Is the Democrats Health Reform Too Much Like Soylent Green?
By Dr. Tony Magana
Changing how doctors get paid from a system of fee for services rendered within reasonably accepted quality standards to an annual salary based upon national quality and economic standards could have a major effect on the mechanics and outcome of end of life decisions made by physicians and families.
The traditional medical model of the doctor patient relationship believed that the best outcomes were obtained in the interests of patients when parties outside the relationship such as government or insurance companies did not have standing in the decision making process. Medical ethics have long documented that the creation of physicians with allegiances to parties outside the patient and his family lends itself to contamination of decision making by other sets of demands and obligations. Some classic examples are the “company” doctor who provides workman’s compensation care for injuries sustained while on the job, military physician’s evaluating combat stress in a combat theater or Veteran’s Administration doctors deciding on a chronic disability rating, and of course medical experts hired by the defense against patient’s claims of injury. The recognition that bias could be introduced into such situations is so widely accepted that almost universally patients have been given the right to challenge opinions and ask for independent evaluations from physicians who are not being directly paid or employed by an entity with an interest against the patient.
Lately there has been a significant volume of discussion raised about the issue of new initiatives that the federal government may take to pay doctors for giving end of life counseling to patients who presumably would be facing a medical condition without a “reasonable chance” for recovery. Up to now, the physician had no personal stake in the decision of the patient and his family as to whether, for example, they chose an all out expensive try everything approach to deal with this situation or contrarily, adopted a passive acceptance of minimal cost hospice type care.
However, imagine that in the future, doctors will be “graded” and paid on their costs per taking care of a certain volume of patients as well other measures such as complications, death rates, days of hospitalization, and other measures. For those patients that have conditions for which there is a likely but not certain death rate such as 50%, one can easily imagine that choosing aggressive care in a few patients with marginally improvement in survival will radically alter the cost/quality curve rather dramatically. On the other hand, non-aggressive treatment will only slight increase the overall mortality rate but could dramatically lower costs.
Physicians will come under enormous pressure to alter their thinking about treatment and their counseling to patients and their families because the higher goal now will not be the individual patient but how the statistics look within a given period of time. This type of cherry picking was seen to occur when the government began to monitor complication rates for cardiac bypass surgery, such that many centers were refusing to treat patients who were high risk for re-do coronary artery bypass surgery because the potential for complications or death could negatively effect the provider’s and hospital’s rating.
I can not help but be reminded of the 1973 science fiction movie, Soylent Green (MGM Production-based upon the novel, Make Room! Make Room! By Harry Harrison), in which a society running out of resources resorts to mercy killing of the elderly and ultimately uses them for a food source. In that society, participants were convinced there was a high value in undergoing a short lived wondrous death experience and a low value in living a life as an elderly disabled or in-firmed nonproductive citizen.
All of us and our families should have frank discussions about what might be appropriate in a circumstance where our quality of life or likely coming death are anticipated. Our most important counselor in that situation should be a physician who is not influenced by an obligation to a government agency to maintain statistics. Such a practitioner may no longer exist under some reform proposals. If the government develops narrow recipes for treatment in the official Washington cookbook of medical care then the discussion with physicians by vulnerable families in these times of crisis will be transformed away from frank discussions of options and into an explanation of government policy.
Thanks for reading Contempo Magazine blog which discusses issues for McAllen, the Rio Grande Valley, and America from a conservative Hispanic point of view. Tony Magaña grew up in McAllen Texas, attended Texas A&M University, served as an officer in Army Reserve, and holds a doctorate from Harvard University. The co-founder of Contempo Magazine has participated in Valley business for over 20 years. He is a member of the National Association of Hispanic Journalists and also writes for the American Daily Review. Follow him on twitter http://twitter.com/contempomagazin
Copyright 2009, Dr. Tony Magana. Some rights reserved.
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