On the same day that DrRich published his post about the American College of Physicians’ new Ethics Manual, Rob Stein of NPR’s Health Blog did the same thing. In his post, Mr. Stein took particular notice of the ACP’s admonition to physicians that, in order to practice medicine ethically, they must practice parsimoniously.

DrRich flatters himself to believe that he may be the one who called Mr. Stein’s attention to this remarkable terminology. Mr. Stein had contacted DrRich just prior to the New Year’s holiday for his reaction to the new Ethics Manual – and DrRich responded with a lengthy e-mail containing a substantial riff on the ACP’s usage of “parsimonious” (a riff that was not dissimilar to the one appearing here on the CRB a few days later).

In any case, whether DrRich had anything to do with his focus or not, Mr. Stein (being a reporter instead of a mere ranter) actually interviewed several persons of interest regarding this curious terminology. Dr. Scott Gottlieb of the American Enterprise Institute and Daniel Callahan of the Hastings Center appeared sympathetic to DrRich’s take on “parsimonious,” that is, that this word, at best, carries some very negative connotations under any circumstance, but particularly when it is used in the context of providing healthcare to people who need it. (DrRich himself was not mentioned in the NPR article. This undoubtedly shows good judgment on the part of Mr. Stein, who has his reputation to think of.)

The most interesting response to Mr. Stein’s questions on “parsimonious” was offered by Dr. Virginia Hood, current president of the ACP. She strongly defended the use of the word, saying, “Parsimonious is a good word in the sense that it means that you use only what’s necessary. I don’t see a particular problem with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

So the mystery raised by DrRich in his last post is apparently resolved. When the ACP says “parsimonious” it turns out they are not referring at all to the “theory of parsimony” (or Occam’s Razor), the theory which states that when there is more than one explanation for a series of observations, one must always default to the simplest available explanation. It seems a shame that this is not what the ACP was referring to. While it would have been terribly misguided for the ACP to make an unqualified demand that doctors apply the theory of parsimony to all questions that arise in medical practice, at least they would have seemed somewhat sophisticated in doing so. For many academic papers have been written about the theory of parsimony, and some of them border on the esoteric.

But astoundingly, that’s apparently not what the ACP meant at all. It turns out that what they meant was, in fact, parsimonious. Dr. Hood purports to believe that “the real meaning of the word” is “efficient.” But she should know that it is not. According to Roget’s II New Thesaurus, parsimonious is “ungenerously or pettily reluctant to spend money.” Webster’s New World Dictionary gives “stinginess, extreme frugality.” Other sources DrRich has found list similar definitions, such as: excessively unwilling to spend, penny-pinching, miserly, sparing, grasping, tight, close, niggardly, illiberal, mean, avaricious, covetous, rapacious and tight-assed. Only one source even mentioned the word “efficient,” and it was the 15th or 16th meaning. The dictionaries make it clear that being “parsimonious” is not a thing to be admired.

Students of philosophy, religion, and psychology have known, at least since Dante, that a vice is a virtue carried to extremes. The vice of lust is a perversion of the virtue of love. Servility is a perversion of humility. Recklessness is a perversion of courage.

And parsimony (or miserliness, or stinginess, or any of the many synonyms that exist for this very common vice) is a perversion of thrift. We do not celebrate the addled stalker because his vice is rooted in a perverted form of love. We ought not celebrate parsimony because, despite its perversion into something awful, it is based on efficiency.

Notwithstanding Dr. Hood’s protests to the contrary, when the ACP admonishes physicians, as a matter of ethics, to provide healthcare parsimoniously, that is not a good thing.

While Dr. Hood may herself not be a lexicographer, DrRich thinks we can be fairly certain that, for a document like the ACP’s Ethics Manual, before final publication each and every word is carefully parsed, analyzed and considered by a number of astute and highly educated individuals. Indeed, one notes that the lead author of this document is an attorney, and attorneys are notorious for understanding every nuance of every word they allow into written documents. One would assume that this is especially true for a word which is so important to the message that it is being placed in a special call-out box, so nobody will miss it. It is simply not believable that “parsimonious” – which describes a well-known vice – managed to slip into this document inadvertently as a synonym for “efficient,” as Dr. Hood suggests. That explanation, of all the possible explanations, is simply not credible.

So perhaps Dr. Hood misspoke, and “parsimonious” really was referring to the theory of parsimony after all, and she either did not realize this (not being a lexicographer), or simply forgot. The only other credible explanation, which Dr. Hood indignantly denies, is that the ACP actually does mean for doctors to practice medicine parsimoniously – with all its negative connotations – and that her present dissembling is merely dissembling.

As it happens, DrRich has a brief history with Dr. Hood. Two years ago, the Covert Rationing Blog and the ACP Advocate Blog were both named as finalists for a Medical Weblog award in the category of Health Policy and Medical Ethics. So DrRich suddenly found himself in an ethics competition with the very organization that had published the notorious “New Physician Charter on Medical Professionalism,” and thus had destroyed the very foundation of medical ethics.  He could not resist the opportunity to publicly challenge the ACP, under the spotlight (and protection) of the Medical Weblog competition, to an open debate on medical ethics.

You can read all about the ensuing exchange here. What may be of some interest for our present purposes is that it was Dr. Hood herself – at the time the Chairperson of the ACP’s Committee on Ethics, Professionalism, and Human Rights – who finally drafted the ACP’s public response to DrRich. And interestingly, in her response (which was heavy on condescension but light on logic) Dr. Hood invoked the need for parsimonious care. So the ACP’s use of this word was not a momentary oversight; instead it has been rolling off their collective tongues for years, as a descriptor for what they consider to be the ideal approach to the practice of medicine.

Another aspect of that Medical Weblog competition between DrRich and the ACP is more to the point at hand, namely, the interesting manner in which the ACP finally beat DrRich out for the award. The way the competition works is that a short list of finalists is determined by a committee of judges, and then for two weeks anyone who is interested can vote for their blog of choice. The voting system allows only one vote per IP address (so if 20 people all vote from their computers tied into a company network, only one vote is counted). During the voting period, a running tally of results is shown to anyone who cares to see it.

Clearly, given the public spectacle DrRich had made regarding the righteousness (or lack of it) of the ACP’s stance on medical ethics, it would have been deeply embarrassing for the ACP to lose this medical ethics contest. So it was probably troubling to that organization when DrRich mounted a substantial lead early on, and held that lead for two weeks, right up until the last three hours before the voting ended, which, as it happened, occurred at midnight on Sunday, February 14. Then, late on Valentine’s night, when most normal people were with their loved ones doing, well, Valentiney things, apparently a large number of ACP members spontaneously rousted themselves from their activities, logged on to their computers, and voted for the ACP – just enough of them to overtake DrRich, and then to maintain a steady 10 – 20 vote lead for the remaining hour or two of the voting period.

DrRich is not relating this story because he is bitter, nor is he complaining. (This blog won the Medical Weblog award the following year, so there is nothing for DrRich to complain about.) Rather, he was and is deeply amused by these events, and he relates this story for a very pertinent reason – namely, for the purpose of illustrating the shortcomings of the “theory of parsimony.”

For what are the possible explanations for the ACP’s stunning last minute victory? One explanation is that, in the waning moments of Valentine’s Day, members of the ACP finally got around to voting. This is of course possible. These are internal medicine specialists, and many of them are the guys (and girls) you knew in college who looked forward to football Saturdays because the library would always be so much quieter. So it is indeed possible that the ACP membership had entered into their iPhones, weeks earlier, a reminder to vote for the ACP at 11:59 PM on Sunday, February 14. Perhaps they figured they would be logged on to their computers at that moment anyway, reading the latest research on the complement cascade.

Another possible explanation is that someone affiliated with the ACP, realizing how deeply embarrassing it would be to lose an ethics contest to a pain in the ass like DrRich, figured out a way to defeat the voting system’s firewall, and to enter the precise number of votes they needed at the last minute in order to gain a victory and save face. We have seen examples in electoral politics, over and over again and perhaps as recently as last Tuesday night in Iowa, that in close contests it is best to withhold a bolus of the votes you control until the last minute, when you know just how many votes you need.

DrRich is not accusing the ACP of anything, of course, as he has no direct proof that they behaved badly – just a series of observations that have more than one possible explanation. But he admits to finding it delicious that a straightforward application of the theory of parsimony – always choosing the simplest explanation for a series of observations – leads us to the conclusion that agents of the ACP apparently cheated in order to win an ETHICS contest.*

_____

*If they actually did this, of course, some would say it would indicate that the ACP has disqualified itself from ever establishing ethical rules for anyone.  But actually, it would simply be another illustration of utilitarian ethics, where important ends always justify whatever means are necessary to achieve it.

_____

Since we know beyond doubt that the ACP would never have done such a thing, and that the ACP won that competition fair and square, DrRich has therefore just demonstrated that applying the theory of parsimony, after all, will often enough lead to incorrect conclusions, and therefore the ACP ought not demand that doctors apply it as a matter of course in all questions of life and death.

So either way, whether the ACP’s use of the word “parsimonious” was supposed to indicate that doctors ought to be stingy and miserly in delivering medical care, or whether they were obligating doctors to always apply Occam’s Razor to medical decisionmaking, delivering parsimonious medical care is a very bad idea, and certainly ought not to be an ethical mandate for physicians.

The leadership of the ACP ought to know this. Indeed, Occam’s Razor suggests that they do know this, which would be the simplest explanation for why, when challenged on their choice of the word “parsimonious,” they insist that they mean the one thing that makes no sense whatsoever.

A key goal of the Central Authority, as it contemplates how best to run our healthcare system, is to do whatever it can to stifle medical progress. Medical progress usually means introducing new drugs or new medical devices, which are often very expensive in themselves, and worse, which often threaten to improve the survival of some category of patients with chronic disease. So typically, medical progress greatly multiplies the costs of healthcare, and all the Central Authority gets in return is more chronically ill people to contend with. For this reason, suppressing medical progress is a critical aspect of covert healthcare rationing.

It goes without saying that a major tactic in achieving this goal is to demonize the drug companies. If the pharmaceutical industry can be made out to be sufficiently evil, corrupt, greedy, and callous to the needs of the people, then it will become the duty of our leaders to constrain them, and in so doing, to limit their ability to develop and introduce new products. This is easily done by adding daunting new regulations, or by piling on oppressive new taxes, or by legislating “windfall profits” penalties, or by using the threat of the regulatory speed trap to threaten them with massive fines or imprisonment. It is indeed fortunate for the Central Authority that the drug companies are, in fact, not the most fastidious members of the corporate community, and that their actions and methods often suggest many fruitful avenues for demonization.

One such avenue that is particularly fruitful, since it recruits the public squarely into the camp of the prosecutorial horde, is to show how the corrupt pharmaceutical industry feeds at the trough of the American taxpayer.

A few years ago, to specifically document this sort of reprehensible behavior, the New York Times pointed us to the case of Dr. Laszlo Bito and the anti-glaucoma drug Xalatan.

In the early 1980s Dr. Bito, a researcher at Columbia University, made a key discovery about a new class of substances that could potentially treat glaucoma. His research was funded with American tax dollars through the National Institutes of Health.

Subsequently, the pharmaceutical giant Pharmacia purchased the rights to Bito’s discovery for a mere $150,000. Based on Bito’s tax-supported work, eventually Pharmacia released the anti-glaucoma eyedrop preparation Xalatan. Xalatan rapidly became a worldwide best-seller, yielding as much as $500 million in sales per year. For their part in this unalloyed success story, Columbia University has netted over $20 million in licensing fees and royalties, and Bito himself became a millionaire.

Meanwhile American glaucoma sufferers are forced to spend upwards of $50 every six weeks for a tiny vial of the drug, which costs the company only a small fraction of that amount to produce, and whose discovery the glaucoma sufferers paid for with their own tax dollars. And, as if to guild this already brazen injustice, Pharmacia makes Xalatan available in Canada, France, and most other countries around the world (where taxpayers decidedly did not support the discovery of the drug), for less than half what American patients pay for it.

It seems, the Times points out, that the American taxpayers are the only parties in this little scheme who reap no financial return on their investment. All they got were some expensive eyedrops.

And so, drug-company demonizers would have us conclude, this is a particularly egregious example of how the evil pharmaceutical industry is ripping us off. Not only are the drug companies mercilessly profiteering from sick Americans (which indeed is their openly-admitted business model), but they are also picking the pocket of every American by using our tax dollars to invent new drugs, then selling those drugs back to us at exorbitant prices. This, one could reasonably argue, is at least as sociopathic as anything the tobacco companies ever did. (The tobacco companies, in contrast, at least had the good graces to eventually stop claiming that their products were beneficial to one’s health.)

And (we in the great unwashed are all supposed to agree), if this reprehensible behavior doesn’t give our government the right to control the prices charged by drug companies, one would be hard pressed to say what does.

DrRich certainly doesn’t want to absolve the pharmaceutical industry of all responsibility for drug prices that seem obviously too high, or for the striking disparities we see in the prices they charge for their drugs between the U.S. and other countries. He has read the complex justifications, published by apologists for the pharmaceutical industry, as to why drugs in Canada cost so much less than in the U.S., and why a tablet whose actual manufacturing cost is five cents is sold to our elderly sick for five dollars. DrRich thinks that, despite all the pretty explanations the pharmaceutical industry gives for these “seeming disparities,” drug companies simply do what every other industry does – they charge the highest price the market will bear, for each market in which they participate. If they didn’t do this, they would be abrogating their fiduciary responsibilities to their shareholders.

There is much not to like about high drug prices, or the fact that people in other countries reap the benefits of American research for far lower prices than Americans do. And it is reasonable for us to seek to address these pricing issues. But as we address certain inequities in drug pricing, we should be careful that in doing so we don’t throw the baby out with the bath water. So if we’re going to alter the arrangement we have with the pharmaceutical industry, let’s be clear on how that arrangement works, and why we set it up in the first place to operate as it now does.

Consider once again the glaucoma drug Xalatan, and consider how Dr. Bito’s discovery was actually used by Pharmacia.

Bito did not discover a finished product. Instead he discovered a new concept for reducing intraocular pressure (that is, for treating glaucoma), and demonstrated that it could be effective – but the specific compound he discovered was not marketable. In fact, it was so highly irritating when applied to the eye that it was simply not suitable for human use. (DrRich does not understand why the drug companies are the evil players in this story, when Columbia University so obviously allowed research to proceed in their facilities in which irritating substances were intentionally placed into the eyes of bunnies or other cute animals.) Indeed, Bito’s new compound was so impressively unusable that, before Pharmacia bought the rights, his discovery had been offered to and rejected by a host of other drug companies as being completely infeasible.

So when Pharmacia finally agreed to pay for the rights to Bito’s patent, they took on an expensive risk that, some estimated, had less than a 5% chance of achieving success. Pharmacia assumed the difficult task of developing a brand new synthetic molecule that would have all the benefits described by Bito, but at the same time would not have the prohibitive side effects. There was no assurance at all that such a molecule could ever be developed, and the cost of searching for one would dwarf the cost of purchasing Dr. Bito’s compound in the first place.

If such a thing turned out to be feasible, then the company then would have to conduct painstaking and extraordinarily expensive human research trials, and if successful, would then have to shepherd their new compound through a time-consuming and costly regulatory gauntlet – which explains why the vast majority of promising new drugs fail to ever gain FDA approval. That their efforts were ultimately successful does not diminish the fact that, when Pharmacia agreed to invest the time, money and opportunity cost to develop Dr. Bito’s discovery, the company was committing itself to an expensive and extremely risky proposition, with no assurance of making a profit or even recouping their losses. It was, in fact, a very long shot.

The folks occupying Wall Street ought to remind themselves that the cool products they are using each day (such as the iPhones they use to organize their flash demonstrations) all came about because the profit motive – and only the profit motive – encouraged some entrepreneur to risk his/her time, treasure, and sacred honor on some new idea. And for each risk-taker who becomes a millionare or billionare, thousands of others achieve only modest success – or fail altogether. (That’s why it’s called “risk.”) But the lure of big profits drives the whole system, and accounts for American progress.

Bito’s (tax supported) idea was a promising one, but the challenge of developing that idea into a product that was useful to patients and that could be brought to market was very expensive and highly risky. Pharmacia took on that risk (all of which was borne by its shareholders, and not by taxpayers) only after difficult, internal corporate soul-searching. If not for the prospect of making enormous profits if this risk worked out, the company (like several other drug companies did in this particular instance) certainly would have walked away.

Before 1980, it is likely none of this would have happened. The Bayh-Dole Act of 1980 was passed expressly to encourage the further development of federally financed, university-based basic research. Until then, a large proportion of basic university research was never “translated” into useful medical products. Such translation of basic research was recognized by Congress to benefit society not only by advancing the practice of medicine, but also by stimulating the overall economy. So industry was actively encouraged to take on the risk of developing promising ideas that came out of federally-funded research. And the profit that greeted successful enterprises was designed to be the one thing that would lure industry into taking that risk.

So when the Times “discovers” a company “profiteering” from work done with tax dollars, it should not be a revelation, nor should it be an unmistakable sign that the company is inherently evil or dishonest. Nor does the company’s activity in this regard give us a justification to arbitrarily restrict its profits. Rather, that’s simply the deal we taxpayers (through our elected officials) have made with the drug industry. We made this deal because we felt it would benefit American society, the American economy, American patients, and quite probably, us as individuals. Of course, if we want to change that deal now, it is within our rights to do so.

Without Bayh-Dole, perhaps patients with glaucoma would still be getting surgical therapy and wearing those coke-bottle eyeglass lenses instead of just using eyedrops. And if we wish to allow the Central Authority to put the brakes on such medical advances (ostensibly to prevent unseemly profiteering, but actually to stifle medical progress), we certainly can. It’s how covert rationing works.

But we shouldn’t vilify the drug companies for taking us up on the deal we offered them, back when we were thinking more clearly.

In a recent post, DrRich described the Regulatory Speed Trap, and alleged that our leaders (long before the Obama administration came along) have learned to use it to intimidate and control selected citizens and institutions when it is to their advantage to do so.

The Regulatory Speed Trap, readers will recall, involves the sudden and arbitrary “reinterpretation” of various confusing, ambiguous, or impracticable regulations which have been on the books for some time, and for which affected citizens and institutions (out of sheer necessity) have established de facto interpretations so that they can continue to function. By their longstanding acquiescence with these de facto interpretations, the Central Authority has at least tacitly endorsed them, and thus commerce is permitted to continue. Until, that is, the time arrives when it behooves the Central Authority to suddenly reinterpret those tangled regulations, and convert selected law-abiding citizens into criminals. By the selective enforcement of ambiguous laws, of course, the goals of Social Justice can be advanced.

As a public service, as a warning to academic medical centers, and as a heads-up to the Central Authority (which DrRich has found in personal encounters to be very scary, and to which he would very much like to endear himself against any future encounters) he will now describe a very serviceable but potentially forgotten Regulatory Speed Trap which was laid more than 15 years ago, and which is ripe for springing.

During the decade of the 1990s, DrRich was chairman of the Institutional Review Board (IRB) in a major teaching hospital. The IRB is the committee that reviews all proposed human research projects in the institution, and assures that the research meets ethical and legal standards as set forth by the Office of Human Research Protections (OHRP) of the HHS, and that the rights and welfare of the human research subjects are protected. The IRB has the duty and the authority to prevent or shut down any research project which is not meeting expected standards. The IRB, unlike any other committee within a hospital, reports directly to the Feds, in order to limit any local influence that may be brought to bear over its decisions by hospital administration, well-endowed researchers, or any other local big wigs.

If the Feds decide that an institution’s IRB is not assuring compliance with all the rules, regulations, guidelines, &c., in all their particulars, then they can arbitrarily and indefinitely terminate all human research in that institution, until such time that sufficient corrections, and sufficient penance, can be made – a process that is typically measured in years. This kind of research “death penalty” – which can ruin an academic institution – has been dealt out more than once.  The prospect is a dreadful one to any academic medical center.

It was, in fact, in his capacity as IRB chair that DrRich first became reasonably adept at reading and interpreting the kinds of obtuse regulations and guidelines commonly promulgated by our government. The official documents under which an IRB must operate are many, lengthy, and often difficult to interpret with absolute surety. Yet, in order for the IRB to function, these regulations and guidelines must be resolved into concrete meanings, which, under scrutiny, would most likely prove acceptable to the Feds. (A difficult task to be sure, but still, not markedly different from the task faced by anyone who wishes to conduct an activity for which the government has devised regulations.)

In any case, readers will understand why it was with some dismay that, in 1994, DrRich received this letter from the OHRP, announcing a new policy regarding diversity in human research.

Now to be sure, such a new policy was needed, since up to that time medical research evaluating new therapies was overwhelmingly performed on adult white males. However, this distribution of the benefits (and risks) of research was not in place because of prejudice against (or in favor of) women or non-whites. Rather, it was there for good and practical reasons. Ever since the thalidomide fiasco, it was verboten to enroll women who might become pregnant (i.e., any woman of childbearing age) in most kinds of clinical research. And African-Americans were understandably and appropriately distrustful of medical researchers ever since the Tuskegee study, and as a group they assiduously avoided participating in clinical research. So the exclusion of these groups was made, for the most part, either out of the desire to protect certain classes of individuals (such as unborn babies), or out of the desire of certain groups of individuals to protect themselves.

Still, DrRich was very sympathetic to efforts to find ways of safely extending research on new products to excluded groups. Otherwise, how could we learn if new medical products were safe and effective in everybody? So he read the letter from the OHRP with interest.

And he was immediately dismayed. While the government’s new policy of diversity in clinical research was advanced for the best of intentions,  the substance of the policy was impracticable past the point of absurdity.

The new policy on diversity in clinical research, in its essentials, stipulated:

1) All minorities and all genders MUST be included in all clinical research studies.
2) Sufficient numbers of subjects MUST be enrolled to allow valid outcome statistics to be performed for each category of participant.
3) Cost is NOT allowed as an acceptable reason not to enroll the stipulated groups in sufficient numbers.

The letter and its supporting documents defined six racial and ethnic categories that must be included: Hispanic or Latino, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, Black or African American, or White.

The letter and its supporting documents defined the three genders that must be included as: Male, Female, Indeterminate or Transgender.

Because each defined subgroup must be included in each study in sufficient numbers to allow for valid outcome statistics to be computed, the new directive seemed to require each research trial to expand its size by 18-fold (to account for six racial/ethic categories, and three genders). So a study which would normally require the randomization of 1,000 patients to achieve statistical surety would now need to enroll 18,000 patients. Notably, the recruiting effort that would be needed to comply with this new policy would be far more than merely 18 times more difficult. For it is one thing to find an “extra” 17,000 people who are willing to risk their health for the sake of medical science, but quite another to find these altruists in just the right distribution, including, for instance, 1,000 indeterminately-sexed Pacific Islanders.

But no matter. The new policy explicitly stipulated that the expense of such a recruiting effort was not a permissible excuse for failing to enroll the proper distribution of subjects.

After carefully examining the letterhead of this document to make sure it did not come from The Onion, DrRich made some well-placed, but gentle and appropriately circumspect, inquiries in an attempt to determine whether he was reading it correctly. How seriously must one take this astounding new federal policy on diversity in research? He quickly learned he needed to stop asking questions. His sources revealed to him that several of the authorities in question actually considered their new directive to be a bit mild – a little too watered-down.

For instance, limiting the number of racial and ethnic categories to only six had been a major concession to practicality. Some of the interest groups that had been instrumental in constructing this new policy apparently had argued, for instance, that each of the 337 federally-recognized American Indian tribes ought to be called out as distinct groups. And the authors had thoughtfully compressed the number of genders to only three (when clearly there are at least four). So the people responsible for this new policy had already carefully considered the issue of practicality, and had mercifully compromised in order to render this policy as reasonable as the principles of research diversity would allow.

So yes, the Central Authority was deadly serious.

As it happened, at this very time DrRich was lodged in the teeth of another Regulatory Speed Trap (which he has described elsewhere), so he took this new OHRP policy very seriously. He knew that while it could not be complied with in all its detail, it also could not be ignored. So he called a special meeting of the IRB to discuss how to respond to the new policy.

A long meeting was held in which this new policy was introduced to the membership, and the members’ reactions were permitted to move through the necessary stages of mirth, horror, disbelief, resignation, and finally, resolution. When sober discussion was finally possible, the members unanimously agreed that encouraging the enrollment of women and minorities in clinical research was an important and laudable goal. We also agreed that if researchers were made to comply with the letter of this new policy, all clinical research in the U.S. would come to an immediate halt. And for this reason, we concluded, it must be true that the policy actually desired by the OHRP must be different from what appeared to be the letter of this policy.

We therefore composed a formal response to this policy, which we placed into the minutes of the meeting, for posterity, and for the benefit of whichever future government agents might burst through the doors with automatic weapons, in order to conduct unspecified investigations. That response went something like this:

Medical research aimed at reducing mortality and limiting pain and suffering is a great boon to mankind, and as long as it is conducted ethically it should be encouraged in every way. Diversity in research is also an important good, and to the extent it is practicable, individuals from all races and genders should be offered an opportunity to participate in clinical research. In deciding which of these laudable goals takes precedence, we note that while research can continue despite imperfect diversity, it will not continue if perfect diversity is an absolute requirement – in which case, one ends up with no research, and no diversity. Such a result, we hold, cannot possibly be the aim of the OHRP.  It therefore seems apparent to the committee that the intent of the diversity policy recently handed down by the OHRP must necessarily be to optimize diversity to the fullest extent practicable, and not to stifle research altogether in service to impossible diversity goals. We therefore interpret this new policy to indicate that all practical efforts must be made to recruit research subjects from all racial and ethnic groups, and from whichever genders we can find, and we will hold researchers in this institution to that policy.

And that’s just what we did.

Our formal interpretation of the OHRP’s diversity policy, it must be admitted, did not follow what certainly appears to be the letter of the policy. But it does work toward the stated intent of the policy, and it has the not-inconsiderable advantages of: a) being actually feasible to implement, and b) allowing medical research to continue. In general, DrRich has found that regulators are somewhat more inclined to look upon your behavior as being relatively benign, if you are able to demonstrate that you have taken their regulations seriously (no matter how absurd they might be) instead of simply disregarding them. Accordingly, our IRB created a record demonstrating that we explicitly acknowledged the new policy, we made a good-faith effort to interpret it in light of universally-recognized truths, and then we acted in accordance with that reasonable interpretation.

DrRich does not know how all the other IRBs in the U.S. responded to this new diversity policy. However, since no institution has stopped doing research on its account, and since no institution has launched massive programs to seek out the tens of thousands of transgender Alaskan Natives that would be required in order to conduct medical research under such a policy, one can only conclude that all those other IRBs also decided not to follow the new diversity policy to the letter. DrRich does not know how many of them took the trouble to make a formal record of their interpretation of that policy, and of their rationale justifying their subsequent behavior. In any case, by the studied inaction of the Central Authority, those interpretations have been allowed to stand for well over a decade, and medical research has proceeded accordingly.

DrRich left the practice of medicine – and the wonderful world of IRBs – at the turn of the millennium. He has no idea how big a deal the issue of “diversity in research” is these days. But to the best of his knowledge the OHRP policy has never been rescinded. Indeed, DrRich finds it extremely unlikely that, at any time during that interval, it would have been politically feasible for any government agency, under any Administration, to soften this or any existing formal policy on diversity.

Most likely, after 17 years, this Regulatory Speed Trap is still set, and waiting to be sprung.

As it happens, the Central Authority today is desperately looking for ways to stifle medical progress, since medical advances are among the chief drivers of increased medical spending. The 1994 diversity policy, whose clear-cut plain-English language is being so universally ignored by medical researchers in every American institution, would seem to offer a fine opportunity for shutting down some of that research.

This Regulatory Speed Trap is not only set and baited, but is swarming with potential victims. Fair warning.

DrRich deeply, humbly, sorrowfully and most abjectly apologizes.

When one fancies himself an ironist, a satirist, one must be very, very careful. The ironist attempts to illustrate the limitations of a point of view with which he or she strongly disagrees, by purporting to adopt that point of view, and then taking it to its logical and outlandish extremes, in order to demonstrate how absurd it is at its root. But the irony only works when the people who actually hold that absurd point of view would somehow be brought up short, or embarrassed, or angered by it.

“That’s not what we’re saying at all!” is the response the ironist hopes to elicit. Because once the opponents make that response, it then becomes their obligation to attempt to explain  exactly how their point of view does not logically lead one to such absurd, counterproductive, or stupid conclusions. And, if the ironist is correct, his opponents will be unable to do so, and will be left with name-calling, labeling, and vituperation – which, by any objective measure, is a form of capitulation.

And judging by the names he has been called, the labels that have been hung upon him, and the vituperations with which he has been pasted, DrRich has generally been quite satisfied with the results of his occasional attempts at irony and satire.

But his most recent effort has failed, and failed badly, and for this he is most grievously regretful.

For, no sooner had DrRich penned his most recent post patiently explaining why Governor Christie is simply too fat to run for president, than sundry Progressives (the very target of DrRich’s badly misjudged piece) began publishing exactly the same opinion, using the same arguments which DrRich had considered to be the fruits of irony. In fact, one or two of them actually predated DrRich’s publication date. (Had he known this, he would have aborted his effort altogether.)

Regular readers will know that DrRich has long railed against the demonization of obesity, and has liberally employed irony to do so. By ostensibly supporting those who would cast the spirits of fat people into herds of swine, DrRich has (until now, he thought) effectively shown the moral bankruptcy of the anti-obesity movement.

The anti-obesity movement, DrRich thinks, is like many of the crusades which have been taken up by Progressives (for instance, the environmental movement and the deification of “diversity”), in that it takes what at its root is a good idea (in this case, the unhealthfulness of extreme obesity), and converts it into a sledgehammer with which to beat the populace into compliance with top-down, expert-driven controls over individual freedoms.

It is an unavoidable result of publicly funded healthcare that any behavior of any individual which increases the likelihood they will need “extra” healthcare services, will potentially rob those of us who do not choose such unhealthful behaviors of medical services which might otherwise be available to us. Therefore, when healthcare is entirely publicly funded, it is inevitable that individual behaviors will need to be controlled by some Central Authority.

The obese are the chosen first target for asserting such controls. To render those controls publicly acceptable, it is necessary to reduce obese individuals to a state in which limiting their individual freedom of action is widely considered acceptable. That is, they need to be demonized.

So we ignore that gross obesity is almost always genetically mediated, greatly enhanced by environmental factors largely out of an individual’s control. We choose to blame obesity entirely on a lack of self-discipline, on a fundamental failure of the individual himself, and we behave as if this failure renders fat people beneath contempt. We do not do this with smokers, or drug abusers, and even seem reluctant to do it with child molesters. But fat people are fair game.

So when DrRich said that Governor Christie is just too damned fat to be a candidate for president, because fat people are lazy, slothful, lethargic, and self-indulgent; and because allowing a fatty to aspire to such a high position would create the false impression that obese people are worthy of any consideration whatsoever, and would make people think that the obese ought to have the same individual freedoms as the rest of us; and when DrRich concluded that Christie’s candidacy would therefore be a serious setback to the Progressive program (which is to say, controlling individual behaviors for the great benefit of the collective); and when he therefore urged the Governor to stay in New Jersey, except perhaps to occasionally cross the state line just long enough to stock up on Philly cheesesteaks; he thought he had taken the thing to the outlandish extremes customary to a master of irony.

So imagine DrRich’s dismay when, just after publishing his diatribe, he saw Michael Kinsley’s article on Bloomberg also declaring Christie too fat to be president. The reason? Because “a presidential candidate should be judged on behavior and character, not just on policies.” Fat people, Kinsley elaborates, are a “perfect symbol of our country at the moment, with appetites out of control and discipline near zilch.” In other words, fat people have shown themselves, by their very obesity, to be entirely unworthy characters, and being unworthy, should not aspire to the presidency  – or presumably, to any other position of importance.

Then there’s Eugene Robinson of the Washington Post, who agrees that Christie’s weight should prevent him from running, but does so for kinder reasons than Kinsley’s. Robinson is worried about the Governor’s health. That’s kind of him, but he also can’t help remarking that the “obesity epidemic” is costing the government a lot of money, and indeed, he implies that people like Governor Christie are responsible for the massive federal deficit. Since Christie is likely to remain fat whether or not he runs for president, when one parses Robinsons’ sentences one can only conclude that his real argument is that it would simply be wrong for a person whose behavior is costing us so much money, and is thus endangering the future of the nation, to aspire to the presidency.

So there you have it. Actual Progressives are making the very same arguments for Christie to stay out of the race that DrRich made, in what he thought was a brilliantly ironic blog post.

DrRich’s description of how the obese are regarded is no longer an outlandish extrapolation of prior statements and policies. It’s now official. The party line on obesity is this: Fat people have chosen to become fat, and by so doing, have overtly displayed, for everyone to see, their utter lack of discipline, self-control, self-regard, and concern for their fellow citizens. So the obese have no reason to expect the same rights, privileges, freedoms and considerations enjoyed by us thinner (or at least, less fat) citizens.

DrRich unwisely tried to satirize the Progressive position on obesity, without realizing that this position had already “progressed” well beyond irony. His readers ought to expect more from him than this, and so he abjectly apologizes.

DrRich only asks his readers to please take into account, when you consider the Progressives’ actual behavior and their own words, how very difficult it is becoming to satirize them. DrRich may soon be reduced to straight reporting.

If we are ever to gain control of our healthcare spending, which is a necessity if we are going to avoid an economic catastrophe during the next couple of decades, we have to come to some agreement, as a society, on a few essential questions.  Chief among these questions is whether healthcare is something we must consider to be a right for all Americans.

The question of whether healthcare is a right has become a very contentious one. One side passionately declares that of course it is a right, as healthcare is so critically important that how could it be otherwise? And the other side, with equal conviction, asserts that nothing can be a right that creates an involuntary burden on another.

That is, advocates on either side of the argument maintain their respective positions as being axiomatic, as primary and irreducible truths – which does not allow much room for discussion or debate. So instead of dispassionate discussion, we get vituperation. For, when one’s opponent denies an axiomatic truth, he declares himself to be beneath contempt, and unworthy of any degree of respect.

Regular readers will know that DrRich is a peacemaker.  Accordingly, he will attempt an apology for each of these mutually exclusive, fundamentally principled positions. He will follow this by a description of the pragmatic (as opposed to principled) position on the matter taken by our current leaders. Then finally, humble as ever, he will offer the “real” answer to the question of whether healthcare is a right.

The Conservative Position

Conservatives (and in most matters, DrRich is among this lot) think of “rights” in terms of “natural rights,” that is, in terms of rights which accrue to every person by virtue of the fact that they are members of the human race. Natural rights are generally considered to descend from the Creator (as the Declaration of Independence explicitly says), or at the very least from the inherent nature of the universe, and thus are not subject to addition or subtraction by any human authority – such as by governments.

Because natural rights are granted equally to every human, it follows that there is no such thing as a right that imposes obligations or limitations on the natural rights of others.

A right to healthcare would most certainly require an abridgement of the rights of others, and so there can be no right to healthcare.

The Progressive Position

Most Progressives do not explicitly deny the existence of natural rights, because doing so would cause them embarrassment when they assert their own inherent and unalterable “truths” (such as the superiority of “diversity” over all other human virtues). However, at their core Progressives do not (and cannot) actually subscribe to natural rights, since the Progressive program virtually requires a Central Authority to assign and distribute and enforce various differential “rights” to various groups, in order to achieve social justice.  And achieving social justice is the central requirement for Progressives to reach their ultimate goal of a perfect society.

To Progressives, creating healthcare equality among all Americans is critical to social justice. And so, it becomes axiomatic for them that healthcare must be a right.

It becomes immediately evident that any such “rights” granted under the Progressive program will necessarily create involuntary obligations upon at least some individuals. So it is likewise immediately evident that any “right” for Progressives will fundamentally violate the essence of a “right” for Conservatives.

This impasse, which occurs at the very first step of the discussion, is what prevents Conservatives and Progressives from engaging in any fruitful discussion of whether healthcare ought to be a right.

The Practical Position (The BOSS Rule)

Our current leaders have taken a more practical position on the question of a right to healthcare. They rely on the fact that “rights” are often bequeathed not because of some overarching principle (as with Conservative or Progressive thought), but rather, because of issues of practicality – or more straightforwardly, because the sovereign authority has the desire and the power to do so. They point out that throughout human history innumerable “rights” have been promulgated by the expediency of raw power.

We need only consider, during the course of human events, such widely acknowledged rights as the exceptional rights of the aristocracy (especially the divine rights of kings), the unique rights of the clergy, or the special rights of the Politburo (or the Congress).  The fact is that all of these rights clearly imposed more-or-less oppressive obligations on, and limited the individual rights of, the people. But that is not the least matter of concern. Rights become rights because the exigent authority has the desire to create them, and the capacity to exert violence wherever necessary to enforce them.

In this light, one might say that healthcare is a right in America simply because of the BOSS rule (Because Obama Says So). If Obama says healthcare is a right (and he has said so, many times), and has the raw power to back it up, then, by God, healthcare is a right.

The Correct Position

It is easy to see why the “healthcare is a right” debate has become so contentious – people mean entirely different things when they use the word “right.” A right to a Conservative is a natural phenomenon, awarded equally to all people and fundamentally unalterable by human hands. A right to a Progressive is an essential social construct, enumerated by enlightened leaders, which is necessary to further the principle of social justice. And to some non-ideologues a right is whatever the sovereign authority says it is.

To DrRich, none of these constructs are useful to solving our current problem of healthcare spending.

The Conservative position – that because healthcare cannot possibly be a natural right, therefore there is no right to healthcare – not only seems callous to a large segment of Americans, but (as DrRich will shortly demonstrate) is wrong. The Progressive and Practical positions – that healthcare is a right either because it is necessary to further the supreme cause of social justice, or simply because the Central Authority decrees it to be so – leave us in an untenable position when it comes to reducing healthcare spending.

That untenable position occurs because, when a “right to healthcare” is bestowed by the government, under either the Progressive program or the BOSS rule, that right is open-ended. It immediately takes on the characteristics of an entitlement, a grant bestowed on individuals by society because of the group to which they have been assigned (such as: citizens, residents, people over 65 years of age, a particular racial or ethnic group, etc.) That entitlement is to “healthcare” – that is, for whatever we can get the authorities (by whatever political maneuvering we choose to engage) to agree that “healthcare” includes, whether it is well-baby checks, artificial hearts, chemotherapy, extravagant end-of-life care, hair transplants, or cosmetic surgery. A right like this – an entitlement – is rarely taken away, or even limited, once granted. Entitlements are soon seen by their recipients (and by the vested interests that quickly spring up to defend those entitlements, such as the bureaucracy that regulates them, the companies that supply the products for them, and the healthcare professionals that administer them) as something that is owed forever, as a natural, God-given right, which can always be expanded, but never ever restricted.

DrRich, therefore, finds all these positions on a right to healthcare to be unhelpful. For this reason DrRich proposes a new position on a right to healthcare, a position which he humbly calls the Correct Position.

To wit: all Americans have an implied contractual right to healthcare. We have this right because we have long since entered into a contract under which, in exchange for implied considerations, we’re all paying for it.

Under the present healthcare system, a system we have devised over the past six decades through our duly elected representatives, every person living in the United States is sharing in the cost of healthcare for every person who receives healthcare. Since every American, in one or more ways, is paying for the healthcare of every American who receives it, every American has a just claim – a contractual right – to their fair share of that healthcare.

Let us list some of the ways in which Americans all share in the cost of all healthcare:

1) Anyone receiving a paycheck is subject to payroll deductions to pay for Medicare for the elderly and Medicaid for the poor.
2) Anyone paying income tax is paying higher tax rates to offset tax-deductible health insurance premiums purchased by businesses for their employees. (That is, employer-provided health insurance is subsidized by the taxpayer.)
3) Anyone buying products in the U.S. is paying higher prices to cover the healthcare costs of American businesses.
4) Anyone living in America is sharing in the massive societal burden we are creating by allowing healthcare spending to be passed off to future generations, by way of the national debt.

These costs, and more, are borne by everybody living in the U.S. And since all Americans are paying the cost of all healthcare – even the cost of so-called “private” health insurance – we all have a right, in the form a consideration under a contract, to claim some of that healthcare for ourselves. To deny this fact would void the contract.

It is important to note that this argument for a right to healthcare is fundamentally different from the arguments typically given. This contractual right is not “granted” to an individual by a beneficent society because of some inherent characteristic of the recipient, but rather, it exists solely because the individual is party to a social contract, created by the peoples’ representatives, under which healthcare is a consideration given in return for certain obligations the individual makes to society. Those obligations would include paying for the publicly-funded healthcare through taxes, and subjecting oneself to whatever limits to publicly-funded healthcare such a system requires in order to maintain societal integrity.

It is critical to understand that this kind of contractual right to healthcare enables us, legally end ethically, to set necessary limits on what we mean by healthcare. The “right” to healthcare is a contractual right, and not a natural right or an ethical requirement.  So, under that contract,  as in any contract between consenting parties, we have a duty to specify the limits of our mutual obligations, that is, to specify what we mean by “healthcare.” Furthermore, we have a duty to specify what we mean by “healthcare” in such a way that fulfilling the contract does not bring about national bankruptcy or otherwise cause societal destruction.

There would no longer be an obligation to provide individuals with every manner of available healthcare under all circumstances, but only to provide individuals with that level of healthcare which is provided as a public benefit to all other individuals, under the terms of the social contract. (An entitlement to healthcare, in contrast, traditionally is an open-ended promise in which “healthcare” comprises anything and everything one might think has any possibility of restoring every bit of health.)

To summarize, as DrRich sees it we have already created a contractual obligation to provide publicly-funded healthcare to all individuals, by virtue of the fact that we have burdened every individual in America with the cost of healthcare for anyone who is now receiving it. In contrast to the Conservative position, DrRich’s formulation recognizes a right that truly exists, by virtue of a contract that is unarguably in force, and that has been enacted over a long period of time through the offices of the people’s elected representatives. And unlike the Progressive position, DrRich’s formulation does not entrap us into an open-ended obligation to pay for all “healthcare,” however our collective sentiments may entice us to define that term.

We might as well own up to our responsibilities by openly recognizing : a) the universally-shared payments we all make to the cost of American healthcare: b) the right of all Americans to the considerations that arise from this universally-shared burden; and c) that it is right and proper for us to establish clear limits to the obligations borne by all the parties, as we must do with any legitimate contract.

The open recognition of this contractual right to healthcare will finally give us the framework we need for a public discussion on setting necessary limits on publicly-subsidized healthcare spending.

And this, DrRich most humbly submits, is the correct answer to whether healthcare is a right.

DrRich’s most recent post attempted to show how the creation of the Independent Payment Advisory Board (IPAB) – the panel created by Obamacare that (as President Obama himself indicates) will be primarily responsible for reducing the cost of American healthcare -  nicely illustrates the Progressive mindset. That Progressive mindset, DrRich maintained, is reflected in the degree of power and breadth of control granted to the IPAB, in the coercive process under which the IPAB was created and its powers granted, and in attempts to bind future Congresses from amending those powers.

DrRich did not imagine that Progressives would like his formulation very much. But as always, DrRich offered his analysis in the hope of engaging readers – friend or foe – in a fruitful exchange of ideas.

And accordingly, DrRich is gratified that the venerable blogger Shadowfax has seen fit to offer a pointed (though to be sure, rather brutal) rebuttal. While the nature of his rebuttal does not exactly invite a civil exchange, DrRich (in the spirit of furthering understanding amongst our mutual readers) will attempt to reply in a collegial manner.

Anyone who has read Shadowfax’s post will know that it would be all too easy for a back and forth to descend into heaped vituperations. Shadowfax begins his presentation, after all, with a scathing ad hominem attack on DrRich’s person. He speculates as to whether DrRich is a confabulist or a conspiracy theorist, and proposes, as the qualities which define DrRich, only the following: “laziness, ignorance, misinformation, or untreated paranoid psychosis.” Along the way DrRich becomes also a partisan hack, deceitful, hysterical, and a purveyor of fluff.

For several reasons, DrRich will not respond in kind. First, when he joined his high school debating team in 1965, one of the first things DrRich learned is that when one has induced his opponent into an ad hominem attack, one has already won the debate. Second, by virtue of his original post on the IPAB, DrRich started it – and when one starts it, one invites and ought to expect a vigorous response. Third, DrRich does not take this ad hominem attack at all personally, so does not feel compelled to return the favor. DrRich comforts himself with the knowledge that Shadowfax does not know him personally, and is confident that if he did, he would be entirely won over (as is everyone) by DrRich’s charm, his joie de vivre, his incisive humor, his charisma, and above all, his humility. And finally, DrRich chooses to view this personal attack clinically, as doing so makes it plain that by its very nature, Shadowfax’s reply is itself entirely illustrative of the Progressive mindset. (In other words, Shadowfax has inadvertently succeeded in reinforcing DrRich’s chief message.)

DrRich will return to this latter point in a short while.

For the record, DrRich does not attribute any negative personality or motivational traits to Shadowfax, and indeed, chooses to believe that he is basically a nice person. (Even if he did not believe it, DrRich would not say so. DrRich notes that Shadowfax is the parent of three children, and he would hate to have those tykes see their Dad publicly subjected to personal insults – despite the fact that Shadowfax neglected to consider the fragile sensibilities of DrRich’s own young ones before publicly besmirching his intellect, motives and psychological health.)

To his credit, the bulk of Shadowfax’s rebuttal (after having dismissed DrRich’s person as being beneath contempt) has to do with matters of fact, or rather, with matters of interpretation of fact. For DrRich thinks he and Shadowfax are surprisingly close on the facts themselves. It is in interpreting the implications of those facts that the difference appears.

And here is where DrRich must diverge for a moment to re-introduce his Theory of Progressive Thought. He has explained this theory at some length in the past, and subsequently has further developed it on several occasions. In so doing, DrRich has explicitly insisted that it is just a theory.  It is a proposed framework for explaining the multitude of difficult-to-explain behaviors we have witnessed from Progressives during the last 120 years. In laying out this theory, DrRich has invited one and all to point out its weaknesses, and to suggest a better theory if they have one. Since DrRich himself does not like the implications of his Theory of Progressive Thought – given that Progressives are now running the show – he will, as he has said more than once, be delighted to abandon it for a better theory, should one come to his attention. But in order to be designated a “better” theory, it will have to explain real-world Progressive behaviors even more effectively than does DrRich’s.

Contrary to Shadowfax’s accusations, DrRich does not impute negative motives to Progressives. Indeed, fundamentally Progressives are motivated by a deep desire to achieve societal good. They are dedicated to achieving a society in which all people – whatever their disadvantages and limitations may be – will thrive equally, or as equally as possible. DrRich stipulates that this goal is inherently a good one.

Furthermore, Progressivism being a product of the Age of Reason, Progressives sincerely believe that such a goal is within the reach of mankind. It can be achieved by careful observation, analysis, and rational solutions systematically applied. And therefore it ought to be the goal – rather, it ought to be the duty – of mankind to strive to thus implement effective solutions to society’s problems. And so, Progressives believe that the goal of mankind ought to be to continually progress toward solutions to ALL society’s problems, and hence to strive unrelentingly for a “perfect” society.

And that’s the theory. Contrary to Shadowfax’s accusation, there is no imputation of evil motives in this theory. Indeed, Progressives, as a group, tend to be motivated primarily by compassion for their fellow humans – at least as a starting position.

Unfortunately for everyone, there are two major problems inherent in Progressive thought. First, the rational analyses and the carefully planned solutions to society’s ills which are prescribed by Progressivism are almost always beyond the ken of your average member of the great unwashed. So designing and implementing the Progressive program inevitably relies on a cadre of “specialists,” a class of elites who have the right stuff (the right intelligence, the right education, the right knowledge, the right motivation, &c.) to do the job.

Thus the rational solutions to society’s problems which are offered up by the Progressive program are inevitably to be provided by an enlightened corps of elites, and accordingly, it is the duty of the average citizen (i.e., the rest of us) to cooperate with these handed-down solutions, for the overriding benefit of the whole. Otherwise, the Progressive program cannot succeed.

This fact places Progressivism fundamentally at odds with the Great American Experiment, that is, with a system of government which at its core maximizes the autonomy of we individuals to do as we please, and which allows us to succeed or fail based on our own actions, to the extent that our actions do not infringe on the rights of others. Thus, there is a natural and unavoidable tension between the kind of broad, centrally planned solutions which Progressivism inevitably offers up, and the severely limited sort of central authority provided by our founders.

The second great problem with Progressivism is even more intractable. It is that the kind of societal solutions dreamed up by Progressives invariably require individuals to sacrifice their freedom of action, to one degree or another, for the sake of what the elite planners have determined will benefit the collective – and in so doing, Progressive solutions always seem to require a fundamental change in human nature. That is, the Progressive program requires individuals to subsume their own individual interests to the interest of the collective.

Such a change in human nature will never be forthcoming, and this fact, in the end, will always defeat Progressivism (though often not before a lot of damage is done). Inevitably, the recalcitrance of substantial proportions of the population to their brilliant solutions drives Progressives, once they have been in power for a while, to great frustration, and finally, to drastic repressive action. A history of collectivist governments during the past 100 years amply demonstrates this ugly fact.*

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* According to R.J. Rummel in his book Death by Government, during the 20th century the world’s governments killed four times as many of their own people, on purpose, as were killed in all wars combined.
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With this brief review of DrRich’s Theory of Progressive Thought (and its implications), let us now quickly visit the differences in how DrRich and Shadowfax view the facts as they pertain to the IPAB.

Is the IPAB designed to function as a dictatorial entity? Shadowfax argues that since it will not be utterly impossible for Congress to overturn the mandates handed down by the IPAB, it is therefore not dictatorial. And from a strict definition of the word he is correct. But DrRich holds that the language of the law (which, to halt the IPAB mandates on healthcare spending, requires a supermajority of the Senate to a) block those mandates, then b) come up with its own cost cutting scheme that will achieve equivalent results),  is meant to achieve for the IPAB at least near-dictatorial powers. Even Shadowfax allows this possibility: “The argument is that the IPAB becomes a de facto dictatorial board, because the bar is set too high to override its recommendations. We will see, I suppose.” This unelected panel* of experts will determine who gets what, when and how, and it will be exceedingly difficult (but admittedly not impossible) for Congress to have much to say about it. Therefore, Obamacare explicitly attempts to severely limit the prerogatives of the peoples’ representatives to control the ability of this unelected panel of experts to determine the medical destiny of Americans.

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* Contrary to Shadowfax’s unnecessarily gratuitous implication, DrRich has not referred to the multitudes of expert panels created by Obamacare as “death panels.” To do so would make DrRich seem as unsophisticated as Ms. Palin. Rather, DrRich has referred to them by the much more accurate name of GOD Panels (Government Operatives Deliberating).
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Is the IPAB designed to be an immutable panel? The plain language of the law very clearly attempts to render it exceedingly difficult (if not impossible) to change the IPAB provisions of Obamacare, thus revealing a wish on the part of its creators to render the IPAB an immutable entity. DrRich agrees with Shadowfax that, in truth, no Congress can actually bind all future Congresses down into perpetuity. But the language of the law clearly expresses a desire to do so. Shadowfax makes some sort of argument to the effect that the phrase “It shall be out of order” gives Congress a pathway to changing the IPAB provisions. And it is true that, under Roberts’ Rules, when a chairman declares some procedure to be “out of order,” there are provisions for appealing that ruling and rendering the thing back into order. But this provision is almost exclusively used to determine whether a member can speak or not. In contrast, the immutability language in Obamacare purports to create a LAW (rather than an ad hoc chairman’s ruling), which declares any action to alter the IPAB to be perpetually “out of order.” DrRich can find no parliamentary procedure addressing this remarkable and audacious circumstance.

In any case, even if the immutability language pertaining to IPAB turns out indeed to be something that can be by some manner overcome, as Shadowfax insists, that fact is not obvious. It has also escaped at least some U.S. Senators, who have interpreted the language the same way that DrRich has. And whatever the parliamentary options that may or may not come into play, the clear intent of the language in this provision is to greatly reduce the ability of future Congresses to alter the IPAB provision (if not actually render it immutable). Once again, this attempt is perfectly consistent with the all-consuming desire of Progressives to implement their expert-controlled programs with only minimal interference from the people (or the peoples’ representatives).

Does the IPAB already have the power to restrict private as well as government healthcare expenditures? Here, Shadowfax appears to concede the point, more or less, and adds that the idea “strikes me as a GOOD thing.”  DrRich has described in great detail how and why our Progressive healthcare reforms will inevitably restrict (and is already attempting to  restrict) the ability of individuals to pay for their own healthcare with their own money. And now, the IPAB (this very powerful and nearly-immutable panel of experts) has apparently been granted the authority to take charge of this important goal.

The bottom line, regarding these points of fact, is that DrRich and Shadowfax disagree less on the fact themselves than on the implications of those facts. We differ greatly on whether these features of the IPAB – dictatorial (or quasi-dictatorial) powers, immutability (or quasi-immutability), and the power to restrict private healthcare spending – are good things. Shadowfax explicitly believes that they are.

DrRich’s view, of course, is that these legislated features of the IPAB are perfectly consistent with, and even predicted by, his Theory of Progressive Thought. And that was indeed the whole point of his original post. Furthermore, based on the recent history of collectivist governments and where they invariably lead, DrRich does not believe this to be a good thing.

Before ending, DrRich must return to the ad hominem attack launched against him by Shadowfax which, DrRich submits, also perfectly reflects the Progressive mindset.

Almost invariably, once the Progressive elite have settled upon their scientifically-based, rational, centralized solution to some dire societal problem (such as healthcare reform), their thinking regarding the unwashed masses goes through a stereotypical evolution. At first they always believe (their proposed solution being so scientifically sound, so logical and so well-thought-out), that by delivering a carefully packaged explanation of their solution, the people will enter into paroxysms of delight.  When the people do not react as expected, and indeed express apprehension or anger at what is being proposed, the Progressives will tell themselves that they must not have explained their solution well enough (but what can one expect, after all, when dealing with the great unwashed?) – and then they will arrange to implement the solution anyway (using whatever machinations and maneuverings are necessary to pull it off), confident that once the teeming masses see the incredible benefits that will accrue to them when the program is actually under way, they will at last display those belated paroxysms of delight. But then, when the program is actually implemented and the people are still complaining about it – or more likely, making their complaints more than merely vocal – the Progressives will begin culling out some of the more prominent troublemakers among them and make examples of them. And if that fails to quell the complaints of the masses, the leaders of collectively-oriented governments have been known to move past disappointment and frustration and into a state of wrath – and this (again, DrRich is simply referring to history) is where the real atrocities have taken place.

The evolution of the Progressives’ frustration regarding the public’s acceptance of Obamacare has moved past the “we can educate them” phase, and past the “we’ll go ahead and implement it and then they’ll like it” phase. They will soon be looking for someone of whom to make an example.

Traditionally, they will diagnose such troublemakers as being either misinformed (stupid), motivated by bad intentions (evil), or mentally deficient (crazy). And (again, historically), the solution to which the dissenter is subjected depends on that diagnosis – typically a re-education camp, elimination, or commitment to a state-run mental institution.

DrRich simply notes that Shadowfax has reacted with distressing typicality to a loudmouth who is not going along with the program. He indicates that the only possible explanations for DrRich’s recalcitrance (since a logical objection is not a possibility) are “laziness, ignorance, misinformation, or untreated paranoid psychosis.” That is, DrRich must be stupid, evil or crazy. It only remains for Shadowfax to decide on which of these diagnoses is correct, so that the appropriate final solution can be prescribed.

DrRich stands by his original contention that the salient features of the IPAB, the manipulative and underhanded process which brought it to life, and now, the reaction of Progressives when they encounter people who complain about it, all perfectly reflect the Progressive mindset.

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This is the third in a series of articles on End-of-Life Care and Covert Rationing.  The first two articles can be found here and here.
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In his previous post, DrRich attempted to satirize the lame attempts of certain payers to “inform” certain of their “covered lives” that, among all the wonderful options available to them under their truly comprehensive health plans, the medical service of physician-assisted suicide would be compassionately offered and cheerfully paid for. DrRich even offered, thoughtfully as usual, some free though invaluable advice to payers on how they ought to go about marketing assisted suicide as a cost-saving strategy, and to do so in a far more sensitive and less ham-fisted way than they have managed so far.

If the mark of good satire is that at least some readers will have difficulty discerning whether the satirist is serious or not, then DrRich is feeling genuinely Jonathan Swiftian today.  For some of his readers (one of whom e-mailed, “I can’t believe what I just read. This is sick.”) have taken his modest proposal for selling assisted suicide at face value.  This is not the first time DrRich has made unfortunate impressions upon readers through his (possibly inept) use of irony. Sadly, it almost certainly will not be the last.

But assisted suicide being such an important and ethically charged topic, DrRich feels obligated to clear things up once and for all. So what follows is DrRich’s honest assessment of the advisability of physician-assisted suicide, in which he will attempt to forgo entirely any satire or irony (though he admits to having great difficulty in controlling his sarcasm).

DrRich believes that physician-assisted suicide is a very, very bad idea.  He has two major reasons for this belief.  On a purely practical realm, embracing and systematizing physician-assisted suicide under any healthcare system that is actively engaged in rationing (whether overtly or covertly) will almost surely lead to some terrible abuses of the practice. In this regard you can either use your imagination, or read the history of Europe in the first half of the 20th century.

His second objection to physician-assisted suicide is based on a consideration of ethics. DrRich admits to being on shaky ground here because: a) he is not formally trained in ethics, and b) it appears for all the world that those who are formally trained in ethics have universally concluded that physician-assisted suicide is perfectly OK in every way.

Debating with modern medical ethicists, at least if you are merely a layperson, is mostly a losing proposition.  This is not because ethicists are intellectually (or even ethically) superior, but rather because they are adept in couching their arguments in arcane twists of logic and webs of jargon that make their arguments difficult if not impossible for the uninitiated to follow.  This technique, of course, places novices like DrRich in the position of having little choice but to accept the ethical bottom line without really understanding how the bottom line was reached. It reduces medical ethicists to a priesthood, and medical ethics to received knowledge.

But DrRich maintains that advancing unintelligible ethical arguments is, well, unethical.

So DrRich will now present his understanding of the chain of logic by which modern ethicists justify physician-assisted suicide – and its close cousin, euthanasia.  (If any of you actual ethicists out there object to this analysis, and can explain where DrRich is wrong in clear language, DrRich will be all ears. Absent the clear language, though, you can pound salt.)

Modern ethicists argue as follows:

Point 1: Our society has already decided that the autonomy of the individual patient is the overriding ethical consideration in making end-of-life decisions. We formalized this determination when we decided – by overwhelming consensus – that an individual has a right to refuse medical treatment even if that treatment is very likely to save their life. Therefore, individual autonomy is the universally agreed-upon controlling ethical precept.

And in adopting this controlling precept, we have already firmly decided that passive euthanasia – allowing nature to take its course by withholding treatment at the request of the patient – is ethical.

Point 2: There is no ethical distinction between passive euthanasia and active euthanasia. That is, whether we let death occur by withholding effective medical care, or by actually doing something to help death along a bit, we’re taking an action that hastens death either way. Ethically, both of these actions are equivalent. So, once we decide that individual autonomy is the overriding concern, we must also allow for active euthanasia when a patient wishes it.

Point 3: Once active euthanasia is deemed ethical, there can be no further ethical objection to the lesser act of physician-assisted suicide.  If it is ethical for a doctor him/herself to bring on the death of a patient who requests it, there can be no objection to doctors preparing the suicide machine and handing the patient the switch.

The striking thing here (to DrRich, at least) is that in establishing the ethical case for physician-assisted suicide, we necessarily also establish – as a veritable pre-condition – the ethical case for physician-provided euthanasia. Whether the patient says, “Help me to take my own life,” or “Take my life for me,” modern medical ethics supports the physician who replies, “Roll up your sleeve.”

For those who don’t see a problem with this, DrRich refers you to the Dutch system, where, in full accordance with modern medical ethics, the rules permit both physician-assisted suicide and active euthanasia for patients who request it. Reports on the results of the Dutch system (reports which both sides have used to bolster their respective opinions on either the glories or the travesties of such a system) do point out one striking finding – hundreds of times each year, acts of *involuntary* euthanasia are occurring. That is, patients are being killed under the Dutch healthcare system at the hands of their doctors, without their explicit permission. All these patients, it is claimed, are being euthanized for entirely humane reasons.

What do our friends the medical ethicists have to say about such involuntary euthanasia? Well, it turns out that it’s OK with many if not most of them. Ethicists don’t like to tell us that their chain of logic doesn’t end with Point 3.  But once we make the principle of individual autonomy the overriding consideration in determining end-of-life ethical issues, the same chain of logic takes us directly to Point 4.

Point 4: Since honoring the ethical precept of individual autonomy makes voluntary euthanasia available for patients with intractable suffering, it would be unethical to withhold the same benefit from suffering patients who are too incapacitated to give their permission. Their incapacity should not restrict them from a good that is available to others, for to do so would be discriminatory and inhumane. To cure this problem, the boon of active euthanasia can and must be performed, even without the patient’s explicit permission, in incapacitated patients whom “reasonable people” would agree are suffering too much. Therefore, involuntary active euthanasia is also ethical.

This conclusion, of course, leaves us in a place where others (i.e., “reasonable people,” like doctors or other agents of the Central Authority) can decide for an individual what constitutes intractable suffering, and further, can decide when such an individual is simply too incompetent to know that euthanasia is the best thing for them. Some of you, of course (hello, ethicists!) think this is just a fine idea. Most apologists for the Dutch system apparently do.

But DrRich maintains that under our system of covert healthcare rationing, where doctors are under extreme pressure to do the bidding of the third party payers (private insurers and the government) who determine their professional viability, and where the payers are under extreme pressure to reduce cost, and have already displayed in numerous ways their willingness to permit suffering and death among their subscribers in order to do so, then opening the door for physician-assisted suicide (let alone physician-administered euthanasia, whether the patient requests it or not), would inevitably lead to some nasty abuses, and would ultimately serve to undermine our civil society. DrRich is too politically correct to use the “other” N-word, but he will take this opportunity to remind his readers that such a thing has already happened, in what recently had been perhaps the world’s most cultured and educated society, within the memory of millions of living people.

DrRich believes that the principle of individual autonomy is vitally important, and indeed it is the foundation of American culture. However, no single ethical principle, no matter how important, can be allowed to overrule all other ethical principles in all other circumstances.  By nature, ethical precepts are often in conflict, creating what is called an ethical dilemma. And (DrRich humbly submits) it is supposed to be the job of ethicists to help us work through those ethical dilemmas, to find the right balance between competing principles, and not simply declare that no dilemma actually exists, because Ethical Precept A is the only one we need to pay attention to.

Individual autonomy is critically important to American culture – and the fact that we must fight to preserve individual autonomy in the face of covert healthcare rationing is indeed the underlying message of this blog – but in no other aspect of our culture do we let it absolutely rule. The autonomy of individuals needs to be checked, and we indeed limit it. This is the fundamental reason that governments are necessary in the first place.

The reason we have laws (supposedly) is to make sure that the behavior of individuals acting in their own interest, especially those who have accrued power (for instance, by accumulating great wealth, by acquiring large weapons, or by becoming heads of state), does not abrogate the natural rights of other individuals. Indeed, most of the political fights we have – between Democrats and Republicans or progressives and conservatives – are to determine where to place those limits, on individuals and on the collective, to best encourage a robust society that honors individual autonomy but that also encourages reasonably equal opportunities for individual fulfillment (i.e., “happiness.”) The main purpose of our public discourse, then, is to find the right balance between the rights and needs of individuals and the rights and needs of society as a whole.

So for ethicists to say, “Individual autonomy is all there is to it, and we have no choice but to follow that principle to wherever it may lead us,” is not only completely irresponsible and dangerous, it also flies in the face of our culture’s history and our everyday experience.  The cost to society not only should but must be taken into account as we consider institutionalizing physician-assisted suicide (let alone voluntary or involuntary euthanasia).  In DrRich’s opinion, ethicists who argue that we need not consider the cost to society in making end-of-life policy have declared themselves unworthy of the title and they ought to be completely ignored.

The cost to our society of institutionalizing and systematizing physician-assisted suicide, especially while we are still covertly rationing healthcare, would be severe and potentially lethal. Within the next decade or two, if things do not change, we likely will be facing cost pressures emanating from our healthcare system that will gravely threaten the survival of our culture. With an existential threat such as this, can we really refrain from slowly transforming the request for assisted suicide from an option to a duty? Can the Central Authority really stay its hand when it has the capability of directing its agents at the bedside to perform euthanasia on unfortunate (and unproductive) citizens who are too “incapacitated” to understand it’s the only thing to do?

DrRich, who opened this post with a promise to avoid irony, apologizes. For when all is said and done, it is deeply ironic that by steadfastly clinging to the ethical precept of individual autonomy at the end of life, within in a paradigm of covert healthcare rationing, we will very likely end up by completely devaluing the inherent worth of individuals.

At least until we solve the fiscal problems within our healthcare system, we simply should not embrace assisted suicide – no matter what we may think of the ethics of the act itself – and we should fight efforts to make it acceptable. The cost to our society would be far too high.

If people want to commit suicide and if medical ethicists insist that assisted suicide is OK, then let the ethicists do the assisting. DrRich has relatively little to say against ethicist-assisted suicide. But, at least as long as covert rationing is the chief operating principle of the American healthcare system, for the love of God keep the doctors out of it.

Having advanced his theory of Progressivism, and having shown how his theory explains certain behaviors on the part of Progressives that otherwise might be difficult to explain, DrRich now proposes to examine the question of the medical ethics of Progressivism.

This ought to be an important question to doctors, patients, and anyone who thinks they might someday become a patient. For, however else one might want to define “ethics,” for practical purposes a system of ethics fundamentally determines how one ought to act when one must act in the face of competing interests. And the healthcare system being rife with competing interests, ethical guidance is critical as we determine who is to get what, when and how.

Because ethicists generally attempt to devise a solution which balances, to some degree, the various competing interests (which all tend to have at least some merit), the field of ethics has become very complex to the uninitiated. Indeed, the arguments ethicists use to justify their positions are frequently so difficult to follow that professional ethicists all too often have been reduced to a virtual priesthood, dispensing their lofty wisdom from on-high.

But since truly ethical behavior requires more than merely following handed-down marching orders, and indeed, requires a certain amount of clarity as regards ethical precepts, DrRich has always considered the arcane work-product being offered up by most modern ethicists to be, well, unethical.

And this is where Progressivism, for all its faults, provides a breath of fresh air. For the chief ethical precept of Progressivism is an item of exquisite clarity, a bright, shining beacon that cuts through all the fog and fuzziness, and points the way.

To review, Progressivism (in DrRich’s formulation, at least) is the idea that the driving imperative of mankind is to devise the perfect society, that, indeed, the desired “progress” in Progressivism is the steady advancement toward that perfect society. The Progressive program is the natural result of the belief, most famously espoused by Aristotle, that man is inherently a social animal, an animal that naturally forms into complex societies; that individual men and women do not have much intrinsic worth as stand-alone units, but only as components of their larger group.

Furthermore, the Progressive program is to be driven by an intellectual elite, who will determine what does and does not advance the perfect society. This requirement for an elite leadership also derives from Aristotle, who recognized that most individuals within a society are incapable of perceiving the greater good, and if left to their own devices would return mankind to the ranks of the apes.

The Progressive program of steadily advancing toward a perfect society is much more than merely a desirable goal, it is an imperative; it is intrinsic to humanity itself. All other programs (libertarianism, conservatism, religions which emphasize the importance of individual salvation, &c.) are not only counterproductive to man’s true imperative, but are heretical.

And so Progressive ethics, if nothing else, are crystal clear: Anything that advances the Progressive program is ethical; anything that hinders it is unethical.

This general statement of ethics immediately implies two corollaries that more directly define what “right behavior” will look like:

Corollary 1) What is best for the collective is best for the individual. That is, since individual humans only achieve their humanity as a part of the greater whole, it follows that the chief obligation of any individual within a society is to act for the good of the collective.

Corollary 2) Since what is best for the collective is determined by the intellectual elite, it is the obligation of all individuals in a society to follow that elite.

With this summary of Progressive ethics, let us now turn to the question of medical ethics.

Classical medical ethics, from the time of Hippocrates, required the physician to always use his/her special training and special capacity for autonomous action for the benefit of the individual patient, and to place the needs of the individual patient above their personal needs. This requirement is what defined medicine as a classical profession.*

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* While the term “profession” has become diluted to include streetwalkers and football players, classically “the professions” were limited to physicians, lawyers and clergy, precisely because of this definition.
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But classical medical ethics cannot be permitted under a Progressive program. Allowing (much less encouraging) physicians to act autonomously for the good of their individual patients will necessarily conflict with that which is best for the collective. This is true because if the needs of the individual were to prevail, then patients who are lucky, smart or rich, and who have doctors who are particularly clever or aggressive, will get more than their fair share of the healthcare resources, leaving the collective wanting.

Accordingly, after years and years of dogged work, the Progressive agenda has succeeded very recently in changing the formal definition of medical ethics. In early 2002, a “new charter” of medical ethics was published in the Annals of Internal Medicine. This new charter has since been formally endorsed by every major medical professional organization in the world. It charges physicians with the ethical obligation of achieving a fair distribution of healthcare resources. Medical students worldwide are now being taught that their main ethical obligation is to work for distributive justice, their obligation to work for the optimal benefit of their individual patients is a secondary concern, because of Corollary 1.

DrRich has described elsewhere how this new medical ethics places patients in great jeopardy, and wrecks medicine as a true profession. But old farts like DrRich (who prefers to think of himself as a “classic” physician), who still care about such things, will be gone in a few decades and can be safely ignored.

(For those who are interested, DrRich had the opportunity earlier this year to engage representatives of the American College of Physicians – chief authors of the New Ethics – in a public debate over medical ethics in this very space. DrRich was, at the end of the day, brushed off by the ACP, but not before eliciting a response from the Chair of the ACP’s Committee on Ethics, Professionalism, and Human Rights. That response, in essence, was, “What is good for the collective is good for the individual, and any jack-dog knows this. Who the hell are you?” In other words she invoked Corollary 1. You can read all the details about the great Medical Ethics Smack Down in this series of articles.)

One might ask, what was the impetus for physicians to voluntarily change their time-honored ethical precepts?

They were coerced.

Significant coercion was being applied to doctors to place the interests of the third party payers – both insurance companies and the government – ahead of their duty to individual patients. The utter impotence of physicians in fighting off this coercion was the impetus for promulgating the new ethical precept (to society) in the first place. This fact was stated explicitly in a 1998 article by Hall and Berenson in the Annals of Internal Medicine (volume 128, p 395) which stated: “It is untenable for the medical profession to continue asserting an idealistic ethic that is contradicted so openly in clinical practice. . .,” and which called for a “new ethic” which was more consistent with how doctors were being forced to behave. Specifically, the proposed “new ethic” was a duty to the group.

This paper was an important impetus to formally changing professional ethics. When the new ethical standard istelf was finally published in 2002, its very first sentence began, “Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.”

In other words, physicians felt powerless to fight off the coercion – so in response they changed medical ethics to make it OK to cave in.

And to say it yet another way, physicians can now act under Corollary 2 with a clear conscience.

Accordingly, it is now become the physician’s ethical obligation – and not merely a legal or regulatory obligation – to follow to the letter the guidelines, processes, and procedures that are handed down to them from various government-established expert panels, when they are caring for their patients. Autonomous actions taken on behalf of individual patients is more than just discouraged, it is, simply, wrong.

Under our new program of medical ethics, then, doctors are absolved of much of the responsibility of clinical decision-making. As many of those decisions as possible – a continually increasing quantity of them as time goes by – will be determined centrally, at which point the doctor is ethically obligated to follow them.

DrRich continues to think this new program is harmful to patients and to the medical profession. He will bring up some specific issues in this regard in future posts.

DrRich has now read large portions of the “Patient Protection and Affordable Care Act,” i.e., Obamacare. He finds in it the very essence of Progressivism.  To understand Obamacare, then, we must understand the basics of Progressive thought.

DrRich has always found American Progressives to be a bit enigmatic. He has found much of their behavior to be persistently, almost defiantly, illogical and counterproductive to the rights Americans hold dear, rights which Progressives themselves also insist they revere – in particular, our inalienable rights to life, liberty and the pursuit of happiness.

As long as 20 years ago, DrRich had developed a sneaking suspicion that Progressives, their protests to the contrary notwithstanding, never really bought into the “inalienable” thing. On this point, he concluded, they were prevaricators. Since by then it was beginning to look like the Progressives were going to be running things for a while, it occurred to DrRich that it would be a good idea to understand what they really think, and what their agenda really was. And so, after much time and study and contemplation, DrRich developed his theory of Progressive thought, which he is now pleased to share with his readers so that they, in turn, might better understand Obamacare.

The Roots of Progressivism

When DrRich began his study of Progressives he did not quite know where to begin. So he decided to proceed, like Descartes before him, from the simplest and most irreducible of truths. Namely, that Progressives are really, really smart – or think they are. We know this because all the professors in all the best Ivy League schools are Progressives.

From this simple truth we can deduce that, whatever it is that Progressives are actually up to, it must have its roots in the writings of The Philosopher.

And sure enough, it was not at all difficult to discover the roots of Progressivism within the teachings of Aristotle.

Aristotle tells us that man is innately a political animal, an animal with an inherent propensity to gather into increasingly complex communities. The essence of man, according to Aristotle, is society.

The formation of complex societies is what defines mankind; it is what differentiates man from the rest of the animal kingdom. Hence, because man is defined by society, society is inherently on a higher plane of importance than the individual. Individuals are entirely beholden to and dependent upon and subservient to the society to which they belong. Indeed, they are defined as individuals by their place within that society. Without society, a man is just an ape (with a persistently infantile face).

In this sense, “socialism” is reduced quite simply to a philosophy in which society – the collective – takes precedence over the individual. Furthermore, the precedence of the collective over the individual is not something we can simply choose to accept or reject; it is the very essence of mankind. It is nature. It is just the way it is.

So, as you can see, Aristotle nailed Progressivism.

Clearly, while the name “progressivism” has only been around for a century or so (and we will shortly see from whence the name came), its roots are a very old idea. This idea, in fact, was the normal way of looking at the relationship between individuals and society until just a few hundred years ago, when humanists began to cautiously explore the radical notion that individuals (rather than the collective) constitute the fundamental unit of humanity. The new humanist heresy – which declared the primacy of the individual – was for a long time called “liberalism” (a term whose meaning has, recently, drastically changed, and is now a synonym for what had always been its opposite). Classical liberalism reached its zenith, DrRich thinks, a mere two and a half centuries after its painful birth, with the Declaration of Independence and the Constitution of the United States.

But to Progressives, classical liberalism has always been an aberration. Despite what America’s founding documents might say, society takes precedence over the individual. It takes this precedence by way of the very essence of mankind, as was taught by The Philosopher, and so it cannot be otherwise.

The Progressive Program

The Progressive Program – the thing that makes Progressives progressive – is to develop the perfect society. This program is not optional; it is dictated by the nature of mankind.

Since society is what defines mankind, it follows, as the night follows the day, that the program of mankind, the purpose, the work, the essence of mankind, is to create the perfect society.

The perfect society has two basic requirements. First, it must meet all the basic needs of the individuals within that society (such as food, clothing, shelter, sanitation, and health), without which individuals will always be tempted to engage in the counterproductive behavior of striving for things. Second, the social order must be of such a nature that it can persist, theoretically forever, without fundamental change. Indeed, the very notion of perfection implies that any change, of any type, is bad, since it will necessarily constitute a movement away from perfection.

The perfect society therefore requires complete stability. This would include (at a minimum) a stable population size, the preservation of natural resources and the earth’s environment (indeed, when one hears the word “sustainability,” one is listening to Progressive gospel), the careful management of the economy, and the careful control – if not suppression – of unplanned innovations. This latter refers both to material (or scientific) innovations, and innovations of thought, either of which will always threaten hard-won societal stability.

The perfection of society is the paramount work of mankind, so any method which may help in achieving this perfection is to be embraced; none discounted out of hand. The only considerations one must make in choosing methods of action are: Is this method practicable? And: Is this method more likely to be successful, or counterproductive? These two questions fully define Progressive ethics.

So that’s DrRich’s theory of Progressivism and the Progressive Program. While it is only a theory, DrRich hereby asserts that his formulation is correct.

He makes this assertion for the purpose of advancing the debate and inviting argument. If any of his readers have a better explanation of Progressivism, one that more successfully fits the facts and explains the otherwise difficult-to-explain behaviors we’ve seen from Progressives in recent years, why, DrRich will be delighted to hear it. If it is convincing, DrRich will cheerfully abandon his own theory and adopt yours.

But to accomplish this feat, your theory of Progressivism will have to offer a more successful explanation of the following Progressive behavioral phenomena than DrRich’s theory does:

Individuals and Groups Within Progressivism

While Progressivism by definition places individuals in a subservient position to society, this is not to say that individuals are merely interchangeable cogs in a great machine, or entirely analogous to worker bees in a hive. DrRich’s prior sarcasms aside, Progressive society is not the Borg.

Indeed, individuals within a Progressive society are differentiatable, and can be publicly celebrated or castigated as individuals. But to a great extent the potential worth of an individual is pre-determined by the group to which the individual belongs. Group identity in Progressive society is critically important, as it provides the only feasible means by which the leadership of Progressive societies can attempt to control and direct individual behaviors.

(Group identity is so critically important to Progressive thought that it has been given a special name – “Diversity” – and has been designated as the Cardinal Virtue, from which all the other, subsidiary, virtues – faith, hope, charity and the like – must necessarily spring.)

And so, to stand out as individuals, individuals must stand out as a member of their group, and the manner in which they stand out must fundamentally reflect the assigned essence of their group. So, for instance, Al Sharpton and Jesse Jackson are celebrated individuals, whose accomplishments nicely reflect their assigned group identities. In contrast, Clarence Thomas and Thomas Sowell are not celebrated by Progressives, and indeed are castigated as abominations, because their individual accomplishments do not reflect their assigned group identities.

Therefore, while individuals within Progressive societies can achieve a certain level of importance, individual importance is merely of tertiary concern, rather than primary or even secondary concern. Individuals can become officially “important” only if their importance reflects the essence of their assigned group; and the importance of the assigned group (the secondary concern), in turn, is proportional to its ability to advance the Progressive Program in general (which, of course, is the primary concern).

While individuals have the potential of rising to a state of importance within Progressivism, the vast majority of individuals will never actually do so. The great masses of individuals will be regarded by society as featureless members of their group, and will be treated accordingly. And the status of a particular group is always subject to change, given the extant needs of the leadership class. Certain groups (e.g. labor unions) may be exulted by the leadership, while others (e.g. the elderly, the white males, or the fat) will be devalued. Yet other groups (e.g. illegal aliens) may be celebrated by the leadership at one point in time (when, for instance, it behooves Progressive leaders to acquire voting rights for them before 2012), but then may be dismissed at some other point in time (in 2013, for instance, after the critical votes have been gathered, and now the group just represents large volumes of mouths to feed and healthcare to consume).

Good and Evil In Progressivism

Many Progressive intellectuals are fond of saying there are no absolutes, and so there is no such thing as inherent good and inherent evil. These intellectuals are wrong, even from within the Progressive paradigm. Because the Progressive Program – which, again, is to achieve a perfect society – is the innate agenda for mankind, there indeed exists a standard by which one can determine good and evil.

“Good” is anything which advances the Progressive Program; and “evil” is anything which threatens it.

Anyone who doubts the existence of good and evil within the Progressive Program need only observe the scores of behaviors and figures of speech which are condemned as unrelentingly evil by Progressives, with all the certainty and fervor of a Jonathan Edwards.

Accordingly, individuals who hinder the Progressive Program are a danger to mankind’s very essence. They are evil, and must be rehabilitated or eliminated.

Progressivism and the Leadership Class

Despite its lip service to the contrary, Progressivism is not egalitarian, even in theory.

The duty of mankind is to strive for the perfect society. The chief tool by which mankind is to achieve this program is man’s intellect and logic. It is axiomatic that only a minority of people will have the intellect and logic necessary to direct the program of mankind. Therefore, Progressivism fundamentally relies on an elite corps of individuals to guide our progress toward a perfect society. The perfect society will not just happen, it must be engineered by those who are gifted enough to lead.

The lack of egalitarianism in Progressive thought is illustrated by the special treatment accorded to the elite corps. The leadership class must be nurtured and valued by society. Furthermore, it must be given special privileges which others in society do not have. Because their work is so critical to the essential program, the elite must be removed from worry over the mundane necessities of life. That is, providing the leadership class with certain luxuries and privileges, and even freedom from having to follow all the rules that apply to the masses, is therefore not hypocrisy, but is an essential good. It redounds to the benefit of the Program.

Anyone who has not noticed recent glaring examples of this “different standard” for the Progressive elite should consider activating their “durable power of attorney” forthwith, so that a more alert individual can manage their affairs.

Progressivism and the Unwashed Masses

It goes without saying that, if left to their own devices, the populace would devolve into some primitive societal arrangement (such as capitalism) in which individuals would spend all their time striving to improve their own individual situations, even at the expense of others.

This means that the great unwashed masses must be “managed.”

Ideally, the best way to manage the population is through education, and so all efforts must be made – through formal education and by controlling the public media – to indoctrinate the population to the great benefits of the Progressive agenda, to the natural duty and obligation of all men and women to work within society to realize the Progressive Program, and to the inherent evil of all the alternatives. Since education will never be sufficient, the unwashed masses may need to be controlled through pacification (i.e., attempting to meet all their basic needs, so as to eliminate their impulse to strive). If this fails, they must be controlled through coercion, intimidation, peer-pressure, or (as a last resort or to serve as an object lesson) violence.

Fundamentally, the Progressive Program relies on all members of the great unwashed to subsume their own individual needs to the needs of the collective. That is, the Progressive Program requires a fundamental change in human nature. This change will never be forthcoming, and so Progressives are apparently doomed to be frustrated in their efforts. (However, as we will see shortly, Progressives ultimately have the answer to this problem, as well.)

So, despite their frequent hymns of praise to the worthiness of the common man, Progressives invariably develop an underlying contempt toward the unwashed masses. It is not difficult to spot this contempt if one is alert to it.

Progressivism and Politics

Under the Progressive Program, just like Aristotle says, mankind is essentially a political animal. In fact, the Progressive Program can only be achieved by political action. This means that politics – and to be clearer, political control – is the fundamental work of Progressives. Without politics, without political control, there is nothing. To lose political power is oblivion.

This attitude toward politics is in stark contrast to the attitude of conservatives, for whom government (and therefore politics) is merely a necessary evil, with which one must occasionally contend, when it cannot be avoided, as a part of life. For most conservatives politics is an afterthought.

For Progressives, politics is everything, the essence of human behavior. And it is worth any cost, any desperate measure, to maintain political control. Indeed, to fail to lie, cheat and steal in order to keep political control would be unethical.

Progressivism and Religion

Progressives have a natural adversity to organized religion. For one thing, religions tend to give a higher priority to some supernatural entity (and worse, to an afterlife), than to mankind’s “true” imperative, which is to achieve a perfect society right here on earth. However, since religious leaders can be readily coerced to serve the needs of the state (and always have been), this is not an insurmountable problem.

The real difficulty with organized religion is that the major ones stress the importance of the individual (since individual salvation, or individual enlightenment, is the major theme of the big religions). Under progressivism the inherent importance of individuals is necessarily subsumed by the importance of the collective, so by focusing the ultimate meaning of life on the individual, traditional religions become a major threat to Progressivism.

Apparently realizing that abolishing religion is far too difficult a task, Progressives have adopted the long-term strategy of infiltrating and co-opting religious establishments, and by means of introducing new ideas – such as group salvation, and the concept of social justice as a religious imperative – rendering religion, this “opiate of the masses,” less incompatible with the Progressive Program.

Progressivism and Eugenics

Since World War II, the enthusiasm with which Progressives publicly embrace the idea of eugenics has become muted. But eugenics is, in fact, inherently bound to Progressivism. One way or another, a perfect society will require far more perfect citizens than we have today. Indeed, the seething contempt with which Progressives regard the current genetic pool that comprises the unwashed masses is often difficult for them to suppress.

To a large extent, modern Progressivism was born as an offshoot of Darwinism. The idea that society could be perfected, and the idea that mankind could be perfected, were two sides of the same notion. And early Progressives unabashedly embraced both of these ideas, such that the idea of “culling the herd” became extraordinarily attractive to them – and they said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger (the founder, as it happens, of Planned Parenthood) are only the most well-known Progressives who extolled the idea of eugenics.

But public support of eugenics among Progressives has become quite subdued, ever since the Nazis committed their atrocities explicitly in the name of achieving societal perfection.

One can argue, of course, whether the recent Progressive support of such activities as late-term abortions, or creating human embryos for experimentation, are partially aimed at desensitizing the public for future efforts to “guide” a more favorable genetic makeup for the population. Either way, DrRich reminds his readers of the history of Progressivism in this regard, and of the inherent attractiveness of eugenics to the Progressive Program, and urges them to remain alert.

Progressivism and Environmentalism

Radical environmentalism and the Progressive Program are not perfectly compatible. But they are close.

Radical environmentalists believe that humanity is a plague upon Planet Earth. Everything man has done since the day he first learned to cultivate crops (and thus for the first time became a different kind of animal) has been bad. And anything which delays, halts or reverses the sins mankind has perpetrated upon sacred Gaia, since that day he first departed from Nature, is a good thing. So the radical environmentalists are in favor of strong central governments which will control the behaviors of individuals (and which might ultimately drastically reduce or eliminate the human population).

Progressives are certainly on board with controlling man’s effect on the environment, but (in most cases) they are not in favor of returning mankind to a hunter/gatherer condition (since most Progressives do not view this condition as the embodiment of a perfect society). Rather, they view the environmental movement – in particular, the Global Warming Theory – as a good way to get the populace to give them the power they need to carry out their Progressive Program. So Progressives have completely embraced the Global Warming Theory as a means to their own political end. Accordingly they have declared man-made global warming to be settled science, and they suppress any efforts to study it further.

DrRich is very sorry about this. He suspects that global warming is happening, and concedes that human behavior may be playing a role, and is saddened that this scientific question has been absorbed into the Progressive agenda in such a way that we are not allowed to find out what’s really going on.

Progressivism and the Great American Experiment

Unlike any other nation in the history of mankind, the United States was not founded because of geography, race, religion or ethnicity. It was founded on an idea. It was founded on the still-radical idea that individual autonomy – the individual’s God-given right to life, liberty, and the pursuit of happiness – is the chief Fact of humankind, and that the only legitimate role of government is to create an environment in which individuals can enjoy those rights to the fullest extent possible.

One can see immediately that the Great American Experiment – which awards primacy to individual autonomy – is fundamentally incompatible with Progressivism. But because a majority of Americans still like the ideas expressed in the Declaration of Independence, the Progressives need to play their cards close to their chests. They need to proceed carefully – but relentlessly.

By slowly re-interpreting the Constitution, and slowly addicting a critical mass of Americans to an array of government programs, Progressives are certain they will ultimately prevail. They have been at it for over 100 years, and have come a long way. DrRich cannot tell whether or not we have already passed the Event Horizon, the point beyond which restoring the Great American Experiment will become impossible. But we are at least very close.

In fact, one plausible theory for President Obama’s headlong pursuit of programs and policies which anger the majority of Americans, and which gravely and immanently threaten the political control which is the center of the Progressive universe, is that he sees America as being at the very cusp of that Event Horizon, and believes that one last, small push will gain it, and make the Progressive Program irreversible, whatever might happen in the next election or two.

Progressivism and Healthcare

DrRich does not need to say much about Progressivism and healthcare right now. Many of the posts in this blog have pertained to this very question, as, undoubtedly, will many more.

But to really understand the current American healthcare system, and to understand Obamacare (the future American healthcare system), it is necessary to understand Progressivism. DrRich sincerely hopes that this current post will help a few of his readers understand, if not Progressive thought itself, at least DrRich’s conceptualization of it.

This week, the Archives of Internal Medicine published four (four!) articles assaulting the legitimacy and the importance of the JUPITER trial, a landmark clinical study published in 2008, which showed that certain apparently healthy patients with normal cholesterol levels had markedly improved cardiovascular outcomes when taking a statin drug.

Superficially, at least, the JUPITER study appears to have been pretty straightforward. Nearly 18,000 men and women from 26 countries who had “normal” cholesterol levels but elevated C-reactive protein (CRP) levels were randomized to receive either the statin drug Crestor, or a placebo. CRP is a non-specific marker of inflammation, and an increased CRP blood level is thought to represent inflammation within the blood vessels, and is a known risk factor for heart attack and stroke. The study was stopped after a little less than two years, when the study’s independent Data Safety Monitoring Board (DSMB) determined that it would be unethical to continue. For, at that point, individuals taking the statin had a 20% reduction in overall mortality, a dramatic reduction in heart attacks, a 50% reduction in stroke, and a 40% reduction in venous thrombosis and pulmonary embolism. All these findings were highly statistically significant.

This study is noteworthy because it is the first large randomized trial to show that taking a statin can markedly reduce the incidence of some very nasty cardiovascular outcomes in people who are considered to have “normal” cholesterol levels. (Notably, typical LDL cholesterol levels among primitive hunting/gathering cultures is around 50 mg/dL, instead of the 100 – 120 mg/dL we consider to be normal. These primitive folks have an extremely low incidence of cardiovascular disease, so maybe humans’ optimal cholesterol level is much lower than we now think. On the other hand, the low risk of cardiovascular disease among hunters/gatherers may instead be related to the fact that many of them are consumed by various species of carnivores before they’re 30.)

To be sure, the JUPITER trial was far from perfect. Because of its design, it could not (and did not) tell us whether the beneficial outcome is specific to Crestor, or is a class effect of all statins (which seems very likely). It did not tell us whether reducing CRP levels is itself beneficial, or even whether using CRP as a screening tool is actually helpful. (The people enrolled in this trial tended to have several other risk factors, such as being overweight, having metabolic syndrome, and smoking, and it is not clear how much additional risk elevated CRP levels really added in this population.) And this trial did not tell us the risks of lifelong, or even very long-term, Crestor therapy.

But JUPITER did tell us something that is very useful to know, and with a very high degree of statistical surety: Giving Crestor to patients similar to the ones enrolled in this study can be expected to result in significantly and substantially improved cardiovascular outcomes, and in a relatively short period of time.

If medicine were practiced the way it ought to be – where the doctor takes the available evidence, as imperfect as it always is, and applies it to each of her individual patients – then the incompleteness of answers from the JUPITER trial would present no special problems. After all, doctors never have all the answers when they help patients make decisions. So, in this case the doctor would discuss the pros and cons of statin therapy – the risks, the potential benefits, and all the quite important unknowns – and place the decision in the perspective of what might be gained if the patient instead took pains to control their weight, exercise, diet, smoking, etc. At the end of the day, some patients would insist on avoiding drug therapy at all costs; others would insist on Crestor and nothing else; yet others would choose to try a much cheaper generic statin; and some would even opt (believe it or not) for a trial of lifestyle changes before deciding on statin therapy. In other words, there is a range of reasonable options given the limitations of our knowledge, as there often is in clinical medicine. As time goes by, more scientific evidence is often brought to bear and clinical decisions can become more informed. But whatever the state of the evidence, doctors and patients can generally get by without violating too severely any ethical or medical precepts that would cause objective and neutral observers to complain very much.

But in recent years, and especially now, as we bravely embark on our new healthcare system, this is not how doctors will practice medicine. Instead, they will practice medicine by guidelines. These guidelines (which, in modern medical parlance, is a euphemism for “directives”) are to be handed down from panels of experts, identified and assembled by members of the executive branch of the federal government.

And this makes the stakes very high when it comes to a clinical trial like JUPITER. For guidelines do not permit a range of actions tailored to fit individual patients (consistent with the uncertainties inherent in the results of any clinical trial). Instead, guidelines will seek to take one of two possible positions. That is, under a paradigm of medicine-by-guidelines, the results of clinical trials generally cannot be permitted to remain imperfect or nuanced or subject to individual application, but must be resolved by a central panel of government-issue experts into a binary system – yes (do it) or no (don’t do it). In the case of JUPITER, the guidelines must decide whether or not to recommend Crestor to patients like the ones enrolled in the study, at a potential cost of several billion dollars a year. It should be obvious that the answer which would be more pleasant to the ends of the central authority, and  by a large margin, would be: No, don’t adopt the JUPITER results into clinical practice.

However, the expert panels which are called for by our new healthcare legislation have not been formulated yet, and we are still operating under the “old” rules. So, still subject to all the duress which is created by unfortunately-resolved clinical trials like this one, the FDA, somewhat reluctantly, approved the use of Crestor for JUPITER-like patients in late 2009. That approval, of course, is subject to review by the new expert panels, whenever they are assembled.

This, DrRich submits for your consideration, is likely what instigated the almost violently anti-JUPITER issue of the Archives this week. DrRich theorizes that what we’ve got here is a bunch of wannabe federally-sanctioned experts, auditioning for positions on the expert panels. What better way to get the Fed’s attention than to let them know that you are of the appropriate frame of mind to assiduously seek out scientific-sounding arguments to discount the straightforward and compelling, but fiscally unfortunate, results of a well-known clinical trial?

Of the four papers appearing in this week’s Archives, three are more-or-less legitimate academic articles that make reasonable points, but do no harm to the main result of JUPITER. The fourth is a straightforward polemic, which has no place in a peer-reviewed medical journal, and whose very presence, DrRich believes, very strongly suggests that the editors of the Archives themselves must be auditioning for the Fed’s expert panel.

So as not to bore his readers any more than necessary, DrRich will make short work of the three reasonably legitimate articles in this issue. One pointed out that JUPITER did not tease out the real importance of CRP levels, or whether lowering those levels is useful. This is true, but that fact does not touch the main conclusion of JUPITER. Another article was a meta-analysis which incorporated several other primary prevention trials using statins, and concluded that there is no overall benefit to statins in primary prevention patients. Aside from the usual problems inherent in meta-analyses, a) the JUPITER study looked at a specific population of primary prevention patients not addressed by these other studies, and b) since JUPITER is the first study to show a benefit in using statins for primary prevention, it is a foregone conclusion that if you assemble enough of the previous, negative studies and lump them together with JUPITER in a meta-analysis, you will be able to dilute the results of JUPITER sufficiently to achieve an overall negative result. Actually doing such a meta-analysis, then, is merely an exercise in math, not in revelation.

The third article criticized the JUPITER DSMB for stopping the trial earlier than originally planned. The DSMB, however, had no real choice in the matter – ethically or legally – given the striking statistical significance of the benefit seen with Crestor. When a patient signs an informed consent agreement to participate in a clinical trial, part of that “contract,” a part required by law, is the statement to the effect that if information comes to light during the course of the study that might impact a patient’s willingness to continue participating, that information must be made available. The fact that the Crestor branch of the study was found to have markedly improved survival, fewer strokes and heart attacks, etc., than the placebo branch, clearly constitutes such information. Stopping the study when they did was not “premature;” continuing the study would have been illegitimate. This is why independent DSMBs exist in the first place – to protect the rights and welfare of the research subjects under the fiduciary agreement that comprises informed consent.

The fourth article is more striking (and more fun) than the other three. Interestingly, it is categorized by the Archives as an “Original Investigation,” despite the fact that it describes no investigation of any kind whatsoever – original or derivative. It merely revisits the data from JUPITER (in a spectacularly biased manner), and offers a spate of ad hominem attacks, alleging bias to the point of corruption, without any supporting evidence, against JUPITER’s sponsor, its investigators, and most astoundingly, the chair of the DSMB (who is a well known and highly respected figure, especially known and revered for his complete objectivity and lack of bias). If such an article has any place at all in a peer-reviewed medical journal – which DrRich doubts – it ought to be clearly labeled as an opinion piece, and not as a piece of original research. Whatever it may be, it’s not that.

But the most delicious aspect of this fourth article is that two of its authors, including its lead author, are members of a fringe medical group known as The International Network of Cholesterol Skeptics (THINCS), whose stated mission is to “oppose” the notion that high cholesterol and animal fat play a role in cardiovascular disease. Members of THINCS also take an extraordinarily strong position opposing statins for any clinical use whatsoever. (One might actually assume that, since JUPITER shows that cardiovascular outcomes can be improved by statins in people with normal cholesterol levels, the THINCS would embrace the study as evidence that perhaps cholesterol is not as important as it’s cracked up to be. But apparently, this argument is completely negated by the fact that statins were the vehicle for making it. Many in the anti-statin crowd would object to statins even if they were proven to cure heart disease, cancer, baldness, and obesity AND produced fine and durable erections upon demand.)

The best part of all this is that the astounding anti-cholesterol, anti-statin bias of the authors was not disclosed in their article – whose main thrust, again, was to criticize the disclosed biases of the JUPITER investigators.

The excellent Pharmalot blog noted this irony, and contacted Rita Redberg (editor of the Archives) and Michel de Lorgeril (THINCS-master and prime author of the fourth article) to ask them why the association with THINCS was not disclosed.

Redberg:

“I’m not clear this is an undisclosed conflict. The policy mentions a personal relationship that could influence one’s work. I think that could be a big stretch. My initial impression is the group has an intellectual message, but doesn’t fit as a personal relationship that could effect the authors’ work.”

de Lorgeril:

“[While it is] very important to disclose financial [emphasis DrRich's] conflicts of interest that can influence our way of working and thinking about cholesterol and statins, there is so far no obligation to provide a CV each time we publish any thing…May I underline the fact that being a member of THINCS – not a group of terrorists, mainly a club of very kind retired scientists with whom I have interesting and open discussion – is not a conflict of interest?”

DrRich may be old fashioned, but he thinks that being a member of an “out there” group like THINCS, which appears to advance selected and distorted data on its website aimed at furthering its stated mission of “opposing” (not investigating or questioning) the cholesterol hypothesis and the use of statins, might make one prone to a bit of bias when writing a broadside critiquing a study like JUPITER, and loudly criticizing anyone associated with that study for their bias. This sort of bias (demonstrably rooted in a willingness to select/ignore/distort data in order to make a preconceived point) is likely to be as strong as any that might accompany, for instance, receiving a stipend from a statin company for participating in clinical research. Membership in THINCS may not preclude one from writing such an article, but DrRich thinks the association at least ought to be disclosed, just as financial relationships must be disclosed.

DrRich has a hard time explaining how this can happen with a prestigious medical journal like the Archives. But like Sherlock Holmes says, when you have eliminated the impossible (such as, the idea that this article deserved to be published in its current form), whatever remains, however improbable, must be the truth.

And this is why DrRich can only conclude that several of the authors appearing in this week’s issue of the Archives of Internal Medicine, along with its editor, are in the mode of ingratiating themselves to the sundry officials and czars within the Obama administration who will be assembling the expert medical panels, those panels which will be making the momentous decisions that will determine the flow of hundreds of billions of dollars, and (forgive me) of life and death.

We wish them the best of luck in their audition, and will be monitoring the memberships of the new panels with interest, to see if any of our new friends are ultimately successful.

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DrRich critiques more arguments for withholding Crestor here.

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_Sources:

_{de Lorgeril M, Salen P, Abramson J, et al. Cholesterol lowering, cardiovascular diseases, and the rosuvastatin-JUPITER controversy. A critical reappraisal. Arch Intern Med. 2010; 170:1032-1036.}

_{Kaul S, Morrissey RP, Diamond GA. By Jove! What is a clinician to make of JUPITER? Arch Intern Med. 2010; 170:1073-1077.}

_{Ray KK, Seshasai SRK, Erqou S, et al. Statins and all-cause mortality in high-risk primary prevention. A meta-analysis of 11 randomized controlled trials involving 65 229 participants. Arch Intern Med. 2010; 170:1024-1031.}

_{Green L A. Cholesterol-lowering therapy for primary prevention. Still much we don’t know. Arch Intern Med. 2010; 170:1007-1008.}

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DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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DrRich’s Independence Day Address to his Loyal Readers:

DrRich has always found it fascinating that the television show, “House MD” has remained so popular for so long. After all, Gregory House embodies the polar opposite of what we all say we want in a modern physician. House may be brilliant, but he’s antisocial, arrogant, sloppy and rude. He holds his patients in contempt, and considers them to be mentally deficient, or prevaricators, or both. He will take any action he deems necessary, however illegal or immoral it may be, to make sure his patients get whatever medical interventions he has determined they need, whether they (or anyone else) likes it or not.

And when he does what he does, the individual autonomy of his patients never, ever enters his mind.

Given that House extravagantly violates his patients’ autonomy whenever he can find any excuse to do so, joyfully proclaiming his great contempt for them and their individual rights, then why is his story so popular in America and around the world?

DrRich believes that the answer to this question ought to remind us of the fundamentally precarious nature of individual autonomy within our healthcare system, and within our culture.

Individual Autonomy in Medicine

Maintaining the autonomy of the individual patient has become the primary principle of medical ethics. And medical paternalism, whereby the physician knows best and should rightly make the important medical decisions for his or her patient, is supposed to be a thing of the past.

It has been formally agreed, by medical ethicists all over the world, that patients have a nearly absolute right to determine their own medical destiny. In particular, unless the patient is incapacitated, the doctor (after taking every step necessary to inform the patient of all the available options, and the potential risks and benefits of each one) must defer to the final decision of the patient – even if the doctor strongly disagrees with that decision. Hence, the kind of behavior which is the modus operandi of Dr. House should be universally castigated.

The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics, of course, is entirely consistent with the Enlightenment ideal of individual rights. This ideal first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this ideal culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy – or to put it in more familiar terms, individual freedom – is the foundational principle of our culture, and it is one that is perpetually worth fighting and dying to defend.

So the idea that the autonomy of the individual ought rightly to predominate when it comes to making medical decisions is simply a natural extension of the prime American ideal. It is obvious, most think, that this ought to be the governing principle of medical ethics.

Dr. House: The Champion of Beneficence

But unfortunately, it’s not that easy. There’s another principle of medical ethics that has an even longer history than that of autonomy – the principle of beneficence. Beneficence dictates that the physician must always act to maximize the benefit – and minimize the harm – to the patient. Beneficence recognizes that the physician is the holder of great and special knowledge that is not easily duplicated, and therefore has a special obligation to use that knowledge – always and without exception – to do what he knows is best for the patient. Dr. House is a proponent of the principle of beneficence (though he is most caustic and abrasive about expressing it). DrRich believes House is popular at least partly because the benefits that can accrue to a patient through the principle of beneficence – that is, through medical paternalism – are plain for all to see.

Obviously, as “House MD” nicely illustrates, the principles of beneficence and of individual autonomy will sometimes be in conflict.  When two worthwhile and legitimate ethical principles are found to be in conflict, that is called an ethical dilemma. Ethical dilemmas are often resolved either by consensus or by force. In our culture, this dilemma has been resolved (for now) by consensus. The world community has deemed individual autonomy to predominate over beneficence in making medical decisions.

DrRich’s point here is that Dr. House (the champion of beneficence) is not absolutely wrong. Indeed, he espouses a time-honored precept of medical ethics, which until quite recently was THE precept of medical ethics. There is much to be said for beneficence. Making the “right” medical decision often requires having deep and sophisticated knowledge about the options, knowledge which is often beyond the reach of many patients. And even sophisticated patients who are well and truly medically literate will often become lost when they are ill, distraught and afraid, and their capacity to make difficult decisions is diminished. Perhaps, some (like House) would say, their autonomy ought not be their chief concern at such times. Indeed, one could argue that in a perfect world, where the doctor has nearly perfect knowledge and a nearly perfect appreciation of what is best for the patient, beneficence should take precedence over autonomy.

Why Autonomy Predominates

In this light it is instructive to consider just how and why autonomy came to be declared, by universal consensus, the predominant principle of medical ethics. It happened after World War II, as a direct result of the Nuremberg Tribunal. During that Tribunal the trials against Nazi doctors revealed heinous behavior – generally involving medical “research” on Jewish prisoners – that exceeded all bounds of civilized activity. It became evident that under some circumstances (circumstances which were extreme under the Nazis, but which are by no means unique in human history) individual patients could not rely on the beneficence of society, or the beneficence of the government, or even the beneficence of their own doctors to protect them from abuse at the hands of authority. Thus, the ethical precept which asks patients ultimately to rely on the beneficence of others was starkly revealed to be wholly inadequate; and indeed, invites horrific results. Thus the precept of individual autonomy won out not because it is so inherently superior, but by default.

Subsequently, the Nuremberg Code of medical ethics was drafted and formally adopted worldwide. The Nuremberg Code officially declared individual autonomy to be the predominant precept of medical ethics, and the precept of beneficence, while also important, was declared to be of secondary concern. Where a conflict occurs between these two ethical precepts, the patient’s autonomy is to win out.

Again, this declaration was not a positive statement about how honoring the autonomy of the individual represents the peak of human ethical behavior. Rather, it was fundamentally a negative statement: Under duress (the Nuremberg Code admits) societies (and their agents) often behave very badly, and ultimately only the individual himself can be relied upon to at least attempt to protect his or her own best interests.

House vs. Autonomy and the Great American Experiment

DrRich will take this one step further: when our founders made individual autonomy the organizing principle of a new nation, they were also making a negative statement.

From their observation of human history (and anyone who doubts that our founders were intimately familiar with the great breadth of human history should re-read the Federalist Papers), they found that individuals could not rely on any earthly authority to protect them, their life and limb, or their individual prerogatives. Mankind had tried every variety of authority – kings, clergy, heroes, philosophers and professors – and individuals were eventually trampled under by them all. In the spirit of the Enlightenment, and because everything else had been tried many times and had failed, our founders declared individual liberty to be the bedrock of our new culture.

There is an inherent problem with relying on individual autonomy as the chief ethical principle of medicine, namely, autonomous patients not infrequently make very bad decisions for themselves, and then they – and their loved ones, and sometimes society – have to pay the consequences. The same occurs, of course, when we rely on individual autonomy as the chief operating principle of our civil life. The capacity of individuals to fend for themselves – to succeed in our competitive culture – is not equal, and so the outcomes are decidedly unequal. Autonomous individuals often fail – either because of inherent personal limitations, bad decisions, or bad luck.

So whether we’re talking about medicine or society at large, despite our foundational principles we will always have the temptation to return to a posture of dependence – of relying on the beneficence of some authority, in the hope of achieving more overall security or fairness – at the sacrifice of our individual autonomy.

In DrRich’s estimation the popularity of “House MD” is entirely consistent with this very strong tendency. Indeed, he thinks, the writers are compelled to make Dr. House as unattractive a person as he is, just to temper our enthusiasm for an authority figure who always knows what is best for us and acts on that knowledge, come hell or high water. If a figure such as Dr. House was also a compelling personality and had a gift with words, he would become almost Messianic – far too dangerous a prospect for a television program.

Those of us who defend the principle of individual autonomy – and the economic system of capitalism that flows from it – all too often forget where it came from, and DrRich believes this is why it can be so difficult to defend. We – and our founders – did not adopt it as the peak of all human thought, but for the very practical reason that ceding ultimate authority to any other entity, sooner or later, guarantees tyranny. This was true in 1776, and after observing the numerous experiments in socialism we have seen around the world since that time, is even more true today.

Individual autonomy will always be a very imperfect organizing principle, both for healthcare and for society at large. Making it an acceptable principle takes perpetual hard work, to find ways of smoothing out the stark inequities that will always result, without ceding too much corrupting power to some central authority. This is the Great American Experiment.

Those of us who have the privilege of being Americans today, of all days, find ourselves greatly challenged. But earlier generations of Americans faced challenges that were every bit as difficult. If we continually remind ourselves what’s at stake, and that while our system is not perfect or even perfectable, it remains far better than any other system that has ever been tried, and that we can continue to improve on it without ceding our destiny – medical or civil – to a corruptible central authority, then perhaps we can keep that Great American Experiment going, and eventually hand it off intact to yet another generation, to face yet another generation’s challenges.

________________________________

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DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

Part 3 of Limiting Individual Prerogatives
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DrRich could go on and on about how our government is intent on restricting the right of individuals to spend their own money on their own healthcare, but (for now, at least) this will be the final post in this series. DrRich has made his point.

Even some of his critics, who have accused DrRich in the past of being overly paranoid on this topic, seem to have gotten it. Some who previously were quite vocal have remained suspiciously silent. Others have fallen back to quasi ad hominem accusations (suggesting, for instance, that DrRich must be a follower of Mr. Beck, with all the horrific connotations that condition entails). And then there is the esteemed Praveen (author of the excellent True Cost Blog), who conceded as follows: “Massachusetts’ attempt to ban direct pay is both unfortunate and unconstitutional. Perhaps you’re right, and the bureaucrats are sneakier than I think.”

So maybe DrRich should just declare victory and move on.

But it is important to make one final point, namely: the notion that our government is intent on limiting our individual healthcare prerogatives is far more than just one of DrRich’s theoretical constructs. Indeed, our government has been acting on this intent for over 15 years. The main case in point, of course, is Medicare.

It has always been recognized that every American citizen “is the proper guardian of his own health,” (Supreme Court Justice Joseph Story, 1873), and accordingly, has a natural right to employ his own individual resources to that end. Roe v. Wade, for instance, was a particularly explicit recognition that a woman has a fundamental right to purchase medical services which she determines to be necessary for her own well-being.

Indeed, when Medicare became law in 1965, Congress also explicitly recognized this right, stipulating that nothing in the new law “shall be construed to preclude [an individual] from purchasing or otherwise securing protection against the cost of any health services.” (DrRich reminds his readers once again that a bold, restrictive statement like this, appearing in legislation, generally heralds an outcome opposite to the statement itself.)

DrRich has already pointed out that under Hillarycare, private medical practice would have been nearly criminalized out of existence. So one ought to expect that the Clinton administration would view an individual right to purchase healthcare as a threat. And indeed, it did. But, as it happens, the erosion of the rights of Medicare “beneficiaries” began even before the Clinton administration. (And even again, DrRich must remind his readers that any universal healthcare plan, even under a Republican administration, will always tend to limit individual liberties.)

In 1991, Medicare administrators published a “carrier bulletin” warning physicians that direct-pay contracts between patients and doctors were strictly prohibited, unless the contract was initiated solely by the patient, and even then, payment rates must be set by Medicare, and further, if the patient later became dissatisfied with that (patient-initiated) contract, Medicare would severely (and retroactively) sanction the physician.

When physicians sued Medicare to prevent this odious new policy from being implemented (Stewart et al. v. Sullivan), the government took the position that it had, in fact, not made any new policy after all, arguing that stuff that shows up in its “carrier bulletin” doesn’t really count. But once this argument was successful in having the lawsuit thrown out in a summary judgment in 1992, Medicare then cynically turned around and immediately made that selfsame new policy “official,” by publishing it in their 1993 Medicare Carrier’s Manual.

But the Feds were still not satisfied. The new, restrictive policy technically still allowed private-pay contracts, as long as the patient initiated them. So the Clinton administration engineered an amendment to the Balanced Budget Act of 1997 – Section 4507 – which prohibited any self-pay contracts whatsoever between Medicare patients and their doctors for medical services which are covered under Medicare. Under Section 4507, which is still the law today, if a doctor provides even one self-pay medical service to a single Medicare patient, that doctor is punished by complete banishment from the Medicare program for at least two years.

The federal government was eventually challenged again in court over Section 4507, but that lawsuit was also thrown out in a summary judgment. The rationale the government offered to the court in justifying its restrictions on individuals’ prerogatives, however, is instructive: “…what you will have is a system whereby the rich can buy what they want and those many beneficiaries who are on fixed income will not be able to afford those services” (United Seniors Association et al. v. Shalala). So again, the interest of the collective (“social justice”) was invoked to justify a law which stifles an individual’s fundamental right to purchase medical services he or she determines to be necessary for his/her well-being.

In any case, since 1997 Medicare patients have been able to purchase Medicare-covered services for themselves ONLY if they obtain that service from a doctor who agrees to opt out of Medicare entirely. This severely limits a patient’s opportunity to self-pay for covered services. The fact that Medicare patients can still buy these medical services from direct-pay physicians, however, is one reason the government hates direct-pay practices, and wishes to stamp them out. More importantly, while some primary care physicians have indeed opted out of Medicare in order to establish direct-pay practices, this path is not a realistic option for medical specialists. So in practical terms, the only “covered services” available for self-pay by Medicare patients, on even a limited basis, are primary care services.

There are several legitimate reasons a Medicare patient might want to self-pay for a medical service that is covered by Medicare. If Medicare “covers” heart valve surgery, for instance, a patient might want to pay for a new, minimally-invasive surgical approach that is inadequately reimbursed by Medicare, rather than the big, open-heart surgery that Medicare reimburses fully. Or, one might want to self-pay for “covered” psychiatric care, or for treatment for a venereal disease, in order to keep embarrassing or harmful medical records out of government-controlled databases.

Furthermore, it is important to recognize that just because a healthcare service is “Medicare-covered” does not mean that it will be covered for a given patient. Whether a specific individual is covered is often determined by a “medical necessity” ruling, made by a bureaucrat. Section 4507 essentially precludes a patient’s ability to purchase a denied (but “covered”) medical service, no matter how badly they want it, or believe they need it.

One can argue, and with some merit, that at this juncture denials of medically necessary services by Medicare have been relatively judicious, and therefore that the “Section 4507 rule” has not had much of an actual impact. In fact, it is likely that most Medicare beneficiaries do not even know that this rule exists.

But while its impact might be relatively small so far, the Section 4507 rule has now been in place for 13 years – it is well-established. So, once Medicare begins reducing reimbursements to physicians and hospitals, to the point where they can no longer afford to offer certain services to Medicare patients (and Medicare has just recently begun doing so, specifically, for some cardiac imaging studies), those patients will be left in the cold. Services which are officially “covered” by Medicare, but which are reimbursed at such a low rate that they cannot actually be provided to them, will become unavailable even to Medicare patients who are willing and able to pay for those services.

DrRich’s main point, once again, is that our government has a deep and abiding need to limit our individual prerogatives when it comes to our healthcare, and has been acting on that need for a long time. The principle for these limitations on our individual liberties, the principle of social justice, has already been established, and has survived court challenges.

Extending these limitations on personal liberties to Obamacare, and broadening their usage, will not require any major changes in direction, or principles, or policy, but will merely require an expansion of already existent – and even “venerable” – rules, rules which have been an established part of Medicare for many years.

DrRich has expressed the idea that such restrictions by our government on such fundamental individual liberties are a very big deal indeed, and, in fact, signal an end to the Great American Experiment. His critics admonish him, however, that he makes too much of it, that, presumably, our government in its benign wisdom is just doing what’s best for us.

DrRich begs his readers to forgive him if he sees, in such a reply, even more evidence that the only nation in the history of mankind to be founded on the principles of individual freedom is well on the way to abandoning those exceptional principles, for the sake of the same, soothing-but-empty blandishments that have been offered, throughout human history, by well-meaning people who end up producing – or becoming – tyrants.

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Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

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The thing about Progressives is that the characteristic which makes them most endearing (and, which makes them most attractive to the unaware), is the very characteristic which makes them the most dangerous.

Fundamentally, Progressives believe in the perfectibility of mankind, or at least, of society. Indeed, they have discovered the very Program which will lead to the perfect society, a society which will maximize the good of the whole. Their vision is so compelling, and their ends so utterly and undeniably right, that it becomes legitimate for them to engage in whatever means are necessary to achieve it. (Indeed, for those who have been paying attention, “By Whatever Means Necessary” appears to have supplanted “Hope and Change” as the catchphrase of our current political leaders.)

The thing that always trips up Progressives (and their more revolutionary cousins, the Communists), is, of course, human nature. In order for their Program to work, it is necessary for each individual to behave in the prescribed fashion. And, at the end of the day, a substantial proportion of the population (any population) will insist on striving for their own individual benefit, rather than (as the Program requires) for the benefit of the collective.

The major competing system of societal organization – capitalism – recognizes this facet of human nature (i.e., the essential imperfectability of mankind, as manifested by the non-suppressibility of self-interest), and attempts to channel it into relatively productive and non-destructive (but still competitive and individually-directed) behaviors that limit the damage, and maximize the public good to a reasonable degree.

In contrast, Progressives attempt to change human nature to fit their inherently superior Program.

The fact that you cannot change human nature to fit the Program is what makes them dangerous. Their initial wide-eyed optimism that us folks will just “get it,” once they explain it to us, invariably evolves to an essential contempt for our limited intellectual capacity. This contempt justifies all manner of prevarications, to fool us into going along. Even in societies where the tyranny of correct-thinking has gone so far as to elicit the cooperation of the people at the point of a gun (rather than through the preferred methods of “education” or misdirection), the achievement of the predicted perfect society is invariably prevented by the recalcitrance of human nature. (The final realization that not even an all-powerful central authority can make people behave in the prescribed way always produces a nearly psychotic frustration that – in virtually every Communist country – has led to atrocities against various subsets of the recalcitrant people.)

DrRich does not believe there will ever be pogroms in the United States.

But this does not mean that the Progressives will always be kind and gentle as they attempt to achieve their goals. As DrRich sees it, in the U.S. the Progressives have clearly evolved to the “contempt for the masses” phase of their Program, a phase which justifies all manner of techniques – just this side of violence – to get us all to cooperate. Currently they are intent on demonizing their opponents as being racist, stupid, uneducated, selfish, overly dependent on outmoded supernatural beings, violent, and (of course) obese. This demonization is quite useful, since there is obviously no need to address any actual ideas put forth by such as these, even if they were capable of the feat of “ideas.”

Healthcare is, at present, the chief battleground in the war between Progressives vs. non-Progressives in the U.S., and the outcome of this battle will likely determine the success or failure of the entire Progressive Program. And the most fundamental (and emblematic) aspect of this battle is over what to do about the “doctor-patient relationship.”

The classic doctor-patient relationship was a celebration of the primacy of individual rights. And, for over 2000 years (at least since the advent of the Hippocratic Oath) guaranteeing the sanctity of that relationship was the basis of all medical ethics.

Until very recently doctors, patients, philosophers and ethicists recognized that, when you are sick, you are no more capable of navigating a complex and hostile healthcare system than are accused felons a complex and hostile legal system, and you are no less in peril if you run afoul of that system. And, just as the felon has a right to a personal advocate, a professional whose job is to protect his individual interests against the conflicting aims of the “system,” so does the patient. That is (quaint conventional wisdom held), when you are sick, you should be entitled to at least the same protections as when you rob a convenience store. And the doctor-patient relationship was supposed to guarantee you that right.

This is why, throughout the ages, the basic precepts of medical ethics were aimed at guaranteeing the sanctity of the doctor-patient relationship. Fundamentally, these ethical precepts required the physician to place the needs of his or her individual patient above all other considerations.

It should be clear to everyone that, under either our “old” healthcare system or the one that Obamacare promises us, this formulation of the doctor-patient relationship cannot be allowed to stand. Neither the insurance executives nor government officials can allow spending decisions – that is, decisions on how to spend their money – to be made by individual patients (and their personal advocates). For this reason, the classic doctor-patient relationship had to go.

And so, in 2002, official medical ethics was formally amended to require physicians (while still giving lip service to their obligation to individual patients) to strive for a “just distribution of healthcare resources.” That is, official medical ethics now makes it ethical for physicians to ration healthcare, covertly, at the bedside – and indeed, makes it unethical for them to fail to do so.

The New Ethics has been enthusiastically supported by medical ethicists worldwide (a field which now seems to be dominated by utilitarians), and worse, has been embraced by all the world’s major medical professional organizations. DrRich has not embraced the New Ethics (on the grounds that it places individual patients at great peril, and destroys the profession of medicine), and neither have many (possibly a majority) of older physicians. But it has been taught in medical schools around the world for over a decade, and in another decade it is likely that the vast majority of practicing physicians will accept as a matter of course that their primary obligation is to control healthcare costs, and only secondarily to try to meet the needs of their individual patients.

The plan, therefore, is for Obamacare to provide physicians with directives from expert panels on which medical services to supply to which patients and when, and for the New Ethics to allow physicians who go along with such directives to live with themselves. The feasibility of this plan depends entirely on physicians acceding to the program.

So, incentives are being put in place to “help” doctors cooperate. Quality measures will be implemented, with “quality” being defined as doctors doing what they’re told, and reimbursement will be tied to one’s quality rating. Possibly more persuasive will be the fact that the Feds can construe the failure to follow handed-down rules, regulations and guidelines, at any time, as a federal crime. (Even doctors who don’t mind being labeled as “substandard quality” – perhaps even considering the label as a badge of honor – will mind going to jail.)

But by whatever means necessary, the happiness of the government is to be the doctor’s first consideration, and not the happiness of their individual patients. The classic doctor-patient relationship is being terminated with extreme prejudice.

To see just how important it is to destroy the doctor-patient relationship, one merely has to observe what is happening to primary care doctors who have the audacity to leave the system, and set up a direct-pay medical practice.

Part of the problem, to be sure, was caused by these doctors themselves. The first few to do so unabashedly catered to rich patients, and to attract the rich, referred to themselves as “concierge” practitioners. This name (and its elitist connotations) have been forcibly affixed to all direct-pay practitioners, even as this style of practice has evolved into a much more democratic form. Today, more and more doctors are starting direct-pay practices (in which patients pay the doctors out of their own pockets) which are easily affordable to anyone who can afford a cell phone or cable TV contract.

While many direct-pay practices offer patients certain benefits they can usually not get from primary care doctors who remain in the approved system (such as phone and e-mail access, same-day appointments, appointments lasting as long as necessary instead of the allotted 7.5 minutes, etc.), the fundamental benefit, to both the patient and the doctor, is that it restores the classic doctor-patient relationship. The physician’s primary obligation is no longer to the 3rd-party overlord, or to the Progressive ideal of social justice, but to the patient.

And while critics (who abound) attack direct-pay practitioners for their elitism, laziness, and greed, their real issue is that direct-pay practitioners are acting as if their primary duty is to their individual patients, and not to the needs of society. This latter fault simply cannot be tolerated.

Having gained nearly complete control over the behavior of primary care practitioners, it is critical for Progressives – in making sure that practice by handed-down “guidelines” is not simply the only legal way to practice, but also the only ethical way to practice – to shut the door to any alternative forms of primary care. Direct-pay practitioners are a menace because they threaten to raise the expectations of both doctors and patients. Perhaps, doctors and patients might tell themselves, there really is a way to maintain individual autonomy within the healthcare system.

The attacks on direct-pay practitioners have followed the usual scheme Progressives follow when they discover a faction they need to suppress. First, they were ridiculed. “For a Retainer, Lavish Care by ‘Boutique Doctors,’” said a headline in the New York Times in 2005. Then, they were demonized, widely attacked for their elitism, laziness, greed, and lack of fundamental medical ethics. In this latter effort, it was not difficult to find fellow physicians – generally, from the medical organizations which promulgated the New Ethics – to lead the attacks. There are countless examples. DrRich will give just two.

Anthony DeMaria, then President of the American College of Cardiology, criticized the practice of direct-pay medicine in an article in the JACC in 2005, saying, “Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality.” As a matter of social justice, direct-pay physicians improve healthcare quality for only some patients, and so have no place in the healthcare system.

In an article in the New England Journal of Medicine, Troyen A. Brennan (M.D., J.D., and M.P.H., so we know we’re in trouble) really gets to the point. Referring to direct-pay practices as “luxury primary care,” he notes that “traditional medical ethics is rather poorly equipped to address issues related to luxury primary care.” That is, while “traditional” medical ethics always places the individual patient first, that kind of thinking is now outmoded. “(M)ost ethicists now agree that the financial structure of health care is an important subject for ethical consideration. Access to health care, in particular, is a salient ethical issue.” Direct-pay practitioners threaten (by their elitism and the limited size of their practices), to limit access to primary care, and thus are in fundamental violation of medical ethics.

The argument here, for those who missed it (advanced by fellow physicians no less), is that, of the two competing ethical precepts now established by New Medical Ethics (i.e., the physician’s obligation to the individual patient vs. the physician’s obligation to society), clear primacy is to be given to the physician’s obligation to society. Physicians must (like it or not) participate in covert bedside healthcare rationing. Physicians who take the only path remaining to them that allows them to make the individual patient their primary obligation are to be castigated as ethically deficient.

When ridicule and demonization fail to suppress their opposition, Progressive dogma indicates it’s time to resort to force. The first pass in this regard, of course, is always to render the opposition illegal. (Actual violence is reserved for criminals who persist in their misbehavior, despite more polite efforts to get them to behave lawfully.)

Making direct-pay medical practice illegal has not been accomplished yet, but clear efforts have been made in this regard. Noting with alarm the rise of direct-pay primary care, numerous Congresspersons have issued statements of concern, suggesting that perhaps Congress should look into the propriety of such activities.

Indeed, the first step by Congress has already been taken. In 2003, as part of the Medicare Prescription Drug, Improvement, and Modernization Act, Congress directed the GAO to study and report on the effect of direct-pay practices on Medicare patients. The GAO did so in 2005, and a fair paraphrase of its report is as follows: “The practice of direct-pay medicine is not currently a threat to Medicare patients, because the direct-pay movement is not large enough yet to have an impact. If it does begin to have an impact on Medicare patients, action will have to be taken.” That is, direct-pay medicine was considered OK in 2005 not because it was inherently an ethical and legal form of medical practice, but simply because there were not enough practitioners at that time to significantly affect Medicare patients. The clear implication is that Congress stands ready to pass laws outlawing – or, at least, severely limiting – direct-pay practices, as soon as those practices begin to “impact” the system.

Certain state governments are not waiting for Congress to ban direct-pay practices. The state of Maryland (and a few others) have taken the creative position that, because many direct-pay practices work on a retainer basis, they meet the definition of a health insurance company. And as a health insurance company, to be considered legal entities, they have to have millions of dollars set aside to pay for unforeseen “claims.” (Interestingly, this same argument was not applied to Maryland lawyers, who also often work on a retainer model.) According to the Baltimore Sun, the state’s stance in this regard has already successfully caused several primary care physicians to abandon their plans to become retainer practitioners.

Less devious (but more draconian) than the state of Maryland is the state of Massachusetts (whose universal healthcare system, we’ve all heard, is a preview of Obamacare circa 2015). A bill is under consideration in the Massachusetts Senate (Bill 2170) which requires doctors, as a condition of their licensure, to accept payment rates as determined by the government. If it passes, it will be the first actual legislation in the U.S. to ban direct-pay medicine, if only by making it completely impracticable. (Thanks to Dr. Wes for pointing out this important development.)

Since medical licensing is controlled by the various states, of course, it would take 50 bills like the one in Massachusetts to really get rid of direct-pay healthcare. But there are other ways for the Feds to accomplish the same thing. Now that the federal government directly controls all student loans, for instance, it would be a simple matter to make those loans contingent on agreeing to become primary care doctors working strictly within the government controlled system, or to offer loan forgiveness for doctors who agree to do so, or to rescind favorable re-payment conditions (retroactively, and decades after the fact, if necessary) for doctors who go to a direct-pay model later in life.

DrRich does not really know how the Progressives will actually place the final nail in the coffin of the doctor-patient relationship. All he knows is that they have – well, more than the desire – the deep and abiding need to kill that relationship, once and for all. Unless we the people decide we ought to stop them, this is going to happen.

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Part 4 of Limiting Individual Prerogatives

A few days ago Mr. Doherty (who is also the ACP’s Senior Vice President of Governmental Affairs and Public Policy), graciously agreed to engage in this discussion, and promised to do so after consulting with the ACP’s Committee on Ethics, Professionalism, and Human Rights.

DrRich had hoped that Mr. Doherty would reply with a post on his ACP blog, which (since it likely has a vastly greater readership than the CRB), would more effectively give this topic some much-needed airing – and in particular, might engage some of the ACP’s membership (specialists in internal medicine) in this important discussion. DrRich was disappointed, then, when the reply came today in the form of a comment, which was tacked on to a long queue of reader’s comments at the end of DrRich’s posting.

DrRich was also very disappointed by the content of the reply which, fundamentally, was: This is a non-issue, and even if it was an issue, it’s now a settled issue. (So go away.)

Because he fears that his readers may not find the ACP’s response (buried as it is), DrRich will post it here in its entirety. But first he will very briefly summarize his complaint against the New Ethics promulgated by the ACP and other Millennialists. The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine.

In the ACP’s response Mr. Doherty begins: “I asked Dr. Virginia Hood, chair of ACP’s Committee on Ethics, Professionalism, and Human Rights, to respond to Dr. Rich’s post. Her reply is below:”

Much ado?

We are surprised to see the comments about ACP and medical ethics. We urge readers to read the actual text of the ACP Ethics Manual (the College’s Code of Ethics) and the Professionalism Charter, which the College’s Foundation helped develop. Both say that social justice is a consideration in medical ethics, but the physician’s primary responsibility is to his or her patient. Resource allocation decisions are policy decisions and are most appropriately made at the system level, not at the bedside. The Ethics Manual discusses at length the clinician’s primary role as an advocate for individual patients. But it also notes the duty to practice effective health care and use resources responsibly, which are not incompatible with being a patient advocate. As the Manual notes, physicians should not overtest or otherwise overuse services:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available [i].

This is nothing new. Indeed using “effective and efficient health care and health care resources responsibly” for all patients is one way to minimize rationing as the result of an over costly system. The Manual also says that physicians and their professional societies should work toward ensuring access to health care for all and the elimination of discrimination, and deficiencies in availability and quality, in health care services. Likewise, the Charter on Medical Professionalism endorsed by ACP and 120 other medical organizations in the USA and internationally, states that professionalism involves commitments to improving quality of care, improving access to care, eliminating discrimination in health care, and yes, to a just distribution of finite resources. But the Charter explains the commitment to a fair distribution of finite resources as follows:

While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others [ii].

The patient-physician relationship and our medical ethics are the soul of medicine. The blog commentators are correct– it is important that we get it right.

Thank you.

Virginia Hood, MD, FACP
Chair, American College of Physicians Ethics, Professionalism and Human Rights Committee

As much as DrRich may feel he has been condescended to here (as if the ACP has found a fly buzzing around its head and has attempted to swat it away), and recognizing that the ACP has decided not to engage in a give-and-take (which, of course is their prerogative), but rather, has responded with a brush-off statement which they have chosen to bury in the comments section of DrRich’s obscure blog (which is also their prerogative), DrRich will attempt to reply as politely and as analytically as possible. (He does, however, sincerely hope that Mr. Doherty – who really seems like a good person and is an excellent writer – will not be called to the woodshed for obligating an august Ethics Committee Chairperson from this prestigious organization to issue a formal response to an annoying blogger such as himself.)

Dr. Hood’s artful (and dismissive, it seems to DrRich) statement can be fairly summarized thusly: After beginning with the implication that DrRich is making much ado (about nothing), and that she is surprised that anyone would dissent from ACP’s New Ethics, she says that the New Ethics does not entail the problem that DrRich alleges; indeed, there really is nothing new about it. Of course patients come first. (Just study the various documents the ACP has published on this point.) Cost-effective and efficient care is a part of good medicine, and always has been. What we mean by a fair distribution of finite resources is to practice medicine wisely, so as not to waste resources and not to expose patients to the risk of medical services they do not need. The legitimacy of the New Ethics is supported by the fact that it has been formally adopted by 120 medical organizations internationally (which to DrRich means that when you go to a doctor anywhere, this is the code of ethics under which they are now officially practicing).

There is a lot in her statement DrRich could comment on, but he does not want to bore his readers with a lengthy parsing of this finely crafted response. Rather, he will just talk about its main point.

Fundamentally, Dr. Hood is denying that there’s any problem. There’s no conflict between “the fair distribution of healthcare resources” and doing what’s best for individual patients – and furthermore, she’s surprised anyone would think so.

DrRich does not accuse her of sophistry. Perhaps she is just deceived.

The fact that there are huge conflicts between providing individuals with all the healthcare that would likely be useful to them, and the inability of society to pay for such a thing, is the fundamental problem with the public funding of healthcare. We simply can’t afford to buy everybody all the healthcare that would likely benefit them. There’s not enough money in the world to do that.

Consider just a few of the examples DrRich has discussed here over the years. Implantable defibrillators have been shown to significantly improve the survival of a substantial minority of patients who have heart disease, and indeed guidelines issued by cardiologists’ professional organizations indicate that defibrillators ought to be implanted at a rate of about five times their current actual implant rate. But if doctors actually did that, it would cost Medicare an extra $7 – $8 billion each year. Then there’s the fact that if doctors used the statin drug Crestor in the way the very well-designed and compelling JUPITER trial says doctors should use it, we would be spending an extra $10 billion per year on Crestor. In a thousand ways, the “best” healthcare for the individual is very often not cheaper (or better for society) than less-good healthcare, and DrRich is impressed that Dr. Hood is willing to say that it is.

Dr. Hood would likely deal with this problem, and implies so, by devising “guidelines” that doctors would be ethically obligated to follow. Obviously, it is entirely possible to convert “guidelines” from just that (i.e., a set of guidelines which doctors ought to take into strong account when deciding what’s best for their individual patients) into a set of formal rules that must be followed, and which will then be enforced by federal regulators (and their posse of ethicists). Indeed, such “guidelines” might be one of the ways in which society imposes its own goals over those of individual patients. But that is not the same thing as insisting that individual patients (who often do not fit the “average” profile) will necessarily profit if doctors always follow the guidelines as a matter of policy, or of enforced expectations, or of “quality”.

(Further, as DrRich has pointed out, the rapidly developing paradigm in which “guidelines” are becoming inviolate rules has led competing organizations to rush to issue their own sets of competing guidelines, that best comport with their individual agendas. While this phenomenon of “guideline wars” is endlessly amusing, it may not always serve the best interests of doctors or their patients.)

And then there’s the problem that, no matter how you define “waste” or “inefficiency” or “unnecessary care,” there simply cannot be enough of it to account for the runaway healthcare inflation we’re seeing (as DrRich has shown here). A substantial proportion of this fiscally disastrous healthcare inflation must necessarily derive from the delivery of healthcare that is actually useful.

So the crux of Dr. Hood’s reply – that all the ACP is talking about when it mandates that doctors fairly distribute limited resources is that they ought to practice good medicine, and if they did that simple thing no useful therapy would need to be withheld from any individual patient – is absurd on its face.

DrRich would be less disturbed by Dr. Hood’s assertion if he really thought it was simply a misapprehension of the truth. And perhaps it is. After all, her statement reads as if she is truly surprised that anyone would think otherwise.

Perhaps Dr. Hood came to her high station within the ACP’s Ethics Committee very recently, and is unaware of the history of the new Professionalism Charter which advanced this New Ethics, or of the controversy that was raised by many critics at the time of its adoption, or indeed, of some of the language that was in its penultimate version (and that was likely removed to silence some of those critics). Indeed, she cannot be aware if it, since she is “surprised to see” that anyone is bothered by the Charter, and since she believes that questioning it is but “much ado.” But to anyone who knows a little of that history, Dr. Hood’s assertion that controversy over this Charter is a novel experience, or most especially, her assertion that this New Ethics is really “nothing new,” would come as a very great surprise indeed.

First, we should note, if the new Professionalism Charter was really “nothing new,” and was just a restatement of the physician’s traditional obligation to place the patient first, and if fairly distributing society’s resources really was just a matter of practicing good medicine, then there would have been no need for a new Charter of medical ethics in the first place. And certainly the need would not have been pressing. It would have served quite nicely instead to produce some sort of document reminding doctors that unneeded healthcare services expose their patients to unneeded risk, so (based on the traditional ethical precept of patient welfare), to remain ethical they must stop being wasteful. Certainly, this kind of wasteful medicine would not produce a need to redefine medical ethics.

But the new Charter’s very first sentence describes something more dire, more pressing, than can be explained by Dr. Hood’s benign assertions. It says, “Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.” So: the whole purpose of this new Charter, its entire impetus, was the frustration of physicians.

Frustration? What frustration is that? Interestingly, the document does not come right out and say it. The closest it comes to spelling it out is to say, “We share the view that medicine’s commitment to the patient is being challenged by external forces of change within our societies.”

But even though the document seems strangely reticent about spelling out which frustration produced the very impetus for its creation, we can rely on the fact that the document must be designed to cure this mysterious frustration (whatever it is), and that the only revolutionary change in the document is an addition to the code of medical ethics requiring physicians to work for “the fair distribution of healthcare resources.” We can only conclude that this new ethical obligation is meant as a cure for that foundational frustration, and that therefore this frustration must be that doctors are finding it impossible to meet their traditional ethical obligation to to place their patients’ needs first.

But, as it happens, we do not really have to resort to this sort of documentary detective work to parse out the purpose of the new Professionalism Charter. That purpose was quite open at the time this document was being developed – and it produced robust controversy that was certainly no secret. One can read about this controversy in many places, but for our purposes now (i.e., in replying to Dr. Hood’s assertion that there’s nothing new here, and that it is a matter of some astonishment that anyone would find the Physicians Charter controversial) it might be best to refer to one of the ACP’s own publications from that time.

An article in the July, 2001 ACP-ASIM Observer, which was entitled, “Charter on medical professionalism addresses issues of finite resources,” goes into some length about the controversy. And it is very plain that the objection many raised to the new Charter was precisely that which DrRich is raising now in his challenge to the ACP: that the New Ethics being espoused in the Professionalism Charter fundamentally and explicitly divides the loyalty of the physician between the patient’s needs and society’s needs. When one listens to the defenders of the new Charter (quoted extensively in the ACP-ASIM Observer article), one finds the unmistakable tones of utilitarianism: We have to change our ethical precepts, the argument goes, because that’s just the way the world works now.

This article also indicates that the draft of the Physicians Charter presented to ACP general membership at their annual meeting in 2001, a few months before the final version was finally published, was perhaps more forthcoming than the final version, regarding what it was really all about. For instance, this nearly-final version of the Charter specifically admonished physicians that they must “be aware that the decisions they make about individual patients have an impact on the resources available to others.” One can only assume that this sort of explicit language was taken out of that final version in response to the critics (who were many, and vocal) to soften the blow.

Indeed, the “softer” language of this strange final version (which has all the hallmarks of a heavily edited document, beginning as it does with a heartfelt cry against the frustrations being experienced by physicians, then neglecting to spell out what those frustrations are, and never explicitly saying which aspect of the document addresses those frustrations), is now possibly soft enough, if not read carefully, to allow defenders of the Professionalism Charter to get away with asserting (as Dr. Hood has done) that the New Ethics is really pretty much the same as the old ethics, and does not change anything. (So move along, move along.)

But the New Ethics changes everything.

DrRich is very sorry about this, and is especially sorry that the ACP’s Ethics Committee, and the other 120 physicians organizations that have adopted this New Ethics, insist they do not see a problem here. DrRich assumes by this response that the ACP has little interest in revisiting its new ethical stance, and further, is undoubtedly busily training today’s medical students that doing what’s best for society is the same as doing what’s best for the individual.

This is a theme, DrRich thinks, he’s heard a lot lately.

Patients who want a true advocate in their life-and-death encounters with the healthcare system, an advocate whose loyalty is not divided between them and a society that, with increasing desperation, wants not to spend its money on them, had better go out and hire their own. Your doctor will now find it officially unethical to serve that office him-or-herself.

And meanwhile, we can now be sure that the physicians organizations which are responsible for protecting the ethical foundation of the profession of medicine are quite satisfied with the job they are doing.

Ever since the inception of the Covert Rationing Blog (and even before that, in his book) DrRich has taken strong exception to the new code of “medical ethics for a new millennium,” formally promulgated in 2002 by the American College of Physicians and several of its equally respected sister organizations (a grouping DrRich has termed the Millennialists). And when he saw that the ACP Advocate Blog (an official publication of a principle component of the Millennialists) had become a co-finalist for a Weblog Award in the category of medical ethics, DrRich could not resist offering to engage in a discussion over same.

DrRich is delighted to report that Bob Doherty, who, in addition of being the author of the ACP Advocate Blog, is also the ACP’s Senior Vice President of Governmental Affairs and Public Policy, has graciously agreed to the suggested exchange of ideas. Mr. Doherty reports that he will be posting a reply to DrRich’s “challenge,” once he finishes consulting with the ACP’s Center for Ethics, Professionalism and Human Rights. And so, dear readers, it appears that DrRich (your humble correspondent) has gotten himself into a situation. It appears he will be engaging – at his own instigation, no less – with actual, certified experts on medical ethics, regarding the topic: medical ethics.

DrRich can almost hear some of his loyal readers gasping: “Why, he’ll be skinned alive!”

But fear not. DrRich will not hurt him. DrRich does not flay anybody, and promises to remain entirely civil and friendly in this exchange. DrRich, upon his honor, will see to it that Mr. Doherty (and whatever friends he may enlist in the cause) will emerge from this encounter entirely intact, integumentarily speaking.

In fact, to show his great good faith (and to level the playing field), DrRich will now break with all the conventions of debate, and before Mr. Doherty posts his reply, will lay the rest of his cards upon the table, so that the opposition will have the advantage of knowing ALL of DrRich’s arguments before they commit themselves to an answer. That is how dedicated DrRich is to keeping this competition friendly and respectful and fair.

DrRich’s Argument So Far

In his previous, challenge-issuing post, DrRich described how the “New Ethics” advanced by the Millennialists obligates the physician to strive for the ethical precept of Social Justice, which is to say, for “the fair distribution of healthcare resources.” So the doctor is now charged with deciding which patients may receive, and which may not receive, certain healthcare resources. To say it another way, under this new conception of medical ethics the doctor is assigned the duty to ration healthcare, covertly, at the bedside.

DrRich further described how this New Ethics fundamentally wrecks the doctor-patient relationship, and thus leaves patients to their own devices within a hostile healthcare system. In addition DrRich asserted that, once they adopted this New Ethics, physicians surrendered their claim to the title “professional,” and accordingly, made themselves fair game to whatever treatment, tactic, or travesty that any more powerful interest group (such as trial lawyers or Congress or regulators or insurers) may choose to foist upon them. Physicians no longer have any ethical standing for turning such attacks aside. Rather, as non-professionals, their ability to withstand attacks can only be proportionate to whatever socioeconomic or political pressure they can muster. So, as DrRich sees it, the New Ethics promulgated by the Millennialists is pretty much a disaster for both doctors and patients.

This is the extent of the argument DrRich has advanced so far.

Here Are The Rest Of DrRich’s Cards

The Millennialists did get one thing right in this effort. They correctly diagnosed the fact that old-fashioned, “classic” medical ethics, as advantageous as it may have been to both patients and doctors, is no longer consistent with reality.

Under classical medical ethics, the doctor’s one and only ethical obligation was to the individual patient. And so, classic ethics did not allow for any limits whatsoever on the medical services a patient may receive. If some bit of available medical care might offer even a small nugget of hope, doctors were obligated to provide it, no matter how expensive it might be to do so.

It is important to recognize that classic medical ethics evolved during a time when medical technology was relatively primitive, limited, and cheap, and more importantly, at a time when patients paid for their own healthcare. So when classic medical ethics was formulated, “healthcare spending limits” (though nobody talked in such terms back then), were self-imposed, by the patient.

But over the past 60 years medical technology has become very advanced and very expensive. And even more to the point, we have evolved a payment system in which people who receive healthcare are spending not their own funds, but rather, are spending publicly-funded, pooled resources. (Those pooled resources are either funded directly through the government, or are subsidized by the public indirectly, through tax-deductable insurance premiums).

It is this collective funding arrangement that has made classic medical ethics obsolete. It is neither feasible nor ethical to leave all decisions on how to spend society’s pooled healthcare dollars to individual doctors and individual patients, who can “take” as much of this pooled resource as they think they’d like to have, with absolutely no constraints. Such an arrangement eventually and inevitably leads to fiscal ruin.

By the 1990s, because spending limits were absolutely necessary, but at the same time classic medical ethics precluded setting such limits, doctors were being coerced by the private insurers and government payers to establish those limits covertly, through bedside rationing. This was the problem faced by the Millennialists when they set out to reformulate medical ethics, and they were right to make the attempt.

But unfortunately, this is where the Millennialists dropped the ball and, as DrRich has shown, settled upon an answer that just made things worse.

The Right Medical Ethics

Medical ethics would be “right” if it could be made to comport with the classic notion that the doctor’s primary obligation is to his/her individual patients (thus preserving the classic doctor-patient relationship), and yet still respected society’s need to control the spending of its pooled resources. That is, the “right” ethics will recognize both society’s needs and the needs of individual patients, will recognize that those two sets of legitimate needs are often in conflict, and will provide an ethical framework for resolving these conflicts.

That ethical framework, DrRich is pleased to announce, is not that hard to conceptualize.

We can solve this problem if we think of the ethics of healthcare as being organized into two concentric spheres. The outer sphere holds the ethical precepts adopted by society to guide the behavior of the healthcare system for the benefit of the entire population; for example, to set overall limits on spending. These outer-sphere precepts help to ensure that the needs of society as a whole are served in an ethical manner by the healthcare system.

Contained within (and therefore subject to) that outer sphere of societal precepts is an inner sphere, which holds the ethical precepts that govern the behavior of individual doctors and patients within the healthcare system. Inner-sphere precepts help to ensure that the rights and needs of individual patients are addressed in an ethical manner.

So, while the physician’s primary ethical obligation must always be for the benefit of the individual patient, and therefore the physician must operate according to ethical precepts that honor this duty to individual patients (the inner-sphere precepts), their behavior must also conform with the ethical constraints imposed by society on the entire population (the outer-sphere precepts).

We can think of the inner-sphere precepts as an immutable core of ethical beliefs that serve the fundamental American commitment to the autonomy of the individual, and of the outer sphere as a coating, fashioned by society and therefore changeable, that places an adjustable (and ethically derived) limit on the individual’s ability to consume pooled resources.

The Inner Sphere – Ethical Precepts For Individuals

The inner sphere of ethical precepts – the core – fully preserves the two precepts of classic medical ethics: the precept of Patient Welfare, which requires the doctor to always act to the benefit of his/her individual patient; and the precept of Patient Autonomy, which requires the doctor to respect the individual patient’s right to medical self-determination. So the inner sphere precepts completely restore the physician’s sacred obligation to the interests of their individual patients. And thus, also restored are both the classic doctor-patient relationship, and medical professionalism.

But while individual welfare and individual autonomy are critical (and comprise the chief ethical obligations of the physician), there are still legitimate limits to what the patient (and doctor) can reasonably expect to receive from pooled resources. When a patient demands that everything possible be done for them, they are exceeding the bounds of autonomy if doing “everything” means that other individuals would thereby be deprived of what otherwise would be rightfully their fair share of those pooled resources. These necessary bounds on individual autonomy are defined by the outer sphere.

The Outer Sphere – Ethical Precepts For Society.

Under any equitable healthcare system we are going to have to carefully define our outer sphere ethical norms, because those are the standards that bound and govern the inner-sphere behaviors of individual doctors and patients. This “outer sphere ethics” is also comprised of two ethical precepts, Societal Beneficence and Distributive Justice.

Societal Beneficence (or social welfare) requires the healthcare system to attempt to maximize the overall public good realized from whatever pooled resources society expends on healthcare. Social welfare is not the same as patient welfare, because what is optimal for an individual patient may often reduce the overall benefit to society, and vice versa.

Distributive Justice requires the benefits of the healthcare system to be distributed fairly, that is, in a way that does not discriminate against individuals or groups based on who they are.

The outer-sphere precepts honor society’s right to accrue optimal benefits from whatever collective resources society provides toward healthcare. That is, the outer-sphere precepts recognize society’s legitimate interest in limiting and equitably distributing those collective resources – and indeed, recognizes its ethical obligation to do so.

Medical Ethics And the Spheres

With this framework it is easy to see why the American healthcare system is presently inequitable and unethical. A hallmark of our present system is the lack (thanks to our culture of no limits) of any attempt to define effective outer-sphere societal norms, which would bound the appropriate behavior of individual physicians and patients. This deficiency makes it entirely feasible, and very common, for some patients to soak up a disproportionate share of publicly funded healthcare resources, while others (though they are also paying into the system) are left with next to nothing.

Achieving equity should have nothing whatever to do with adjusting the inner-sphere precepts. Individuals in the United States (to paraphrase the Declaration of Independence) have a self-evident right to their individual autonomy. The inner-sphere precepts are granted to us by our founding documents, and as Americans we should avoid modifying the inner-sphere precepts at all costs, since, once we do, we are abandoning our foundational principles. (This means that the Millennialists have done more damage, with their New Ethics, than merely harming doctors and patients. They have begun – or continued – undermining the principle of individual autonomy upon which the United States was founded. ) (Sorry to have to mention it.)

It is the outer-sphere precepts – those that can be negotiated legitimately by society, and which can legitimately limit the scope of inner-sphere behaviors – that we need to get into proper order.

A properly functioning system of medical ethics, therefore, would require society to devise workable outer-sphere precepts, and through these ethical precepts, establish transparent rules for setting necessary limits on collective healthcare spending. Then, within that system of rules, doctors and patients would work together, under a fully restored doctor-patient relationship, to assure that every patient has access to all legitimately available medical options. And the doctor would be allowed (and expected) to leave no stone unturned in obtaining those legitimate medical services for his/her patient.

This arrangement is analogous to the attorney-client relationship, where the attorney, acting within the bounds imposed by the law (outer sphere norms), is expected to do everything within his/her power to see that the client gains every conceivable, allowable advantage (inner sphere behavior) as they navigate the complex legal system.

To further illustrate this point, we Americans are now engaged in a debate over whether the Christmas Underwear Bomber ought to be eligible to receive all the legal protections afforded to an American citizen under the law. It is notable that ALL the discussion in this case is in regard to whether American outer-sphere legal norms should apply to the terrorist. Nobody is suggesting that his attorney ought to abrogate his (or her, as the case may be) sacred “inner-sphere” obligations to this client, in order to achieve some sort of “fair distribution” of society’s legitimate interests. Nobody expects the terrorist’s attorney to refrain from advising him remain silent, for instance, even though that silence may expose us all to substantial additional harm. The lawyer’s inner-sphere obligations are secure, even here. Rather, the argument we’re having is strictly limited to how we should apply outer-sphere legal protections to this case.

It is the right argument to have. And it’s the very argument we should be having in regard to medical ethics.

And as much as DrRich does not like lawyers, he very much admires the tenacity with which they have preserved their fiduciary relationship with their clients – even in cases like this one. If physicians (and their organizations) had behaved with the professional integrity displayed by the despised attorneys, doctors and their patients would be in much less difficulty today.

A Plea

It is instructive to re-consider the New Ethics, which now has been formally implemented by the Millennialists, in light of DrRich’s proposed two-sphere system of ethics (which he audaciously labels “right ethics,” but to show his humility he will not use caps). The New Ethics can be seen to have resulted by the simple expedient of moving the outer-sphere principles of Societal Beneficence and Distributive Justice (lumped together as Social Justice) down into the inner sphere, where individual doctors are expected to deal with them.

You can’t actually do that, of course, because these are intrinsically outer-sphere norms. But nonetheless, New Ethics formally puts doctors into the position of having to serve the best interest of their patients (individual beneficence and autonomy) while at the same time, covertly rationing their patients’ healthcare (societal beneficence and distributive justice). It is quite impossible for individual physicians to reconcile these competing interests in any equitable sense, and charging them with the job of doing so is illogical, nonsensical – and (DrRich respectfully submits) unethical.

Doctors and patients would be much better served if physicians’ professional organizations, such as the ACP, would revisit their new-age Physician’s Charter on ethics. DrRich understands that our modern society is exceedingly reluctant to establish outer-sphere rules for limiting pooled healthcare resources, and for distributing them equitably. But that reluctance is not a sufficient justification for physicians themselves, through their professional organizations, to initiate and implement new ethical standards that sacrifice their sacred obligation to their patients.

My goodness, can we not muster up at least the ethical sensibilities of lawyers?