Month: May 2013
The nation has opted to create some form of universal health care. That is clear.
“…physicians, as an ethical duty owed to society, must practice efficient, parsimonious, and cost-effective health care.” from The American College of Physicians Sixth Edition of its Physicians Ethics Manual
While this statement is reasonable and reasoned with regard to national health care, it is in clear contrast to the time-honored ethical position that ‘Every life is beyond price”.
Though an ambitious endeavor like the creation of national health care is a process, to be revised and restructured as required, strident debates continue. Consider these quotes:
“Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.” From ‘New Rules” by Troyen A. Brennan and Donald M. Berwick MD MPP
“…the GOD panels (Government Operatives Deliberating) – … which will determine the most cost-effective way to practice medicine, and… distribute rules down to American physicians for deciding who gets what, when and how – tell us that what’s good for the herd is certainly what’s good for the individual.” From the DrRich blogsite January 3rd, 2012 “…
“M.D.s do not think of … patients as (a) herd (but) future health care decision-makers will.” From ‘Obama’s Herd Health Program’ by Heather McCauley DVM
1. a) A group of cattle or other domestic animals of a single kind kept together for a specific purpose.
b) A number of wild animals of one species that remain together as a group:
2. a) A large number of people; a crowd:
b) The multitude of common people regarded as a mass:
I am not a veterinarian. Yet it is reasonable to observe that in general veterinary medical practice is found in two forms:
Herd Medicine -focused on the greatest benefit to the greatest number of animals, and the economics of health care; and ‘Companion Animal Medicine’- fee for service care focused on individuals.
The term herd, when applied to human health care is disturbing to some, who see in it Huxley’s Brave New World; on the other hand, some see in our current medical ‘system’ much of Dickens’ 17th century industrial Britain. I contend that both views are flawed, and that the voting public in general, should realize that these two aspects of health care are not mutually exclusive; they are necessary in a national health program.
The table below provides side-by-side comparisons between herd and companion animal medicine. They are not altogether translatable to human health care, yet they are helpful in considering the implications of the national health care like that of the Affordable Care Act.
Herd-Vet Medicine Pet-Vet (Companion Animal) Medicine
Focus on large populations Focus on individuals
Collective outcome central Individual outcome central
Greatest benefit to greatest number Greatest benefit to the individual pet
Cost /benefit a major factor Cost limiting, but not central
Economic viability/profit critical to all Profit a consideration for ‘providers’.
Herd owner pays Pet owner pays
Decisions based on outcomes , economics Decisions based on emotions and owner resources
Ethical Considerations: Ethical Considerations:
Euthanasia, cloning, etc. justified by economics. End of life and advanced tech decisions by law.
Animal Rights not a prime consideration Animal (‘patient’) Rights of prime importance
Special considerations & legislation Special considerations & legislation
Valuable animals treated as individuals People can be jailed longer for abusing a
Animal rights laws may affect outcomes pet than a person.
In a sense, ‘Pet-vets’ infringed the patent on physician fee for service medical care. (So did hospitals, phone companies, government agencies, and other entities that bill for ‘services’ through a lengthy and unintelligible list of charges; but that’s different essay!)
Society needs now to infringe the patent on veterinary herd medicine, in a dual system to make national health care effective, practical and viable. In fact, dual- herd/individual care- systems have always existed in medicine, like the county hospital/private hospital dichotomy that survived until half a century ago,which was imperfect but functional. In fact, every nation that has a sustainable national health program allows or employs both types of health care: one focused on large numbers, outcomes, and economics, and the other focused on the rights of individuals. Both rest on ethical and practical considerations, which address different aspects of national health care. The ACA is such a duality, theoretically and functionally imperfect but subject to revision and improvement.
Every nation able to offer ongoing universal national health care to all its citizens has found it necessary to develop some sort of ‘two tier system’. Can we do so now in our democracy? We’ll see. I believe we can, and will. Any objective look at the life of people on this earth makes clear that over the centuries, people have lived progressively longer, healthier, more comfortable lives. I predict we will develop a functional, ethical, and affordable national health care consistent with our own culture and history. It will reflect one key word in the Affordable Care Act that implicates features of herd medicine; that word is: Affordable.
Dust from the graves of time-dead stars
waits in the magma of a planetary core,
is delivered of earth’s molten womb
against the will of a jealous gravity,
unaware it’s only inert stone,
as blind and dumb as dirt,
but wonders why things sing and weep,
on a rock whirling between infinities.
A sculptor imagines stone’s child
can be chiseled free to take part
in a conversation about eternity
among mortal children of mortal stars.