Medical Ethics and Obamacare
I am hoping someone can help me with a conundrum. I do not see how a physician can work under (frankly "for") Obamacare and remain true to accepted principles of medical ethics.
Every doctor who graduates a U.S. medical school swears the Hippocratic Oath, either the original or a modernized version written by Dr. Louis Lasagna in 1964. (Don't laugh at his name. He was a widely respected medical doctor and ethicist.)
While semanticists and lawyers quibble about the precise meaning of the words, real-world doctors understand the Oath's "prime directive." We swear that the best interest of our individual patient comes before all other matters: personal gain or comfort, complying with rules and regulations, and even the best interests of other patients. As an ethical doctor, my commitment and first responsibility is to do whatever it takes to help the patient before me.
The only constraint to that commitment is that we will not actively harm another person in the process. Thus, I would not take out a healthy kidney from someone else against her/her will to transplant that kidney into my patient who needs it.
So with that one exception, the ethical physician will do whatever it takes to help a patient. Lord knows that doctors in this country fight with insurance companies every day to get our patients what they need. We sometimes adjust, reinterpret, bend, or just plain ignore rules and regulations in the patient's best interest. In "The Cancer In Healthcare," I tell a story where, because of insurance eligibility requirements and contracts, I had to put a baby's life in danger temporarily in order to get her the heart surgery that would save her life.
The ethical doctor does whatever it takes to serve the welfare of the patient. The ethical doctor would never deny a lifesaving treatment to a patient, for any reason other than the patient's wishes.
How might Obamacare create an ethical dilemma for doctors? Keep in mind the Law's full name, especially the first two words: Patient Protection and Affordable Health Care Act (PPAHCA). ObamaCare, now abbreviated as ACA, ostensibly agrees with our Hippocratic Oath -- patients come first, period. (That is a real "period"-- no exceptions or exemptions; no weasel words; and no lawyerly parsing of what was meant versus what was said.)
When you add IPAB/HTAC to the mix, you begin to see our ethical problem. The Independent Payment Advisory Board (IPAB) is an independent, in fact opaque, federal agency created by PPAHCA to cut costs. It was recently renamed as the HTAC (Health Technology Assessment Commission) probably to hide it.
Whatever you call it, this body of bureaucrats meets in secret and decides which healthcare treatments they will approve and which they will not. Many of the "not approved" are medically effective but considered too expensive.
The community of health care providers will then, under ObamaCare, be expected to use the Approved procedures and not use those deemed Not Approved. If a doctor has a patient who needs a Not Approved (unauthorized) therapy, the patient can pay out of pocket... or die.
Let's suppose that IPAB/HTAC follows in the footsteps of its role model in the British National Health Service and decrees that kidney dialysis is "not cost effective" over the age of 55 years. Therefore, it will not be paid for.
Next suppose that you are a doctor treating a patient who goes into kidney failure. This patient could be saved by dialysis. What do you do after January 1, 2014 when ObamaCare takes effect?
For the non-physician readers, know that kidney dialysis is very expensive, often more than $10,000/month. At least 99% of the U.S. population cannot afford to pay that.
So, doctor, what do you do with "Joe the plumber's" uncle who is in kidney failure? Do you just let him die when you know there is something that could save him? Do you just say, "It is God's will, or in this case, it is in Washington's hands." Is that okay with you?
How can doctors support a Law that violates our first and most sacred ethical principle? Is IPAB/HTAC how ObamaCare "protects patients?"
Deane Waldman MD MBA is the author of The Cancer in Healthcare, a member of the Board of Directors of the New Mexico Health Insurance Exchange, and a former pediatric cardiologist who retired from clinical practice after SCOTUS upheld Obamacare.