medical ethics

Herd Medicine?

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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

herd  (hûrd)

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:

IMG_4818

 

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.

 

 

 

Reflections

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Body and mind raced as he responded to the code blue call. There is no day or night in a busy emergency room, no Time, no season. “An emergency room is light” he thought.“We are hens tricked into accelerated laying by the light. It comes on and BAM there’s another one, you’re welcome, thank you very much!”

 

An ER staff moves constantly in cool restless filtered air, and it’s kept that way because they are almost always very active; so blankets must be handed out regularly to patients.  He spent the first ‘overnights’ in a small ‘ER’ as a junior medical student.  The $8 pay was a bargain since he could sleep intermittently, and miss only the early lecture or clerkship round, slipping into the back layers of students, avoiding the eye of the professor.  Forty years in ERs followed. At first the harsh cold fluorescent light, an electric wind of sorts, used to leave his eyes  light- burned after a long shift. Black wrap around sunglasses would have helped but they were too hostile, too military. The noise, lights, crush of duty were conditions that soon seemed as natural as never waking up feeling totally rested due to constant change in work-sleep patterns.  He learned to eat, or inhale, a full meal in three minutes, to sleep any time, anywhere, instantly; and awaken as quickly, fully functional. Or usually so;  he chuckled, remembering when, as an intern after delivering twins, his first, alone, he immediately fell into a dark deep sleep of relief and exhaustion; a nurse called and asked something about the infants, and he responded;

“Give them each 100 mg of Demerol!”  Should have left the lights on!

 

As supervising attending physician he would observe closely while the resident physician ran the code.  Slipping quietly into the room like a late med student, but now  was an experienced physician prepared to offer occasional constructive question or a suggestion, if needed.

 

The old man was handsome; a golden black face and slender habitus made him seem young.  But it is always the eyes and the backs of the hands that  confess a person’s true age.  And they said, “ Well over 80.”  The man seemed vaguely familiar, yet he couldn’t place him among the accumulated codes and years of people threatening to die. Ventricular Asystole. No heart activity. He reflected;

“Not very likely we we’ll be able to send him upstairs to the ICU; and if we do they’ll probably send him way upstairs. Or downstairs if he’s Greek or somesuch.” But that thought was cynical and he quickly brushed it aside.

 

The new resident did not disappoint. Nor did anyone else. Resuscitation is always a team effort. Compressions, oxygen, intubation, confirmed, IV access, and  Drugs IV, labs.  All at the same time.   As he watched an attractive nurse do chest compressions, an unwelcome recollection of the first chapter of The House of God invaded his mind, and again he thrust it aside thinking,

“Some books should have warning labels: ‘ Said to be brilliant, insightful, but the Surgeon General has determined that the reader may be infested with mental garbage.’

 

After the initial chaos, the action became more ordered, deliberate, thoughtful. Team members commented and suggested.  And suddenly the monitor revealed Ventricular Fibrillation!  There was hope.  Electricity, three shocks, and the faint smell of burned gray chest hair. No change, more of the same, and once again, Asystole. Algorithms or recipes for resuscitation were followed.

 

The chart appeared.  The patient was almost 90. He  rather uncharitably thought,

“There must be a new person in records. Someone is awake”.  The charge nurse stepped in to say the patient’s wife and son were in the quiet room, so he stepped out to speak briefly with them, and review the history provided by the ambulance crew. The man, always very physically active, had been mowing the lawn with his push mower when he collapsed. Outside it was 112 degrees F.  His only surgery had been for cataracts, and his sole medication was estrogen for prostate cancer. There were no risk factors for heart disease except age and male sex.  The patient had been retired since age 65.  He had no special  activities or interests. “ My God!” he mused, “How has he survived 25 good years without the most addictive of all drugs: work.” In one of those recurring coincidences of life, his father had been a miner, and worked in the same mine at about the same time as the patient¸ Noranda, Quebec, where he had been born.  He wanted to ask more detail but had to return to the code. “Back to the henhouse.”

 

Relaying the information to the resident, he found that the patient’s situation was grim; a pulseless wide slow complex.  The labs were back, the x-ray studied.   He watched the resident methodically repeat the algorithm, consider and actually attempt to treat the only other possible treatable conditions. Yet she seemed to unable to make the obvious conclusion.

 

The resident was a single mother. She and her two children lived at a distance where rents were reasonable, in tiny apartment,  paid for child care, paid taxes, social security, drove back and forth to on street parking.  Her son had had a recent serious injury, and he had treated the younger child for severe asthma.  “We weren’t paid, but had free housing for me and my family, and free food.  We were really residents, working 36 on and 12 off. Why are they still called residents? But perhaps she will not beccome a robo-doc. The young docs don’t tend to abandon their spouses and children in the name of Hippocrates, like I did. I hope so.”

 

The seconds became minutes. The code team awaited orders. The inviolate code atmosphere was pierced from outside the room by voices, sounds of pain or retching, paging , buzzers,  bells and smells. The regular electric convulsion of the big code wall clock second hand soundlessly shredded the air.

 

Abandoning his role as observer, he called the resident aside and spoke in a whisper.  “ Good job. Very well done. But, unless you want to crack an 90 year old chest for practice, don’t you think you can ‘call’ the code?”  And in that moment he knew he had been negligent. He had not remembered that the resident was just returned from her own father’s funeral the week before.  He had forgotten that a resident is family. Like the family that he had so often neglected to value to nurture, to simply share his time with.   “What do the architects say”, he thought,“ ‘Function follows form?’  But in living it is the other way round. We become what we do. I hope she will do better than I have. ”

 

After the usual and always painful talk of informing the family, he asked as usual if they would like to visit with the patient. As usual, yes, but briefly. They left.  Returning to the bedside with the resident to review documentation of the code, nothing, however was as usual.   He felt as if he could see beyond the veil of Time. He had the sensation of gazing into a three thousand year old mirror from the side rather that front on. He could see, or sense, centuries of reflected images bouncing back and forth between the silvered and face surfaces of glass. It was clear that he and the dead man and the resident and Hippocrates are the same person, each a reflection of the others.

Fearing some sort of revealed truth or understanding would dominate him, he hurried away, out of the blinding eternal light, into the clean and translucid blackness of rain washed night air.