Why Not Apply the Oath of Hippocrates to Health Care Reform?

Tonight in his speech on health care, President Obama acknowledged the values of “self-reliance, rugged individualism, love of freedom, and healthy skepticism of government,” which, held dear by so many American people make the U.S. such a remarkable–and remarkably successful–country. But I did not hear much in his speech–or in the ghostly outlines of a plan that he delineated–that honored those values.

Rather, the picture he drew of what the health care system would look like seemed to exclusively prioritize other values–the need, in an advanced democracy, to protect people from hardship, the need to provide people stability and security, the need to reduce costs–all very important priorities, but not the only ones.

The humanitarian provisions he mentioned–insurance companies would no longer be able to drop coverage when you get sick or water down coverage; insurance companies can’t place a limit on how much can be charged for out-of-pocket expenses “because in the U.S. no one should go broke because they get sick” sound good to me. Given that insurance companies make big money by insuring that people will be taken care of should they become sick, it is only logical and fair to hold them, legally, to that promise. After all, if they don’t come through in the clutch, they are violating a contract and, in effect, stealing from people. So the idea of promoting this type of reform of the health insurance industry strikes me as excellent and long overdue.

However, when the President claims that his administration will insure the tens of millions of uninsured, bring down health care costs across the board, and improve the quality of health care, all without spending any additional money on health care, I am deeply skeptical.

Common sense dictates that almost everything in life involves tradeoffs. Too many priorities, pursued to an extreme, usually means something does not get done, or at least does not get done very well. Health care is not an area of expertise for me, but from a common sense perspective, it does not make sense to me that all of the above will be true. But I hope I’m wrong. I can imagine that, with more people insured and some sort of serious incentives promoting prevention, fewer emergency room visits might be required. But it does seem rather idealistic to believe the government can actually create this improvement for individuals.  And it seems unlikely to me that, with the government paying doctors and operating from an imperative to cut costs, so many of the best and the brightest will continue to choose to become doctors, or that, again given the imperative to see more patients and cut costs, the quality of health care will not decline. It also seems unlikely to me that, with so much profit motive gone, the U.S. will continue to provide the world with as high a degree of groundbreaking medical advances as this country does now. There are reasons the U.S. has been the world’s leader in cutting edge medical research and treatment. And it isn’t thanks to government control.

On the other hand, from a humanitarian perspective, the idea that everyone will be insured has great value to me. I agree with liberals that in a country as properous and developed as the U.S., basic health care is a human right. In fact, although I value education, I think a case can be made that basic health care – the right to see a doctor and be cured, for instance, of a curable disease — is a more basic right than the right to a public education (the latter is never mentioned in the Constitution and is not essential to that first right outlined by the Founders, the right to Life).

All that said, I think the plan should be designed in such a way that reflects not just our value of the human rights to health care and Life, but the value the Founders thought to mention second: the right to Liberty. For good reason, liberty is associated with the other values President Obama mentioned in his speech: love of freedom, rugged individuality, self-reliance, and healthy skepticism of government. These are extremely important, even sacred; for without them, we become a nation of dependents who expect government to take care of us, cradle to grave. Also, we become a nation of individuals whose values–and whose value–is determined not by our individual visions and beliefs but–and heaven forbid it–by our value to the State (that is why Sarah Palin’s “death panel” concern was, while perhaps phrased in an alarmist way, not off the mark. It only stands to reason that “end of life counseling,” when combined with the imperative to cut costs and a profit motive for doctors to initiate such discussions, is a recipe for the encouragement and even normalization of euthanasia).

We should beware the slippery slope of collectivist thought and policy. To paraphrase former NYC Mayor Rudy Giuliani, you don’t want government doing too much for people, because then people get out of the habit of doing it for themselves. Giuliani believed this applied not only to income-generating work but to civic involvement and volunteerism as well. 

That said, some people require assistance. And in a developed society like ours, health care should not be denied to some.

The Oath of Hippocrates, the ancient Greek statement of medical ethics, was: “First do no harm.” Doctors are supposed to honor this oath when treating a patient. I understand this statement to reflect a humility, and to be an acknowledgment on the part of the doctor of his or her limitations. In other words, the doctor is not supposed to interfere or prescribe in an invasive way unless truly necessary and such intervention is genuinely thought to be what the patient requires. My favorite doctor, a very wise podiatrist named Dr. Howard Diamond, put it to me this way: “My dear, I am going to try what is least extreme first.” To treat a nail infection, a good doctor does not amputate a toe, or even an entire toenail, immediately. Unless it is a bona fide emergency, he tries what stands some reasonable chance of working, but is least invasive, first. Only afterward, if that treatment has failed, does he or she try more invasive treatment. Of course, I would assume that if the doctor is treating something serious, he or she must take into consideration the relative risk of not doing enough, the amount of time he/she has to attempt less invasive treatment, etc., but the basic principle is one of respect for the integrity of the patient, body and soul, for natural processes, etc. Also inherent within the pledge is the idea of “if it ain’t broke, don’t fix it” and the implication that anything invasive carries risk, and therefore should only be done if truly necessary. In other words, treatment can end up making the patient worse. So it should only be done if necessary. The doctor pledges to refrain from employing the full scope of his/her power and authority to take some dramatic action simply because he can, but instead acts with humility because he recognizes his own limitations.

Why not apply the oath to health care reform? Clearly, with outsize health insurance costs for the majority of Americans and a significant minority of working poor uninsured, reform is necessary. But is it really necessary that the entire system be overhauled? Given the recent failures of the U.S. government in controlling spending–the bankruptcy of the social security system, of medicare, of medicaid, is some humility not in order? Is it not more realistic, say, to take a step-by-step approach?

After the President’s speech, Tim Pawlenty, governor of Minnesota, made the point that, with regard to the President’s idea that eliminating waste and fraud in the Medicare and Medicaid systems would pay for the public option, “if you can save all this money via Medicare and Medicaid why not try that now” (as opposed to waiting to clean it up until some kind of massive health care reform system is developed) and use the money saved to start insuring the 25-30 million uninsured in this country who want coverage?

Why, instead, insist upon a massive overhaul of the system, including provisions that would penalize young, healthy people who choose to opt out of getting health insurance?

To paraphrase Rep. Charles Boustany (R-La.), who gave the Republican rebuttal following the President’s speech (and who was a good choice to give such rebuttal, as a heart surgeon who is clearly not a slick politician), why create dozens of new offices of government bureacracy in an attempt to create greater efficiency?

Why not show some humility, some effort to first do no harm to a health care system that, despite its serious flaws, remains the world leader in medical innovation, research advances, and quality of care?

First, do no harm. 

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