New Hippocratic Oath? - "First, do no harm (to the bottom line)"

[tyto]

President Obama appointed Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel as a top health advisor. The problem, his controversial views on rationing healthcare.

Savings, he writes, will require changing how doctors think about their patients: Doctors take the Hippocratic Oath too seriously, "as an imperative to do everything for the patient regardless of the cost or effects on others" (Journal of the American Medical Association, June 18, 2008).

Yes, that's what patients want their doctors to do. But Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else.

Many doctors are horrified by this notion; they'll tell you that a doctor's job is to achieve social justice one patient at a time.

Emanuel, however, believes that "communitarianism" should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those "who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia" (Hastings Center Report, Nov.-Dec. '96).

Translation: Don't give much care to a grandmother with Parkinson's or a child with cerebral palsy.

He explicitly defends discrimination against older patients: "Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years" (Lancet, Jan. 31).

Full article at NYPOST
Source: http://www.nypost.com/seven/07242009...941.htm?page=0

[FrenchieGirl]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

Doctors take the Hippocratic Oath too seriously, "as an imperative to do everything for the patient regardless of the cost or effects on others" (Journal of the American Medical Association, June 18, 2008).

Yes, that's what patients want their doctors to do. But Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else.

OMG!!! *?%&(?*?"+&???!#?|?*?%&/("+? - pardon the expletives. I cannot express how strongly I feel about this, for having literally screamed "First do no harm" in very extreme circumstances and reminded two medical professionals of the Hippocratic Oath in a hospital corridor.

If there is not enough money to treat all patients according to the Hippocratic Oath, then it is for society to decide, collectively, what ought to be done. It certainly isn't, to my mind, up to the doctors how to allocate scarce resources - even though I realise many will be obliged to do so. In this instance of the H1N1 pandemic, there has been many years where concerned citizens have tried to warn TPTB that planning for an eventual pandemic needed to be done. The failure of TPTB to do so should not have them try to land the blame on, and wash their hands off the matter by getting, the medical professions to assume the responsibility of so-called "social justice".

[oldman]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

I hope I didn't use up all my health care 40 years ago. Do we need the equivalent of ration cards for healthcare, like we did for certain rations during the Vietnam war?

[Lizw]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

If there is not enough money to treat all patients according to the Hippocratic Oath, then it is for society to decide, collectively, what ought to be done. It certainly isn't, to my mind, up to the doctors how to allocate scarce resources - even though I realise many will be obliged to do so. In this instance of the H1N1 pandemic, there has been many years where concerned citizens have tried to warn TPTB that planning for an eventual pandemic needed to be done. The failure of TPTB to do so should not have them try to land the blame on, and wash their hands off the matter by getting, the medical professions to assume the responsibility of so-called "social justice".

I hate to be the lone dissenter here, but doctors have always been in that position. I disagree with Ezekiel Emmanuel's statement on a general basis, but when you get down to two patients and one ventilator, it's the doctor who necessarily has to decide, tragic as that is. It's called triage. At its most basic level, triage means saving the ones you can save and letting the others go. We tend to think of triage as being part of mass casualty emergencies, or battlefield situations, but throughout history, doctors and nurses have had to make those decisions when there wasn't enough of whatever to go around, whether it was medication, or equipment or even sometimes transportation. Think of the soldier on the battlefield who says, "I can't make it--take my buddy instead" when there's only room for one more stretcher on the helicopter. Or the medic who has to make that decision, for that matter.

I'm not comfortable with "society" having to make these decisions because you can't always make the rules in advance. The policy that says save the younger people over the elders could result in a younger career criminal being favored over an older statesman or researcher whose knowledge and experience might be invaluable to society. Yes, that's an extreme example and probably wouldn't actually happen. Why? Because the doctor on the scene would make the decision whether the rules were being broken or not. So I'm all in favor of talking about this subject, but I think the people who have to actually do the awful job of allocating the resources should be allowed to make the decisions.

[morningperson]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

I hate to be the lone dissenter here, but doctors have always been in that position. I disagree with Ezekiel Emmanuel's statement on a general basis, but when you get down to two patients and one ventilator, it's the doctor who necessarily has to decide, tragic as that is. It's called triage. At its most basic level, triage means saving the ones you can save and letting the others go. We tend to think of triage as being part of mass casualty emergencies, or battlefield situations, but throughout history, doctors and nurses have had to make those decisions when there wasn't enough of whatever to go around, whether it was medication, or equipment or even sometimes transportation. Think of the soldier on the battlefield who says, "I can't make it--take my buddy instead" when there's only room for one more stretcher on the helicopter. Or the medic who has to make that decision, for that matter.

I'm not comfortable with "society" having to make these decisions because you can't always make the rules in advance. The policy that says save the younger people over the elders could result in a younger career criminal being favored over an older statesman or researcher whose knowledge and experience might be invaluable to society. Yes, that's an extreme example and probably wouldn't actually happen. Why? Because the doctor on the scene would make the decision whether the rules were being broken or not. So I'm all in favor of talking about this subject, but I think the people who have to actually do the awful job of allocating the resources should be allowed to make the decisions.

I agree.

[mixin]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

Because the doctor on the scene would make the decision whether the rules were being broken or not.

Then why even have rules, if they are only going to be broken? I really don't like rules with exceptions because that leaves us in the hands of people who may have personal agendas.

[tropical]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

"commune"/"community" is usualy a sinonime for sharing, not eutanasing some of the folks by triages because of previous med device funding shortness ...
as seems to pointed the #1 post description of ""communitarianism"".

Maybe a wording lapsus: "eugenitarianism"

Following such things could conduct us to other historic failures.

Such path remember some similarities with some particular med policies existed 70 years ago, or present unfortunate destructed areas ...

[prepdeb]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

I have to agree with Lizw too.
The quotes from the article are an unfortunate choice of wording, in my opinion. I also agree that there has been ample warning and a lot of money spent in the US to be better prepared than I think we are.

However, if I needed a ventilator to survive (I am 57) and a 28 year old needed the same ventilator, I'd expect them to use it on the 28 year old and try to keep me alive without until one was available.

Sooner or later, we all reach a point where we are on our way out, if we're lucky enough to reach that point.

[AlaskaDenise]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

I believe the article was NOT referring to normal triage. It was referring to denying care based SOLELY on age. I'd like to see how he would explain this to his parents when they needed care.

Frenchie makes a good point - TPTB made a conscious decision not to allocate adequate resources to pandemic preparation, instead those resources were directed to wars, etc. Why should the elderly pay the price for the consequences of the decision not to: build more vaccination plants, purchase more anti-virals, purchase more ventilators, etc., etc.

It would be interesting to find out who voted against full funding for pandemic preparation and deny care when they come down with novel H1N1.

In 2006 I met a young man who was on a "working vacation" with papers and a laptop. I asked what he was working on that was so important. He was writing "health policy" for the current US administration. Without knowing anymore details I told him my request would be for more vaccination plants. He smiled and said that was exactly the subject of his work. We had about a 30 minute discussion on the subject. But, it was clear that he was of the opinion that more vaccination plants weren't warranted, because as he said "we don't know for sure if there will be another pandemic". I did my best to convince him & he even came to my migratory bird talk that evening.

That was a conscious policy decision which is now resulting in inadequate resources. To preplan to discriminate against the elderly is most certainly eugenics and as Tropical said - " Following such things could conduct us to other historic failures." Before they decide not to treat anyone over a certain age, they better look at the ages of many corporate CEOs - people over 60 and often over 70 are performing very valuable leadership roles in many parts of society. Then take a look at the age of the prison population. Are you sure you want to wipe out the elderly?

.

[AlaskaDenise]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

........However, if I needed a ventilator to survive (I am 57) and a 28 year old needed the same ventilator, I'd expect them to use it on the 28 year old and try to keep me alive without until one was available.

Sooner or later, we all reach a point where we are on our way out, if we're lucky enough to reach that point.

Basing a decision solely on age is wrong. Many 57 year olds have families to support, so denying them care hurts their children. Many 28 year olds are: druggies, prisoners, etc.

What is the age of the average infantrymen in Iraq? Have you seen all the very young men in those battalions? We put our young in harms way to fight for very questionable goals around the world, so why do you suddenly want to kill off elderly?

.

[prepdeb]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

You're right AlaskaDenise. I was being way too general.

What upsets me is the amount of money that has been spent in the US over the past few years on pandemic planning, yet few resources have been acquired or stockpiled other than Tamiflu.

I could be way off base, but it seems that the majority of the funds allocated ended up in purses around the nation that produced pdf documents.
While I understanding that there is a need for analysis and planning, there is an even greater need for material goods and personnel who can tend to the healthcare needs of the infected.

Too much paper and not enough substance.

[AlaskaDenise]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

While I understanding that there is a need for analysis and planning, there is an even greater need for material goods and personnel who can tend to the healthcare needs of the infected.

Too much paper and not enough substance.

Yes, materials and personnel are what it takes to handle a surge. While materials could have been addressed with money, trained personnel is another matter. As someone in another thread pointed out - you can buy ventilators, but without trained personnel to run them, they're useless.

The only solution for a surge demand for personnel is longer hours, recruiting the retired professionals (don't let them die), or allowing HCW to work out of their specialty.

Another important way to deal with the surge is to spread it out by vairous NPI - encouraging social distancing, etc. If closing schools & major social events can spread out an epidemic so more people can receive appropriate treatment, then close the schools.

To let a surge hit the system with no attempt to lessen its impact and then use the surge as an excuse to deny care to any group is pure negligence. How much of our tax dollar over our lifetime goes to saving lives? So we should be able to do with less profit/income now to help more people get adequate care during a surge. Manipulating lifestyles to maximize available care is part of "doing no harm."

.

[FrenchieGirl]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

I have seen denial of complete/proper healthcare to aged people, twice in the recent few years, for financial reasons of the greater "good" of an abysmally badly managed sickness insurance scheme.

And again YESTERDAY too I witnessed this!

Which human being can ever say that one life is more valuable than another?

If there's a choice in a pandemic of saving either a 75 year old doctor or an 18 year old thug, who can determine this?

Is the life of an old lady whose only diploma is to know how to tend sheep and speak languages worth more or less than that of a 50-ish Frenchie blogger?

According to which culture?

Some people in the world may have different "worth" values. Horrendously, a recent past, less than a century old, has shown this. Will the world ever learn?

We have an example where most societies in the world decide: when a ship sinks and not enough dinghies are available, usually, it's women and children first. Anyone would question this?

I know that in scarce resources doctors will have to do their best and save those that are most likely to survive. I hope they do this only on the basis of the physical possibilities of survival and that they will never ever make such a decision on the "perceived value to society" of the persons subject to triage.

As to money matters, they should not even come into consideration, I say. One cannot assign a financial variable to a life. By simply being alive, a human being is of an X-value which cannot, and should not, ever be measured.

And quite frankly, when I see the money, everywhere in the world, being squandered to offer what I consider "useless" frivolities to some minorities who have the power to decide whether I should live or not, when that money could buy tetrazillions of medical equipment for those in need of it, I am revolted!

I'd like to see TPTB, many, if not most, being over the age of 50, some nearing their 80th or 90th birthdays, when they are lying in bed, badly sick with flu and underlying conditions such as obesity, type II diabetes, cardiological problems, etc., and see how much value they will draw out of the bank in order to pay for a needed respirator that will rob someone else's life whom they previously decreed should be saved first!

A decent society can only be one that takes care of its weak and sick properly before financial or cultural considerations, using all of its revenue to accomplish this goal.

Surely, we do not, in our "democratic countries" lack enough brains at the top of these societies. These brains we vote for. Have we voted in self-centered intelligent hypocrits or roasted and liquified brains? Is it too much to ask that our PTB use their abilities to save people and the medical institutions, instead of having fun in sunny islands, dining themselves obese in fine restaurants, and, for many, squandering tax payers' money?

No doubt, if this pandemic does the damage which we all fear here on this forum, many people will start thinking along more or less my line of thought!

That is the exact recipe for social disorders throughout the planet and TPTB must use their grey cells to take the measures necessary to mitigate or avoid this. We still have a (very) little "God given time" to quote Mr. Nabarro to try and maximise our health care resources so that there may be only minimal disruptions in the world.

Sorry if this sounds very strong, my views on the subject are also very strong!

[Lizw]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

I believe the article was NOT referring to normal triage. It was referring to denying care based SOLELY on age. I'd like to see how he would explain this to his parents when they needed care.

Frenchie makes a good point - TPTB made a conscious decision not to allocate adequate resources to pandemic preparation, instead those resources were directed to wars, etc. Why should the elderly pay the price for the consequences of the decision not to: build more vaccination plants, purchase more anti-virals, purchase more ventilators, etc., etc.

And that's exactly why I don't agree with Dr. Emmanuel about making this kind of policy. You can't make hard and fast decisions based on a single criteria--that's obviously wrong. And as soon as you start making exceptions, you don't have clear rules any more. That's why I think the only people who can make those decisions are the ones who 1) are there at the time the decision must be made, and 2) have already sworn to uphold the Hippocratic Oath, because implicit in "Do no harm" is "Do the very best you're able to do."

I'm 64, with no one dependent on me but my older and already disabled housemate. So no one really needs me. If I have to give up my ventilator to someone younger, or more likely to survive, or a parent with dependent children, or whatever the criteria is, I'd rather that decision was made by a doctor who has to look us both in the face than a policy-maker somewhere in government who doesn't have to take any kind of responsibility for it.

Re triage--no, it's not what we usually think of as Mass Casualty Incident triage, but it boils down to the same thing--more victims than resources. The difference is that in a MCI situation, you have to make decisions in a split second--this person gets the last oxygen mask and tank, that person gets a toe tag. A hospital setting may provide more time for agonizing over the alternatives, but it still boils down to someone having to say "This person gets the vent."

And I agree 100% with FrenchieGirl. Money has been spent on everything except what's really important.

[FrenchieGirl]

Re: New Hippocratic Oath? - "First, do no harm (to the bottom line)"

That's why I think the only people who can make those decisions are the ones who 1) are there at the time the decision must be made, and 2) have already sworn to uphold the Hippocratic Oath, because implicit in "Do no harm" is "Do the very best you're able to do."

Then, perhaps, societies may want to have some people re-swear the Hippocratic Oath, because I have seen some that have forgotten it so much that I had to scream it at them. And I'm certain this is the case in many countries, not just mine. If one may not agree that society lays the rules, at least then society ought to offer a true debate on this issue, and possibly lay general guidelines or publish a consensus reached after thoroughly examining this question.