July 2009
Any Argument in the Storm: Postrel Gets It Wrong on Kidney Donation
Virginia Postrel is picking a fight with the National Kidney Foundation for saying that paying organ donors would be an "affront" to unpaid donors and that it would "cheapen the gift", according to The New Yorker.
Taking them on, living unpaid organ donor herself Virginia Postrel says that NKF's argument is itself an affront to her gift to her friend, Sally Satel, to whom she donated a kidney in 2006. Ultimately, Ms. Postrel's position amounts to the idea that unpaid organ donors shouldn't care one bit care whether organ donors are paid or not--either they give their kidneys freely to benefit those they care about, not to feel morally superior or to have someone feel obligated to them for life.
All other arguments against payments for organs aside, Postrel clearly sees nothing wrong with paying for organs--as it doesn't cheapen HER gift to HER friend. Yet, I challenge Ms. Postrel to consider what life would be like for Ms. Satel right now had she not had so good of a friend. Ms. Satel would be one of 80,000 people in the US waiting on a list to receive a kidney, and one could only hope that she would not be one of the 4,000 who die each year while waiting on that list.
But rather than focusing on your disgust that the National Kidney Foundation will not let others sell their kidneys to strangers, Ms. Postrel, perhaps that ire could be focused upon the more practical policy options that are out there that may actually come to pass if the American public could be convinced that, for example, an opt-out system would not result in American doctors and hospitals becoming body-snatchers for human organs on a black market and a significant increase in available organs for donation. (See AJOB's Target Article on this topic this month.)
There simply are not going to be enough living donors, like you Ms. Postrel, or even 4, 6, and 8-way organ swaps, to go around to make up for the 80,000 people waiting for kidneys. We need to find another way. Even with the system of sale for kidneys with with you are so sanguine, too few people think that the commodification of the body is okay and fear that those of lower socioeconomic status will be at risk for harm.
Given your passion for the issue, perhaps you could turn your disgust into something positive and help us bioethicists find a solution for the Sally Satel's of the world who are literally dying for kidneys all across this country.
Summer Johnson, PhD
Caplan Offers Reality Checks on Health Care Reform
What are the facts and fictions being bandied about in the debate over universal access to healthcare as promoted by President Obama's health care plan? Arthur Caplan in his MSNBC column today attempts to straighten out some of the true claims from the false ones and make a few predictions as to what is likely to happen if Obama's health plan were to come to pass. The upshot: health care insurance for all Americans isn't as simple to provide as some claim, but isn't as impossible either. When everyone has a horse in the race, there's bound to be some skewing of the facts and some biases in the arguments. The key is to remember the goal: healthcare access for all.
But this is my view, to read the full text of Caplan's arguments, read below, or click here to read it at MSNBC.com.
Summer Johnson, PhD
Doc shortages to deficits: Reform reality check
Sorting out the scare tactics and challenges facing health care overhaul
It can be hard to separate the fact from the fiction of the myriad claims and questions separating health care reform. Some charges -- that reform means the end of private insurance -- are quite simply bogus. Other worries -- that more insured Americans could worsen doctor shortages -- are more justified.
As President Barack Obama's health care reform plan faces a possible delay from opponents including Republicans, some conservative Democrats, health insurers and many pharmaceutical companies -- it's time to sort out the scare tactics from reality.
Claim: If millions of Americans become newly insured, there won't be enough doctors and nurses to handle them.
Reality check: This truly is a problem but it's coming anyway. If current trends continue, the shortage of primary care physicians will reach 40,000 in a little more than 10 years, according to the American Academy of Family Physicians. Medical schools are only graduating about half the needed number of primary care doctors.
The overall shortage of doctors may grow to 124,400 by 2025, according to a study by the Association of American Medical Colleges. In a recent report, the researchers warn, "if the nation moves rapidly towards universal health coverage" which would be likely to increase demand for primary care and reduce immediate access to specialists, the shortages "may be even more severe."
We need more primary care providers whether reform happens or not. We will need them sooner if reform does happen. What to do? Two simple ideas -- forgive all medical school loans for any student willing to go into primary care and practice for a minimum of 20 years and extend more authority to nurses, pharmacists, physician-assistants and other health care professionals to help fill in the primary care gap.
Claim: Any public program will kill private insurance plans.
Reality check: This is not going to happen. The centrality of a public plan in Obama's health reform push is to insure that an affordable basic package of services is available to all Americans, regardless of their health problems or health status. By pooling a large number of currently uninsured people into this plan, along with some others currently holding insurance, the cost of insurance should come down.
There will be many Americans who won't want the public plan. They will want better coverage, or might even be able to get a cheaper plan by sticking with a one that just covers certain hospitals or doctors.
Still, it is hard for private insurers to compete with government plans, if for no reason other than the lower administrative costs a public plan can offer. That's why more thinking needs to go into what sort of public plan the government should offer. My suggestion is a pretty bare bones public plan to start.
Americans like to believe, and their insurers and medical organizations like to tell them, that everyone gets the same quality of care in America regardless of income. This is pure fantasy -- as anyone who has visited both the Mayo Clinic and the troubled Martin Luther King-Harbor Hospital in Los Angeles, to pick two places at random, could quickly attest.
Congress needs to keep the basic plan basic. Otherwise, it will not be affordable and it may be too attractive to those who might otherwise buy private insurance.
Another point about public plans to consider: We do have not-for profit insurers in many parts of the nation -- Blue Cross Blue Shield and Kaiser Permanente, for example. Any chance of working out the public plan together with these already existing not-for profit insurers?
Claim: Health reform is moving too fast.
Reality check: Sen. Jon Kyl, R-Ariz., recently addressed this idea when he said, "President Obama was right about one thing: He said if it's not done quickly, it won't be done at all. Why did he say that? Because the longer it hangs out there, the more the American people are skeptical, anxious and even in opposition to it."
Well, the senator has a point but not for the reason he thinks. The longer reform stalls, the more the forces of the status quo can try to kill it.
That said, there is nothing magical about passing reform by August. The critics won't be all that much more empowered if reform gets finalized by the end of the year. But it had better not take much longer. The Washington lobbying crowd can crush anything in town given enough time and money.
Claim: Reform will result in the government rationing health care.
Reality check: This is perhaps the scariest argument about health care. Even supporters of reform acknowledge rationing could happen.
The main flaw with this criticism is that it implies we are not rationing health care now, that rationing will become a new feature in the post-reform American health care scene.
Rationing is already a daily part of the current system. How? By denying coverage to about 20 percent of the population, including a large number of children. These uninsured Americans either get no care, put off care until they are really sick, or simply use the emergency rooms of hospitals where they wait hour-after-hour to get care.
If that is not an unfair form of rationing, what is?
Another form of health care rationing that exists now is the out-of-pocket fees patients have to pay, either due to high deductibles or generally lousy insurance coverage. Some doctors are simply opting out of the health insurance mess to set up boutique, concierge or cash-only medical practices -- which results in another form of rationing.
Can we limit exploding costs by some form of rationing other than telling parents not to take their sick children to the doctor?
Claim: Health care reform will increase long-term federal spending on health care, thereby ballooning an already rapidly escalating deficit.
Reality check: Congressional Budget Office Director Douglas Elmendorf told the Senate Budget Committee in early July that the reform bills now circulating in Congress will lead to greater federal spending in future years. The Obama administration and some Democratic proponents of reform wished very hard that Elmendorf would go away. However, his caution has to be taken seriously.
The financing of reform to provide access to those who lack it needs to be strengthened. One way is to put a new income surtax on the wealthy, defined as households earning more than $350,000 a year. More sensible would be to start to tax those health benefits which are now enjoyed by the middle- and upper-class tax-free.
The issue of containing costs is more important. Obama has been talking a lot about pushing information technology into the health care system to make it more efficient and safe and collecting more data on what works, and what does not, in terms of tests and therapies.
The IT push will not show that much in the way of cost-savings, even though it needs to get done. Collecting data on what works is fine, but that won't save any money if we cannot agree that those things which are only marginally beneficial or completely experimental are not going to get reimbursed unless whoever wants them buys broad coverage from private insurers. Politicians don't like to talk that way but proponents of reform need to 'fess up on cost-containment.
Reality check: The chairman of the Republican Party Michael Steele has been comparing President Obama's health care overhaul to socialism.
This complaint is not worth five seconds of your time. Quick -- name the biggest government-run health care system in the world. If you said the Veterans Administration health system, you would be correct. Yet, instead of calling to dismantle the VA, most Republicans want to see more money spent on the system.
Claim: Health care reform will create a mind-boggling web of bureaucracy.
Reality check: Reform critics have taken to trotting out a complicated-to-follow flow chart showing the complexity of the Democratic proposal, a tactic meant to turn Americans against the reform plan. But bureaucracy is already choking health care in the United States. There could not be a more complex, inefficient, frustrating and absurd bureaucracy than the system we have now.
Have you looked at a hospital bill lately? Have you talked to your doctor about the amount of paperwork that needs to get done simply to get paid? Ask any hospital staffer about drowning in bureaucracy.
Compare the costs of administering health care in Medicare or the Veteran's Administration: They have a single payment form without a lot of back-and-forth on the billing. On the other hand, doctors have to deal with multiple payers. Major insurance companies like Aetna, Cigna and United Health have high administrative costs, sometimes don't pay the bill properly, or will put up obstacles to stop payment -- forcing the consumer to track them down.
Claim: Health reform will empower Washington -- not doctors and patients -- to make health care decisions.
Reality check: No one in Congress or Washington wants to play doctor. They are too busy to have any time for prescribing medication for your allergies or to tell you what surgeon to see for your gall bladder operation. With the Obama team taking a cue from the Clinton administration, there will not be any single government-run health plan.
Claim: Health reform is the end of innovation in health care.
Reality check: It is true that innovation is in trouble in an age of cost-containment. There is no way, health reform or not, that we can continue to pay for medical research and innovation the way we have done so in the past. But the way we have done so in the past is crazy.
Basically, Americans have paid for the cost of developing and marketing new drugs and devices from laboratories to hospitals and pharmacies by paying two to three times as much as the rest of the world. This is not the way to pay for medical innovation. In the future we need to take the cost of innovating out of the insurance side of the system and put it firmly into the research side, where we can all then decide how much we really want to pay to innovate.
Chi-Town Is A-Buzz With Bioethics Happenings...
Chicago's Museum of Science and Industry is encouraging the Chicagoland area to come out for a panel discussion about bioethical issues fed from topics and questions sent from Twitter and Facebook, says the Chicago Trib.
The project called, "Science Chicago", will include local bioethicists from Northwestern University and the University of Chicago to talk about current questions that residents of the Windy City want to know the answer to, or at least have been pondering.
If only every medium to large-sized city in America were holding such a discourse on the major bioethical issues of the day, perhaps we might have a public that were both educated on the basic science of these current and emerging issues as well as informed about the ethical issues at stake in rapidly advancing science. An idealistic goal, I know, but one to dream of.....
Also happening at Northwestern University: it's under new leadership! Congrats to Tod Chambers, PhD, former ASBH president and AJOB Editorial Board member, who is now the Director of the Medical Humanities and Bioethics Program at Northwestern University.
Summer Johnson, PhD
Keeping Your Skin Youthful, The Stem Cell Way
Stem cells are, apparently, all the rage in the world of cosmetics. Slather them on your face to keep your face young and ageless or to simply make yourself more beautiful on your eyes, cheeks, or lips. New products like Lancôme's Absolue Precious Cells claim to "help restore the potential of skin stem cells and bring back the skin of youth". But there are many more products on the market than just this single creme, according to the Times Online.
But is this even true? Will slapping on stem cell creams keep your skin as youthful as a brand new embryo or is it just a bunch of hype? The truth is that while most of these stem cell creams aren't likely to do much more than make the surface of your skin appear smoother (rather than giving you new skin regenerated by the stem cells in the cream), they aren't likely to harm you either.
As for me, I will agree with the conventional wisdom--the best way to keep skin young and healthy is just keep it out of the sun--and I'll pass on the stem cell concoctions for now.
Summer Johnson, PhD
IVF Mom Who Lied Isn't The Problem....
Headlines last week about a Spanish mother who at age 69 died leaving behind two, two-year-old twins sparked controversy about the wisdom of providing IVF treatment to women of advanced maternal age. In the case of Maria del Carmen Bousada de Lara, she lied about her age (at the time she was 67) to be able to receive fertility treatments at the Pacific Fertility Center in California.
But what matters about this story now is not Maria's decision to lie on her application or to get a fake ID or any of her other choices, but that now there are two children that will grow up without their biological mother or their biological father and will have a different understanding of family than most children do.
Is this bad? Of course not. The "traditional" notion of family as bound up by biological relationships comprised of a mother and father genetically-related to their child has been abandoned my most for some time.
But the deeper question is: do we want the Maria del Carmen Bousada de Lara cases to become more mainstream with the chance that mothers of advanced maternal age, even if they can give birth to healthy babies, may die before their children grow to adulthood?
For me, the only key requirement for candidacy in these circumstances is that the prospective IVF mothers have a plan in the event that the very worst world happen. Ideally, these mothers would be required to designate a set of "second-string" parents (if you will pardon the sports metaphor) who would be younger than the biological mother be more likely able to care for the child continuously throughout their childhood and adolescence until adulthood.
If there is an extended family, as would be the case in many cultures and situations that would also be caring in large part for the child, all the better--but the primary caregiver would be someone who would be younger than the original mother (but of course chosen by her) who would care for that child until adulthood.
Having more than one adult designated will ensure that in the event that one of these adults could not serve as the parent, the other could. The sole goal of such a system is to ensure that young children are not left without caregivers of the original IVF parent's choosing and that advance planning is done, especially for mothers of advanced maternal age, given the greater likelihood that they may not live to see their child grow to adulthood.
Now, some may argue that all parents (young or old, reproducing naturally or artificially) should have such a plan as any parent could be struck with an unexpected injury or illness at any moment. While this may be true, it is the children born to single mothers, mothers of advanced maternal age, or mothers without extended families or social networks that suffer the most from such tragedy and for whom such advanced planning must be done. For nothing could be worse than having twins left without a mother and no plan for who will care for them.
Giving IVF to mothers of advanced maternal age isn't the problem--giving it without making sure they have a plan in the event of unexpected illness or tragedy is.
Summer Johnson, PhD.
It's Not August! But The August Issue of AJOB is Already Online at Bioethics.net
Now available at bioethics.net is the August issue of The American Journal of Bioethics.
This month's issue contains articles ranging in topics from organ conscription and whether the US ought to have an opt-out system for organ donation and a number of thought experiments supporting that position by Delaney and Hershenov. Their conclusion? Consent for organ donation? Why bother?
Liao et al. discuss whether there is a duty to disclose adverse events in clinical trials and conclude that perhaps the best solution is a regulatory one: a database to list all adverse events that is publicly available. Will it work? Will it happen? We don't know. But it certainly is creative.
Ballantyne et al. ponder the question as to whether it is ethical to offer prenatal genetic diagnosis in countries where there is no access to abortion. Is the knowledge ultimately harmful to the parents? Simply useless? Or is it in someway useful?
Whatever you are interested in, early and available now check out this month's issue here on bioethics.net. Plus, be sure to note the cover art from Denver, CO artist David Foox whose organ donor toys are one of a kind in the world. To read more about them, click here.
Summer Johnson, PhD
Is There a Fitness Requirement to Be Surgeon General?
Art Caplan asks whether you have to be thin to be S.G or whether it's simply a "big job for a big lady" in today's MSNBC column.
Caplan has a point--with a President who has openly acknowledged that he struggles to kick his smoking habit and and a previous first couple who had to get off the the sauce and a few other elicit substances--it can hardly be argued that our public figures--even public health ones have to be either moral or physical exemplars in every way. In fact, who better to teach our young children about the importance about physical fitness and obesity than someone who struggles with it herself? Not to mention, as Caplan does, that what matters for the S.G. is her MD, not her lbs.
Summer Johnson, PhD
Surgeon general post is a big job for a big lady
Do you have to be thin to be fit for the role of nation's Top Doc?
by Arthur Caplan, PhD
Since President Obama announced his pick for the nation's Top Doc, Internet message boards have been atwitter with the observation that Dr. Regina Benjamin is fat.
Critics seem to believe it's ironic that the nation's top doctor would be overweight, and it's led the most nattering of nags to conclude that she should not be picked for prom queen, er, I mean, surgeon general.
You would think the entire population of the blogosphere had suddenly reverted to the seventh grade.
"I refuse to let fat be socially acceptable ... The President should have known better and picked a doctor who could kick start the debate on fat not perpetuate it," commented one reader on a national news site.
Another has some mighty specific requirements for the post: "Rather than select a fat Black woman Obama should have chose a Black woman with a body mass index of 25 or less."
But amid the fat-bashing tirades resides a point worth addressing. One more restrained discussion board poster poses: "How can Dr. Benjamin promote healthy eating if she herself is obese?"
As a man who is constantly trying to trim down, let's talk some turkey -- lean, of course -- about Benjamin, the office of surgeon general and body lard.
No, you do not have to be thin to be fit to be a great doctor or even the nation's No. 1 doctor.
Just as in sports, the best coaches are rarely those who were the best players.
And who said the surgeon general or doctors in general or anyone working in health care must be paragons of health and risk avoidance?
C'mon now. Sure, Benjamin could lose some weight. Other doctors smoke or drink too much. Others ski or pilot small planes. Most don't exercise enough and nearly all work way too much.
I have even heard tell of a certain skinny president who smokes once in awhile.
I am not saying we give an inch on the war on blubber. Obesity is an epidemic in the U.S. and growing quickly around the globe.
But people need to relate to the surgeon general, and if she can battle her weight on the job, she will do more to curb obesity then all the salads added to the menus of burger joints everywhere.
In fact, if this Alabama physician can connect with fat Americans of all ethnic groups because of her own weight, she stands a very good chance of reaching them about the problem.
Besides, weight aside, Benjamin does bring some rather impressive bona fides to the job. She was awarded the Nelson Mandela Award for Health and Human Rights, was the first person younger than 40 to be appointed to the board of the American Medical Association, is the immediate past chair of the Federation of State Medical Boards (meaning other doctors think highly of her) and won a "genius grant" from the John D. and Catherine T. MacArthur Foundation.
Most remarkably, she chose to practice among the rural poor at the clinic she built herself in Bayou La Batre, Ala., charging her poorest patients nothing.
I don't know about you, but a doctor who chooses to care selflessly for the poor and who has the respect of her peers as a good clinician is a doctor whom I am willing to listen to -- even if she wears a plus-size lab coat.
Dr. House is Pro-Life? Just Ask The Vatican.
It was unbelievable enough that House, M.D. has become the world's most watched television program, but even more astonishing is the news that the Earth's most beloved show espouses pro-life values according to the Catholic Church.
Television's greatest misanthrope is pro-life! At least according to the analysis done by the Vatican newspaper L'Osservatore Romano. I wouldn't have guessed that one.
For all of his callous attitude, barking at patients, pranks on everyone he knows, cutting corners at every chance to do anything to save a patient, and his mantra "Everybody lies", it turns out that House ultimately fits right into a culture supporting the preservation of life (even though they conclude that he is "evil" and "cynical").
How is this possible? The authors conclude that a therapeutic power can come even from a bad person and that a healing force is possible from even the most unexpected places, increasing "trust in ourselves as fallible (but redeemable) human beings."
This is nothing more than co-opting the world's most popular television program and perhaps personality to try to project pro-life values. The only way in which House is pro-life is that he simply hates to see any of his patients die--because he just can't stand to lose or leave a puzzle unsolved. In a completely ridiculous and unrealistic way, hardly a single patient ever dies on House, M.D. despite the fact that they come into Princeton-Plainsboro Teaching Hospital with the most exotic ailments known to man. This is a wholly different motivation to keep human beings breathing rather than being pro-life for the sake of life itself in any real sense in which the Vatican is attempting to connect up House MD with the Church.
The entire argument that House is pro-life is simply an attempt by the Vatican to leverage the world's most popular television program as a teaching tool for pro-life values--and one that falls flat on it's face. Catholics and non-Catholics alike--just watch House and enjoy him for his evil ways and his unbelievable differentials and life-saving abilities and just chuckle at his misanthropy when he reminds you that "everybody lies."
Summer Johnson, PhD
Common Ground on Abortion? Not Likely.
President Obama isn't really asking for much. Really it's quite simple: both sides of the issue, conservatives and liberals, must give up a little bit to reach a "common ground" on a perennial issue to lay this "culture war" on abortion aside. Then both sides will have achieved a little good (in their eyes) and not have given up completely on their issues.
As Dan Giloff's God and Country blog explains this week, the White House is attempting to package an all-in-one abortion bill that would satisfy both parties--and provide access to reproductive services for pregnant women and provide contraceptives and sex education. Both stated goals ideally would reduce the need for abortions, or so the argument goes.
Seems smart, seems reasonable--but it will never happen. It's a little too smart and too reasonable for the one issue that seems to elude our rationality--at least in this country. The culture wars cannot be "repackaged", tied up with a tidy bow, and then sold as a problem so easily resolved. I think anybody can see the plausibility of such a proposal in an ideal world and see the utility of a moderate abortion policy for the United States. However, ours is not such a political world--ours is one filled with advocacy groups (on both sides) hanging on to this issue, in particular, as the barometer of their social policy and the future of women's health. More than that, It is simply just one of those issues that is supercharged, laced with all the emotion a policy issue can have, and therefore, is not amenable to the kind of reasonable approach President Obama's White House is attempting to exercise on it.
While this is probably the most imaginative policy approach to abortion policy in years, I am a bit skeptical as to its success. Asking both sides to give a little to get a little is more likely to result in each side asking the other side to give a little more for them to get a little more until the bills do not resemble anything like what was started with. Ultimately, the issues may have to be uncoupled and pushed through the Democratic Congress if progress is to be made on this issue. Common ground will be lost, but progress (at least in one direction and according to one set of folks) will be made.
Summer Johnson, PhD
