'Tis Only My Opinion!

April 1998 - Volume 18, Number 4

Health care progress - is it time to measure the cost/benefit ratio?

A recent article by Lester C. Thurow, the MIT economics professor, in USA Today on March 9, 1998, stated:

"In the last two decades, life expectancy, for example, is up 4% while spending on heath care is up more than 500%."

In any other aspect of life, business, or government, a rational person would probably agree that this is "not much bang for the buck."

Medical care is not inexpensive.

During the past few decades, the nation has decided to commit vast sums of money to improving the longevity of our population through the Medicare and Medicaid programs, the group health programs to supplement Medicare and Medicaid, long-term nursing insurance, etc. The political fights surrounding the Medicare and Medicaid programs are amazing to say the least.

Unfortunately, no politician is willing to take on the AARP and its growing legions and the burden of keeping these programs solvent is piled upon the backs of a dwindling workforce. Is it any wonder that our younger generations are skeptical about ever receiving anything from their social security contributions.

But two things are lost in the sight of all this compassion:

  1. Quality of life of the elderly, and
  2. The vast transfer of family wealth from those persons who have spent their lives earning the funds to a group of people and industries that in the final analysis really don’t improve the end result very much.

Statistics from the U.S. Government indicate that over 80% of all medical costs including the cost of nursing homes incurred by a person in their lifetime is spent during the last 6 months of life.

What Quality of Life is There?

Further, in most cases, the quality of life of the individual is poor. If you don’t believe me, you have not visited the elderly lately. All voters should be required to visit nursing homes for 3 days a year. And every politician should be required to spend a week taking care of the elderly in a full-care facility. Perhaps, then, we would begin to look at the problems of the elderly with compassion, dignity and economics. There is no quality of life being confined to a bed 24 hours a day, being fed intravenously, not knowing whether it is day or night, and being unable to communicate with family and/or staff. Existence of life should never be confused with the quality of life. Dying is just another phase of homo-sapiens life cycle. Prolonged suffering is not normal.

Medicare Care Costs are still increasing faster than the cost-of-living.

Despite the growth of HMO’s, the costs of medical care have not decreased and in fact, many doctors and most patients would argue that the quality of care has deteriorated as the accountants have turned the medical industry upside down in the quest for profits.

The Hippocratic Oath does not talk about money!

It seems to me that many physicians and health-care providers now give only lip-service to the famous Hippocratic oath. For my readers edification, it is reproduced below:

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee

or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly

medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and,

further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

Source: Hippocrates, Works trans., Francis Adams (New York; Loeb) vol. I, 299-301.

Two years ago, the following appeared in the NY Times.

Physician Protest and The Hippocratic Oath

By Stephen Harlin M.D.

"I will guard the sick from harm and injustice."

-- From The Hippocratic Oath

Managed health care "innovations'' are encroaching upon the doctor patient relationship. Insurers are demonstrating an expanding repertoire of practices designed to reduce the provision of medical care. Medical decision-making is no longer a privileged domain for those involved in direct patient care. The market has been brought to bear in health care.

Under the guise of cost-efficiency and accountability, dangerous constraints are being placed upon doctors and their patients.

But patients are patients; not commodities. Patients need medical care; not management. The complexity of clinical reasoning makes it virtually impossible to link medical ethics with business ethics. Conflicting obligations are certain if clinicians deliberate resource allocation.

Physicians have a moral duty to make clinical decisions based upon the biological, the empirical. the empathetic, the ethical; not the fiduciary.

Ethical dilemmas in the profession of medicine have long been inseparable from its practice. Notwithstanding, recent problems raise extraordinary concerns. A revised code of ethics now permits third party insurers to refuse treatment. In behalf of their patients, physicians have a moral obligation to lodge explicit protest.

The Revised Standard Version of the Hippocratic Oath

How different is the original Hippocratic oath from the modern version . . .

The Corporate Physician's Oath

"I swear by Humana and Columbia HCA and Cigna and Prudential and FHP and Wellpoint and HMO and PPO and IPA making them my witnesses, that I will fulfill according to my ability this oath and this covenant:

To hold the one who has taught me this business as equal to my corporation president, and to live my life in partnership with him or her, and if he or she is in need of capital to give him or her some of mine, and to regard his or her offspring as equal to my colleagues and to teach them this business - if they desire to learn it - for a fee and under contract; to give a share of my practice,

management techniques and computer systems and all other business acumen to my children and the children of those who have taught me, and to students who have signed the contract and have taken an oath according to Medicare law, but to no one else.

I will apply dietetic measures for the benefit of the obese, the alcoholic, the smoker, and the drug addict, but in this culture and in this political climate I will seldom be able to keep them from self-harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to that effect (depending on the outcome of Oregon's Ballot Measure 16). As an internist I will not do an abortion, leaving that to the obstetricians. In fear of malpractice I will guard my life and my business.

I will not use the knife, but I will try to learn some form of endoscopy.

Into whatever clinics I may enter, I will come for the benefit of the members, required to remain clear of all except capitated care for the indigent.

Things which I may see or hear in the course of treatment, or even outside of treatment regarding the life of human beings, things which one should never divulge outside, I will report to government commissions, immigration officials, hospital administrators, or use in my book.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and business, being able to retire at age 50 in the sunbelt. If I transgress it and swear falsely, may Milwaukee be my lot.

[NEJM Jan 2, 1986, revised by David Schiedermayer May 27, 1995]

The time has come to rationally look at a system which consumes almost 20% of our gross national product and yet provides so little benefit in the final analysis.

Until the health care community and our population come to understand that death is just a part of living and that death is not to be feared, we will continue to expend vast sums on delaying the inevitable thus continuing to deny persons facing death and long-term terminal illnesses the reality they deserve.

False hope accomplishes nothing but does enrich those providing it in a monetary sense.

But then - - ‘Tis Only My Opinion!

Fred Richards
April 1998

This issue of 'Tis Only My Opinion! was copyrighted by Adrich Corporation in April 1998.

All rights reserved. Quotation with attribution is encouraged.

Tis Only My Opinion is intended to provoke thinking, then dialogue among our readers.


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