Wednesday, June 24, 2009

Honor your father and mother

From Wesley J. Smith's blog, Secondhand Smoke, a series of posts describing how rationing actually works in a country that has nationalized health care.
In the UK, utilitarian bioethicists control who gets–and who is denied–treatment via the Orwellian named organization NICE (National Institute for Health and Clinical Excellence). NICE explicitly uses a quality of life judgment (QALY–quality adjusted life year) to determine which patients are worth treating. It has now denied coverage for anti-dementia medications to mild Alzheimer’s sufferers. From the abstract of the story in the British Medical Journal:
The hopes of people with mild Alzheimer’s disease have been dashed again by the agency that appraises treatments for use by the NHS in England and Wales, which has reaffirmed its original decision to deny them treatment with dementia drugs. The National Institute for Health and Clinical Excellence (NICE) has issued amended guidance but still asserts that the drugs would not be cost effective for the mild stages of the disease.
Interesting that NICE is also the acronym for the sinister scientific research foundation in C.S. Lewis's That Hideous Strength.

In another post Smith describes "Futile Care Theory," the idea that care should be withheld when doctors decide it will do no good - something that a NICE-like agency would probably decide once the public cost of health care forces rationing.
A UK bioethicist named Daniel K. Sokol, who writes nary a word in opposition to Futile Care Theory, aka medical futility (meaning, I suspect, he is a futilitarian), has nonetheless written a valuable informative essay in the British Medical Journal (no link, 13 JUNE 2009 | Volume 338) called “The Slipperiness of Futility.” For example, he defines the different “kinds” of futility:
Although ethically aware clinicians need not be familiar with the vast literature on the concept of futility, they might wish to remember the following four points:
  • Futility is goal specific.
  • Physiological futility is when the proposed intervention cannot physiologically achieve the desired effect. It is the most objective type of futility judgment.
  • Quantitative futility is when the proposed intervention is highly unlikely to achieve the desired effect.
  • Qualitative futility is when the proposed intervention, if successful, will probably produce such a poor outcome that it is deemed best not to attempt it.
And he points out, physiological futility–which I think a physician should refuse–is the only objective “type.” Indeed, Futile Care Theory isn’t about truly futile interventions, but about withdrawing wanted treatment based on the medical team’s or bioethicists’ values:
As futility is so rhetorically powerful and semantically fuzzy, doctors may find it helpful to distinguish between physiological, quantitative, and qualitative futility. This classification reveals that a call of futility, far from being objective, can be coloured by the values of the person making the call. Like “best interests,” “futility” exudes a confident air of objectivity while concealing value judgments.
Frankly, I would prefer that such "value judgments" about my care be made by me, or by family members or friends, rather than by guidelines prepared by bureaucrats with the incentive to reduce government costs.

Finally [for now], Smith reports an example of what I have no doubt would become common here in a health rationing regime:
Stories like this continue to mount in the UK, and are a warning to us of the growing utilitarian, quality of life/cost-benefit bent in health care. A stroke patient, it is charged, was almost neglected to death–if not worse–at a UK hospital. From the story:
John MacGillivray, 78, from Auchterarder, was admitted to Perth Royal Infirmary having suffered a stroke on May 22. Two days later, his family were told by hospital doctors he would die within hours. His daughter Patricia MacGillivray told Sky News:…”There were several issues we already had with the level of care he had received in the short while he had been in the hospital, so we started to become suspicious. That’s when we started asking about his medication. It was then we learned that the medication we had been told he was going to receive when he was first admitted, which was specifically for stroke, had been changed to medication for treating seizures which we’d never seen him have.

The MacGillivray family instructed doctors to immediately withdraw all medication and launched a round-the-clock bedside watch.Within two days, Ms MacGillivray says her father had made such a good recovery he was being recommended for stroke rehabilitation treatment and four weeks later he was back home walking around his garden in Auchterarder. Ms MacGillivray feels if her family had not intervened in the treatment her father was receiving at Perth Royal Infirmary then her father would not be alive today. “The effect of that medication was to sedate him.”
Not to prejudge the matter, but I think that is a pretty good bet. Indeed, if my private e-mail is any judge, the disdain for the moral worth within the health care community for elderly people with serious brain injuries or illnesses is growing here too. (That being said, I believe American health care remains fundamentally moral precisely because of the people working in the trenches at hospitals and in nursing homes.)
Note: the illustration of a medical ration book is also taken from Smith's site. Its appearance is based on the ration books used during the Second World War.

Update: 6/25 from Warner Todd Huston at RedState:
Obama said during the ABC Special on Wednesday night that a way to save healthcare costs is to abandon the sort of care that “evidence shows is not necessarily going to improve” the patient’s health. He went on to say that he had personal familiarity with such a situation when his grandmother broke her hip after she was diagnosed with terminal cancer.

Obama offered a question on the efficacy of further care for his grandmother saying, “and the question was, does she get hip replacement surgery, even though she was fragile enough they were not sure how long she would last?”

But who is it that will present the “evidence” that will “show” that further care is futile? Are we to believe that Obama expects individual doctors will make that decision in his bold new government controlled healthcare future? ....

Government does not work by negotiation. Government does not work from the bottom up. It works from the top down. This singular fact means that no doctor will be deciding if you are too old or infirm to get medical care. It will be a medically untrained bureaucrat that sets a national rule that everyone will have to obey. There won’t be any room for your grandma to have a different outcome than anyone else’s. ....
Secondhand Smoke — A First Things Blog, Did Obama Say We Should Kill the Old Folks to Save Money Last Night? - Warner_Todd_Huston’s blog - RedState

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