Spring 2018 - Vol. 13, No. 1



 
Looking back at the long span of my career, it is hard to recall a time when moral issues were such a great concern for physicians. Once upon a time, if we did our honest best for each patient, without prejudice or self-interest, we could feel content that we were fulfilling the moral obligations of our profession.

But gradually things got more complicated. As technology advanced and the options for diagnosis and therapy became more extensive and vastly more expensive, we were forced to consider the cost of our choices. We also had to accept the counterintuitive fact that – with a few exceptions such as childhood immunizations – preventive care does not save money, though it can improve the quality of life.¹ And even aside from the matter of cost, we were obliged to question the wisdom of preventive choices that once seemed obvious; we became increasingly aware that screenings for breast or prostate cancer aren’t always wise, as they cause harms as well as benefits.

As the introduction of exorbitantly expensive drugs made the formerly simple act of writing certain prescriptions a complicated moral dilemma, we also became familiar with a new, morally fraught term: the cost in health care dollars of an additional year of life.

But those issues all relate to decisions about individual patients. In the previous issue of the Journal we highlighted the moral dilemma of whether and how physicians should react to policies that threaten public health, such as those that favor fossil fuel production, or ignore climate change.² (Previous articles in JLGH by Drs. Alan Peterson³ and Joseph Kontra⁴ described the health consequences of environmental policies.)

But when we turn to our leaders in the public sphere for moral guidance, we are dismayed to find an insistent denigration of truth, facts, and science, and an erosion of moral authority. The resultant loss of commitment to the shared values and ideals we once considered “self-evident” undermines the concepts of “we the people” and “e pluribus unum” that have always been fundamental to the American project. Our Founding Fathers foresaw this possibility when they warned against the dangers of factionalism.⁵

It isn’t necessary or appropriate to discuss here all the factors that are to blame for the degradation of trust in our public leaders and institutions. Suffice it to say that though we choose our leaders in a democracy, those choices are now being influenced – and often distorted – by a 24/7 news cycle that is increasingly politicized, by partisan cyber-hacking that disseminates falsehoods, and by social media that magnifies the effects of “fake/alternative” facts – often attributing them to erroneous or even nonexistent sources.

If we cannot depend on the moral authority we find in the public sphere, as physicians (not to mention as human beings), we must rely on our inner sphere. We must look to our intrinsic moral values to guide us as we address the challenges posed daily by constantly changing health care laws and regulations, as well as by the health care needs of our patients.

My purpose in this editorial is to point out that questions we have customarily thought of as budgetary or administrative, are often essentially moral issues, and we must decide how we will engage them as physicians.

What is the proper moral response of physicians when:

a. Scott Pruitt, who doubts that human activity is an important driver of climate change, is appointed to head the EPA, and instructs EPA scientists not to speak at a scientific conference that features the impact of climate change, which affects all humankind.⁶

b. Kentucky, Indiana, and a growing number of other states, seek to impose work requirements on “able-bodied” Medicaid recipients.⁷ Since physicians will likely be called upon to certify the fitness of individuals for work, we should recognize that “able-bodied” is a political term, not a legal one, and is being used in this context to distinguish the presumably “worthy” from the “undeserving.” Its use ignores the reality that many factors other than physical condition can prevent people from finding and keeping a job. Conversely, a blind person may not be considered “able bodied,” yet may perform certain tasks superlatively, such as blending perfumes, wine, or scotch whiskey!

c. A former executive at Eli Lilly, Alex Azar, was appointed as Secretary of HHS, and policy analysts at the CDC have been told they are forbidden to use the words “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based” and “science-based.”⁸ (Instead of “science-based” or “evidence-based,” an alternative suggested phrase was “CDC bases its recommendations on science in consideration with community standards and wishes.” Surely, we are moving closer to a dystopian Brave New World^* if any benighted community can be the judge of a scientific fact’s validity.)

d. Family planning continues to be threatened in America despite the overwhelming evidence that population growth and climate change are a lethal combination. Because of a prolonged drought, and despite intensive efforts to conserve water, Cape Town will declare “Day Zero” in less than three months if water levels keep falling behind the dams that supply the city. Taps in homes and businesses will be turned off until rains come, and the city’s four million residents will have to line up for water rations at 200 collection points. The army will likely be needed to maintain order. (Hospitals and schools will still get water.)

South Africa’s problems are neither an aberration, nor unimaginable here. Southern California, with its incessant population growth coupled with the enormous water requirements of the state’s agricultural economy, is running out of water. (It takes almost 2,000 gallons of water to produce one pound of almonds, compared with 34 gallons for a pound of potatoes.⁹)

e. The “Dreamers,” i.e. those brought here as children and protected from deportation under DACA (Deferred Action for Childhood Arrivals), enjoy sentimental public support, but – like all undocumented immigrants – they are not eligible to receive Medicaid or to buy insurance in the affordable Health Insurance Marketplace. Like anyone with an acute health problem who cannot afford the exorbitant cost of unsubsidized health insurance, they can only go to the nearest ED, where they cannot be refused care under EMTALA. Is this an efficient, effective, and moral way to run a health care system?

There are many more I could list. What is a physician to do? The Merriam-Webster Dictionary defines “compassion” as “sympathetic consciousness of others' distress, together with a desire to alleviate it.” The Dalai Lama’s definition goes further: “the essence of compassion is a desire to alleviate the suffering of others and to promote their well-being.”¹⁰ His Holiness’ definition encompasses a more comprehensive goal, and it fits precisely with our objectives as physicians.

His Holiness continues: “Actively promoting the positive inner qualities of the human heart that arise from our core disposition toward compassion…will be appreciated by all. And the first beneficiaries of such a strengthening of our inner values will, no doubt, be ourselves. Our inner lives are something we ignore at our own peril, and many of the greatest problems we face in today’s world are the result of such neglect.”

Shouldn’t our inner values guide our attitude toward the public policies that define our society’s approach to health care?
 

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*  A 1931 dystopian novel by Aldous Huxley about a totalitarian state in which the masses are kept in line by pleasurable distractions, unlike Orwell’s 1984, where they are controlled by inflicting pain. Page 225 contains the line: “Science is dangerous; we have to keep it most carefully chained and muzzled.”
 

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REFERENCES
1. Bonchek LI, Screening for cancer: cost vs. value. J Lanc Gen Hosp. 2013; 8(1): 1-2.

2. Bonchek LI, Who speaks for physicians? We all do, each one of us. J Lanc Gen Hosp. 2018; 12(4): 97-98.

3. Peterson AS. Shale gas (methane) extraction and public health: Why doctors should be concerned. J Lanc Gen Hosp. 2017; 12 (3): 88-89.

4. Kontra JM. Zombie Infections and Other Infectious Disease Complications of Global Warming. J Lanc Gen Hosp. 2017; 12 (1):12-16.

5. http://www.hattiesburgamerican.com/story/opinion/columnists/ 2016/06/22/founding-fathers-feared-factionalism/86258792/

6. https://www.washingtonpost.com/national/health-science/epa-yanks-scientists-presentations-at-conference-on-narragansett-bay/2017/10/22/7429e65c-b76a-11e7-a908-a3470754bbb9_story.html?utm_term= .8c3e886a24ad

7. https://www.nytimes.com/2018/01/11/us/politics/medicaid-work-requirements.html

8. https://www.washingtonpost.com/national/health-science/cdc-gets-list-of-forbidden-words-fetus-transgender-diversity/2017/12/15/f503837a-e1cf-11e7-89e8-edec16379010_story.html?utm_term=.4992e6edab96

9. https://www.huffingtonpost.com/2014/10/13/food-water-footprint_n_5952862.html

10. H. H. The Dalai Lama. Beyond Religion; Ethics for a whole world. 2011. Houghton Mifflin Harcourt Company. New York.