Sunday, December 26, 2010

Obamacare Unconstitutional!

I begin this post a few thousand feet in the air, in the aisle seat in the rear of the aircraft. I suppose it is fitting that a gastroenterologist would be in the rear section. Fair is fair. Flying is a psychological test of one’s mettle. After enduring the security process, which is designed to find bad stuff instead of bad people, there are other layers of hassle to face. When I reached the cabin door, I was told that there was no available overhead space to store my bag. This development is often tolerable, as gate-checked bags are brought directly up to the arrival gate walkway after arrival, so you can avoid the hand-to-hand combat of the baggage claim arena. Not this time. For reasons, known but to the Almighty, my bag will be directed to the baggage claim, where I hope and pray that I will be properly reunited with it. Meanwhile, I will enjoy the luxury of an airline seat that would be quite comfortable for an average sized 4th grader. If the lady in front of me tilts her seat back, and my tray table is extended, then I will receive a Heimlich maneuver. Who knows? Maybe this could save my life if she leans back at the moment that the filet mignon I will be served gets trapped in my trachea.

Obamacare has hit an important judicial roadblock when Federal Judge Henry Hudson of Virgina ruled that the individual mandate was unconstitutional. Judge Hudson is the 3rd federal judge to rule on the constitutionality of the president’s health care plan. The first two judges gave the law a pass. Earlier today, oral arguments began in a Pensacola, Florida federal court before a judge who is suspected to harbor constitutional concerns of the health care plan. Already, 4 federal courts are involved, and it’s only 9 months since the law was signed. This is going to be a rocky road, and no one can predict the ultimate outcome. It is likely that the Supreme Court will ultimately have to reconcile various diverging views from lower Federal district and appellate courts. This emphasizes that a president who fills vacancies in the Supreme Court has a powerful tool to protect his policies against legislative threats and reversals.

Of course, courts are not supposed to make policy. They are charged to determine if an action or a law is lawful. Often, court decisions are criticized by folks who are not happy with the outcome, even though the legal issue before the judges may be arcane and not directly related to the actual issue. For example, the headline may read: “Judge Rules that Hospital May Withhold Chemo from Child with Cancer”, but the legal issue may be far removed from this emotional vignette. I’m not suggesting that judges rule in a robotic fashion without compassion or considering their own human experiences. I do feel, however, that it is not their role to depart from the law to provide extrajudicial remedies that should originate elsewhere. While the law does evolve, this is a gradual process that respects precedent and judicial restraint, at least in my view.

Is Obamacare constitutional? I have no idea. If a handful of wizened judges can’t agree, I don’t think that a mere colonoscopist in Cleveland should opine on the issue. Despite its legality, it remains a very unpopular law. Polling still shows that the majority of Americans would like the law totally or partially repealed, while 43% of us approve of the plan. This does not augur well for the president, since the tough medicine in his plan won’t appear for a number of years. Of course, Obama could dodge the fallout, which is inevitable if the law survives. He could be a ‘one termer’ and leave the angry mess to his successor. 

This is how the issue appears from 30,000 feet.  How does it look to you on the ground?

Sunday, December 19, 2010

Whistleblower Holiday Cheer 2010!

Readers immerse

In my rhymed universe

And decide if my verse

Is for better or worse.

An imam, a rabbi

Along with a priest,

Were seated together

At a holiday feast.

They smiled and they laughed

And enjoyed swapping jokes.

Can you believe

They ducked out for a smoke?

Was their bonhomie real

Or just a facade?

Didn’t they pray

To the very same God?

When together as men

Without enmity,

Walls can be broken

They realized, all three.

Can you still scorn a man

And give him the blame?

When you raise up your glass

And toast him by name?

When it’s all over

And the three of them part

Will they remember

The warmth in their hearts?

Or will the noise and the static

And political din,

Return them once more

To division and sin?

Who will you choose

To your table this year?

Family and friends

Who come year after year?

Perhaps, there are guests

Who could join you this time,

Who could sing at your hearth.

Together in rhyme.

There are friends on your list

And family, no doubt,

But, is someone missing

Who you may have left out?

Wishing you joy and peace!

Sunday, December 12, 2010

Medical Ethics: President Obama Makes the Right Call

I have always felt that issues should be judged by the context of their times. For some issues, however, context provides no justification. Thankfully, the field of medical ethics has evolved into a robust discipline, and there is an enormous need for it. I have read defenses of prior ethical lapses, and even some recent ones, suggesting that context matters. If a 3 month placebo-controlled study is conducted in the developing world testing a medicine that was highly effective against a serious illness, are the ethical dimensions considered and respected? Were the pharm companies choosing this study locale as a cheap test run for their drug, which will ultimately be marketed in the west? Is it ethically problematic not to provide additional medications to ill subjects after the 3 month trial ends? Can we be assured that a rigorous informed consent process was followed? Sadly, outrageous practices have been reported in the very recent past.

Our president and secretary of state recently and rightfully apologized to Guatemala for American experiments performed there in the 1940s when patients were intentionally infected with syphilis. These patients were mentally ill. While I can concoct a distorted and tortured rationale that would justify this reprehensible practice, such reasoning passes no threshold of decency. Some behaviors and practices are always wrong, in any context.

How can decent folks behave indecently? We have seen in the Holocaust how ordinary folks can tolerate, and even perform, evil during the week, and then attend religious services on Sunday. Many of these dark acts were committed by physicians, who are sworn to heal and to comfort. Here’s a perspective on this issue from a man who is known as the conscience of the world.

These are frightening notions. First, they suggest that we may not have innate inclinations to do good, despite our belief that we are all equipped with powerful superegos. If we were all good by nature, then we wouldn’t need such an expansive criminal justice system and thousands of laws telling us what not to do. The reason that the bible is replete with ‘Thou shalt nots’, is because human behavior is often ‘I shalt’. Secondly, these repeated ethical lapses and catastrophes point out that all of us are vulnerable to do wrong, even when we know what the right choice would be. While we might like to think we would push back against a black tide, it is less certain what we would truly do in that situation. Would we risk a job, for example, to take a righteous stand for another person?

I recognize that medical ethics addresses tough issues, where one person’s rights are weighed against another. The resolution of ethical issues yields winners and losers. Yet, despite these controversies, we need a firewall separating what we must do from what we must never do. The argument that the ends justify the means must be resisted. What American scientists did in Guatemala nearly seventy years ago was appalling and morally indefensible. It was wrong then, it is wrong today and it will be wrong tomorrow. The president has just ordered a review of all research involving human subjects being funded by the federal government to assure that medical ethics are being properly practiced. Recent history demonstrates that oversight is necessary. Third world citizens deserve first class ethics.

Sunday, December 5, 2010

Privatizing Medicare: Caution! Highly Explosive!

Photo Credit

In response to my recent post where I averred that the cigarette companies were treated as scapegoats, I have had several cyber and actual conversations about personal responsibility. I believe that folks should realize the consequences and the benefits of freely made decisions. While we want American society to be compassionate, we do not want to punish success and reward failure. Our goal is to do all that we can to maximize everyone’s success. We should be ready to assist those who need and deserve our private and governmental assistance, but personal effort and responsibility are necessary elements of these interventions.

In our gastrroenterology practice, when we see patients who are in financial difficulty, my physician partners and staff will do all that we can to help them. While it is not our policy to do colonoscopies for free, we will make whatever adjustments that are necessary to make sure that the patient receives necessary medical care. However, when patients who owe us money hang up on our calls, or express their view of medical entitlement with foul language, then we forward these accounts to a collection agency.

There is also a self-interest angle to supporting assistance for those in need.. One day, we may need a boost ourselves.

Recall the concept of privatizing social security, a sound proposal that was vilified and snuffed out during George W. Bush’s presidency. Antagonism against this modest proposal was seasoned with a large measure of arrogance, a splash of hubris and a dash of paternalism.

In summary, this proposal argued that if folks could manage a small portion of their own social security money, which they earned themselves, that it could be a force that could empower earners and reinforce the system. The political left turned white hot over the notion of the government transferring any responsibility for managing retirement funds to the citizens who earned the money. Isn’t this preposterous? They predicted doomsday when our imbecilic citizenry, who were somehow smart and industrious enough to earn the money in the first place, would squander it all, vaporizing the last remaining safety net that would keep them afloat. Then, the lefties argued, the rest of us would have to rescue them at much greater expense.

Their argument is transparent. Review some pesky facts below.

The plan only permitted individuals to invest 4% of wages that are subject to social security taxes into private accounts, with modest increases permitted in subsequent years. So, even if these investment tyros lost it all, which is hard to do in any investment, it wouldn’t be a game changer.

The government was not permitting folks to invest in hedge funds, penny stocks or junk bonds. They were required to select from a list of legitimate investment vehicles.

The program was voluntary. If an individual did not have the skill or desire to make personal investment choices, he did not have to. He could continue to allow the government to manage his money.

The program is so modest and so reasonable; it seems that it would be difficult to attack it. Why, then, did it provoke such ire and vitriol from the left?

These guys were scared. They weren’t frightened that folks would lose money and be vulnerable during their retirement years. They weren’t spooked that it would jeopardize the social security system’s financial stability. They were terrified that the program might actually work. They couldn’t tolerate any fissure in their edifice that stood for total government control of other people’s money and personal decisions. If this initial privatization effort succeeded, they knew that the public, now empowered, would demand greater control of their own money.

Yes, I am familiar with some of the criticisms. The government would have to borrow gazillions of dollars to replace the monies being deposited in beneficiaries’ private accounts. In addition, retirees would have to repay the government their privately deposited funds back, plus interest, so it is possible they would lose money if their accounts did not outperform this low interest rate. It would increase the federal deficit, and is not risk free, as stated above. As is obvious, I am not an economist or an actuary. It may be that the dirty details of the program would pose drawbacks, more dire than I realize. Indeed, many liberal advocacy groups vigorously denounced and derided this program. Yet, I support the notion that I have the right to participate in a voluntary program to manage money that I have earned.

To those who believe that the government knows best how to invest my social security retirement money, then why shouldn’t it control all of my investments? Should I be trusted to invest money that will one day be used to pay tuition for my kids? Indeed, anti-privatizers could argue that all of our money should be turned over to the government, so they can wisely manage it and then disburse it as it sees fit.

Recently, Alice Rivlin, a Democratic economist and Paul Ryan, a Republican congressman, both members of the president’s deficit reduction commission, advised consideration of privatizing the Medicare program. Of course, this is political dynamite, but their bipartisan proposal from two thoughtful public servants shows that this strategy deserves air time and public discussion.

So, when you stumble across dynamite, what should or response be?  Call the bomb squad or light the fuse?