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Overhauling Morality for American Medicine, Part 1

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Ever since John McCain foisted her upon the American people, Sarah Palin has come to be regarded – rightly or wrongly, fairly or not - as more of a blurter than a thinker.

Last summer, Palin blurted her way into the middle of the national discussion concerning the legislation which had been proposed for overhauling the American health care system. Virtually without forewarning, Palin decided to bluntly, directly, and ever so publicly let the American people know an horrific truth she had realized about the health care changes that the Democrats intended to enact. She blurted:

The sick, the elderly, and the disabled … will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether [those sick, elderly, and disabled] are worthy of health care.

Proponents of the Democrats' plans to remake the American health care system were aghast. Most, such as political consultant Leo Jennings, simply dismissed2 Palin's remarks as “lies”. Dr. Sherwin B. Nuland, on the other hand, used a rather more circumspect tone when he reported and assured:

All of the provisions to be included in the final bill are not yet known, but one thing is certain: There is not a single statement in the voluminous number of pages under study that contains the slightest consideration, no matter its remoteness, of death panels, euthanasia, or any such fearsome concept.

In like manner, the Pulitzer Prize winning web site, PolitiFact4, assures everyone that, were Palin's pronouncement true, then they would

agree with Palin that such a system would be evil … We have read all 1,000-plus pages of the Democratic bill and examined versions in various committees. There is no panel in any version of the health care bills in Congress that judges a person's “level of productivity in society” to determine whether they are “worthy” of health care.

Nuland also picked up on the the morality matter inserted by Palin and noted by PolitiFact when he said:

At times, morality can be dismissed as a matter of personal conscience, no matter how widespread its acceptance. Ethics, on the other hand, arises from societal or group commitments to principia of behavior. A formulated code of ethical precepts--whether philosophical, legal, or religious--is a statement of commitment that the group has a right to insist upon from its members, even to the point of punishing breaches.

While Nuland's remark might be taken as displaying a fairly quick willingness to dismiss morality and personal conscience in favor of societal ethics, PolitiFact - being apparently less ready to accept even the possibility that the denial of medical treatments should ever be part of the “principia of behavior” - delves more deeply into the claim that health care judgments would or could be based upon “whether [certain patients] are worthy of health care.”

Although Palin's blurt most definitely did not make mention of the Comparative Effectiveness Research aspects of the health care legislation, for some reason PolitiFact wonders if Palin's remark were based upon her having “jumped to conclusions about the Obama administration's efforts to promote comparative effectiveness research.”And, just as quickly as it wonders about those hypothesized “jumped to conclusions”, PolitiFact proclaims that

Such research has nothing to do with evaluating patients for "worthiness." Rather, comparative effectiveness research finds out which treatments work better than others.

PolitiFact is correct that none of the health care legislation versions ever casts Comparative Effectiveness Research in terms of patient “worthiness”. And we can be sure that none of this sort of research is explicitly based upon the concept of patient “worthiness”, nor need it explicitly conclude with determinations of patient “worthiness”.

However, the fact of the matter is that Comparative Effectiveness Research most definitely is not limited to “find[ing] out which treatments work better than others.”

PolitiFact tries to make it appear that President Obama “and his budget director Peter Orszag” share the understanding about Comparative Effectiveness Research as put forth by PolitiFact wherein this research is intended

to make it easier for doctors, health care workers, insurance companies and patients to find out which treatments are the most effective, as determined by clinical studies and other research.

Putting aside for the moment the matter of just what “other research” in addition to “clinical studies” could conceivably be necessary or even helpful in determining “which treatments are the most effective”, it could well be that President Obama actually does equate Comparative Effectiveness Research with comparative clinical or therapeutic effectiveness research, but we have very good reason to believe that Peter Orszag's interest in what gets compared extends well beyond merely clinical matters.

Back in 2007, when Orszag was its Director, the Congressional Budget Office put out a paper5 about Comparative Effectiveness Research. In the very first sentence of the preface to that paper, Orszag says:

Rising costs for health care represent a central challenge both for the federal government and the private sector, but opportunities may exist to constrain costs in both sectors without adverse health consequences.

There is absolutely nothing in that statement which is in the least bit controversial. However, what that statement does make plainly clear from the very beginning is that, in a paper about Comparative Effectiveness Research, it is not only clinical effectiveness which is at issue or which will be considered. Even so, there would appear to be some comfort to be had from the indication of an interest not in cost containment alone but, rather, in cost containment “without adverse health consequences.”

The problem is that within a few short sentences the notion of “without adverse health consequences” begins to metamorphose. In that very same opening paragraph, Orszag says:

only a limited amount of evidence is available about which treatments work best for which patients and whether the added benefits of more-effective but more-expensive services are sufficient to warrant their added costs … generating better information about costs and benefits of different treatment options – through research on the comparative effectiveness of those options – could help reduce health care spending without adversely affecting health overall.

The first point to note is that according to Peter Orszag, President Obama's current budget director, Comparative Effectiveness Research need not be limited in scope to mere clinical effectiveness. This means that the PolitiFact assertion that this research is intended “to make it easier for doctors ... and patients to find out which treatments are the most effective” is neither necessarily nor obviously true inasmuch as that PolitiFact assertion is - at the very least - imprecise.

In fact, owing to its imprecision, the PolitiFact statement is, or can be, in effect, quite misleading – even if not intentionally so - certainly inasmuch as PolitiFact presents its conclusions without having taken explicit account of the fact that there can be a difference between comparative clinical effectiveness research and comparative cost effectiveness research, both of which can be components of - or combined as - Comparative Effectiveness Research.

It is certainly desirable for physicians making clinical judgments to have at their disposal information about which seem to be the most effective treatments for a given condition. Who would want it any other way? Who could possibly insist that it is in the best interest of patients for them to have physicians who are unaware of which are the most effective treatments?

What is not so clearly desirable is having physicians include cost-effectiveness information as part of their clinical judgment. Who would want a physician, after having determined what is likely to be the most clinically effective treatment, to then take account of cost, and then decide that because of cost he would present some other therapy as the most effective, the most clinically effective? Who could possibly insist that such a judgment has as its ultimate interest the health of the patient?

When Orszag says that Comparative Effectiveness Research might determine “whether the added benefits of more-effective but more-expensive services are sufficient to warrant their added costs”, can it reasonably be asserted that the ultimate interest of such research is the health of the patient? If the focus or the goal of such research is something other than the health of the patient, then just how useful, just how appropriate, just how relevant is such research to the clinician whose interest is supposed to be the health of the patient for whom he is caring?

To be continued ...


1 see

2 see

3 see

4 see

5 Research on the Comparative Effectiveness of Medical Treatments: Issues and Options for an Expanded Federal Role; see


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