growing problem in the United States regarding disparities in healthcare. This criticism is countered by advocates who claim that concierge physicians have not only more time for their patients but also for volunteering. As stated above, MDVIP has opened a clinic for over 600 Medicaid patients who receive the same services as those who pay a retainer fee for concierge medicine. MDVIP also allows concierge physicians to offer scholarships and fee waivers to approximately 10% of their patients who cannot afford concierge care28. In addition, Qliance Medical Management offers concierge type services but with a monthly retainer fee of forty-four dollars.  Qliance is targeting the working poor, the uninsured and small businesses looking for affordable and quality healthcare29. Critics contend that concierge medicine is elitist but upon further examination many practices work out to roughly $4 to $5 a day—about the same amount people spend on cigarettes or a coffee at Starbucks. This does not seem to be elitist but a matter of priorities. If healthcare is a priority, then concierge medicine can become mainstream and affordable, not an unjust practice.

Second, critics are also concerned about reimbursement issues. Physicians in concierge practices do not normally sever their ties with third-party payers. If reimbursement issues are handled improperly, then serious legal issues can arise. The American Medical Association Code of Ethics is quite clear on this issue:
Physicians who enter into retainer contracts will usually receive reimbursement from the patients’ health care plans for medical services. Physicians are ethically required to be honest in billing and reimbursement, and must observe relevant laws, rules, and contracts. It is desirable that retainer contracts separate clearly special services and amenities from reimbursable medical services. In the absence of such clarification, identification of reimbursable services should be determined on case-by-case basis.53

Michael Blau, director of the Health Law Department at McDermott, Will and Emery, in Boston argues that concierge physicians need “to draw a very bright line between the non-covered concierge services for which you’re collecting a fee, and covered services for which you’re billing54.” Blau suggests that concierge practices that bill insurers should consider setting up a complete separate business corporation alongside their professional corporation. “The business corporation, which is not authorized to engage in the practice of medicine, collects the non-covered fees; the professional corporation, which is authorized to practice medicine, accepts payment in fill for covered services from third-party payers, subject to coinsurance, deductibles and copays53.” Justice demands that resources be equitably distributed, fairly priced and properly paid for by patients. Failure to do so is ethically irresponsible and morally objectionable.
If proper guidelines and safeguards are established nationally for concierge medicine it can be medically, legally and ethically justified. However, without these guidelines and safeguards numerous problems can and will arise.

Health Care Reform and an Old Fashioned Virtue

The Elephant in the Room

Most of us Americans are blessed with too much health insurance, and we do not use it wisely. The insured demand the most expensive treatment without a thought to how much it costs. We too blithely say, “my insurance will pay for it” without realizing that, in the end, we all pay for it.

The patient has an ethical responsibility to maintain or improve his or her own health as well as control costs. While it would be impossible to implement a program that forces people to live healthy lifestyles, it is reasonable to assume that healthier living would lead to lower healthcare costs.

The United States spends 18 percent of its GDP on healthcare, and the rate of increase far exceeds the rate of inflation. This trend is unsustainable. Healthcare economists estimate that between 40 and 50 percent of annual cost increases can be traced to new technologies or the intensified use of old ones. Economists say the control of technology is the most important factor in bringing costs down.

The problem is that patients expect high tech health care; doctors are primarily trained to use it, medical industries make billions selling it and the media loves to write about it. Technological innovation is as fundamental a feature of American medicine as it is in the industrial sector.

While doctors are often accused of over-prescribing diagnostic tests, this practice may be the result of patients who demand multiple tests – even if some are unnecessary. As health care technology innovates and its use increases, patients with insurance want the newest, most advanced and expensive treatments that insurance will cover. The most expensive treatments are not necessarily the best, and the patient has a duty to participate with the physician in making reasonable and cost-effective choices.

However, there is fierce opposition to any limitation in the use of medical technology; its use is deeply rooted in American culture. And politicians are reluctant to buck public opinion. Under the previous administration, Congress, with the support of physician groups and the health care industry killed two federal agencies designed to assess medical technology from a scientific and economic perspective.

Controlling healthcare costs requires a change in American culture. Since many of the effective means of controlling costs will be painful, due to our love affair with technology, resistance to change will be formidable. Effective control will force patients to give up treatments they think they need, doctors to sacrifice to a considerable extent their ancient tradition of treating patients the way they see fit, and industry to reduce its drive for profit. The fact that European countries can control costs and limit technologies without harming health is a patent rebuke to our way of doing things.

I worry about the Generation Y students in my college classroom. Upon graduation they’ll enter the workforce. Social Security and Medicare payroll deductions and escalating health insurance premiums will shrink their take-home pay each year. Today’s workers are paying the healthcare costs of today’s retired community. Will the money be gone when Generation Y reaches retirement?

Traditional virtues still receive attention in American culture, but discussion of one virtue-thrift-has all but disappeared, as affluence and extravagance have taken center stage. Perhaps we should reflect on the advice of the American Apostle of Thrift – Benjamin Franklin.

Old Ben would view our current healthcare reform discussion as a clarion call to change our ways and embrace the old-time virtue of thrift.  If all new diagnostic tests, procedures and treatments were subject to the rules of evidence-based medicine – objective evidence of superiority as opposed to traditional practice – that would be thrift. If pharmaceutical firms were required to prove the superiority of new and more expensive drugs over older and less costly ones, that would be thrift.  If medical equipment companies, which design new gadgets before the old ones get cold, were required to meet the same test, that would be thrift. If insurance companies were regulated more strictly and less ruled by the bottom line, that would be thrift.

Politicians are reluctant to propose any legislation that would place limits on the consumer. To do so, they fear, would be political suicide. Are they underestimating the virtue of the American people?  The healthcare debate is a “test of the national character. Perhaps the words of Ben Franklin have something to teach us: “Be industrious and frugal, and you will be rich”. If we elephants accept our duties and responsibilities in the healthcare reform process, our thrift will ultimately enrich us with affordable and high-quality healthcare.