Tuesday, October 13, 2009

Patient, Heal Thyself: A New Vision for Self-Directed Healthcare

Originally written July 16, 2009.

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The Current State of Healthcare

I have a prosaic admiration for medical science, but a secret love in my heart for nursing science. Few things warm my heart as the sound of hearing an ambitious young person say that they are pursuant of a Practical Nursing degree. This laudable profession demand so holistically from the practitioner and provide so holistically for the recipient. The quintessential nurse has within an unfettered appetence to serve, an ameliorated mental alloy of theory and practical knowledge, and an Empathetic Unmoved Mover, divvying out apportioned doses of clemency while measuredly developing an iocane powder-like immunity to the harsh vicissitudes of a healer’s daily work. The medical provider is the physical counter-point to a priest: they are midwives to life and witness at death—humanity’s Janus-like gatekeepers. Adept with evolving technologies and keepers of the old magic, with eyes trained to find bedsores, ears to detect death rattles, noses for accidents and hands for the terrified.

Almost without doubt, the 20th century brought more advancement in medical science than all the centuries before it, and one may portend the same will be said of the 21st. Knowledge appears to be growing at an exponential rate, and the future of science will not only make Man healthier, but perhaps a New Man; doubtless, science will continue to revise our conception of him. When the future unveils this new ubermensch with a vociferate ecce homo, we may scarcely recognize him. Dystopia upon dystopia predict a Frankenstein—a monster we cannot contain. Perhaps our greater, unspoken fear is creating an angel that with which we cannot contend.

Man may be at a scientific and spiritual crossroads, but the current state of medicine has meandered onto an economic cul-de-sac. Medicine has, not unlike modern food production, given us too much of a good thing. A thousand years ago, a man could expect to live to the ripe old age of 24; a hundred years ago, 49. President Calvin Coolidge, who in 1924 had the best medical services one could buy, lost a son due to an infection after playing a game of tennis. If someone was born in 2000 and lives a healthy lifestyle, they can expect to live to be over 100. We are seeing a perfect storm of an increasing elderly population, increasing medical care costs, and the prolonging of life spans. In short, we’re going broke and we don’t know how to pay for all the things we want.

Yesterday an article written by Princeton bioethicist Peter Singer came out in the New York Times. In it, he puts about as fine a point on it as a person can: How do you measure the value of a life of young and old persons? I will not discuss Singer’s piece, but I highly recommend it because this is going to be a major concern for all of us. If we go along as we are now (we won’t), Social Security will be in the red by 2025; and, if I were to live to be 100 (I won’t) Medicare and Medicaid alone would be approximately 18% of GDP. “Do not fear, for the worst is yet to come.” We used to fantasize about jet packs, flying to Mars and a cure for cancer: now most of us dream about a future with 401Ks.

The Plan

Nevertheless, I’m not a doomsayer: I believe most problems have solutions and all we need is the right one. This solution is not so much to get at or past the monolithic costs of healthcare per se, but to recast the vision of medical intervention. Bringing me to this issue was a Cato podcast I listened to called The Politics and Science of Medical Marijuana. In the podcast, two physicians discussed the issue of medical marijuana with a pro-marijuana advocate. The person I want to highlight is the second speaker, Robert Dupont, M.D. He spoke with passion as a doctor who wants to address health issue along the lines that the medical gemeinschaft has done for the past several decades. I must admit, I was at first taken by his sincerity; at first blush, he seems like a man who went into medicine for the right reasons and I don’t doubt he has his patients' best interests at heart. But as he spoke I felt my appreciation turning. As he went along, he sounded more and more like a person who felt he ought to be in control, and that he not only felt an obligation to foster health in his patients (which he should), but he would in fact use his authority as far as he could to ensure that his patients did live healthy lives, regardless of how it might impinge upon their lifestyles.

We have taken it axiomatically that a physician’s job to his patient is to prescribe a lifestyle of health to the best of their abilities. My change is simple: the physician’s job would not direct their patients’ healthcare, but empower the patient to make informed decisions about the lifestyle they wish to have. What I propose is that drugs and other therapies would not require a medical doctor’s prescription (or “permission”), but any substance, for any reason, would be available to anyone of legal age if they could afford it. Under my system, there would in fact be no “controlled substances.”

Where does this leave the physician? Does he now just go home and find another profession? No, because people would still wish to have a certified physician to guide their healthcare. We would still need trained professionals to diagnose our pains and aches and wounds. One particularly valuable service doctors provide is making sure drugs don’t counteract each other or have other unintended consequences. But, the physician would no longer be the sentry of healthcare.

Why should we change the system? Is not the medical industry, for all its failures, a relatively successful and well-working engine? I would argue yes and no. I am not an enemy of the American medical system, but my criticism of them is both pragmatic and ideological in nature. Let me give three groups of people whose lives would potentially be greatly improved upon if my plan was enacted.

Who Benefits and Disputations

I have seen in my own family that there are people who cannot get the pain killers they need to manage their pain. This is not so much a problem my plan needs to solve: I believe a more liberal policy on narcotic prescriptions would quickly deal with this occurrence. Currently, if a doctor prescribes too much pain medication, they can be brought up for review and risk losing their medical license. This means that many people who live with chronic pain often turn to alcohol or illicit drug use to handle their suffering. This is unacceptable. I believe at the heart of this is that we live in a post-Victorian society, and we fear that people will over use drugs for their euphoric effects. I have two things to say to that—so what? We all have something that helps us cope in this life: television, sports, overeating, sex—who is to say which mind-altering activity is acceptable? (On the latter two, I recommend this column by George Will: Prudes at Dinner, Gluttons in Bed.)

When discussing the issue of healthcare on the national stage, we often hear about the millions who are uninsured. In cases where they need surgery, this change would not affect them. But, in cases where a poor person needs, for instance, an antibiotic for their sick child, they won’t need to go into an expensive doctor’s office to get a prescription for penicillin. Here is a good place to interject one common counterpoint to my plan: People would buy these drugs and live self-destructive lives. Some would. The biggest concern with my idea is that there will be a sharp spike in drug abuse. While I don’t think it’s as dangerous a notion as these crepehangers might purport, I can’t prove them otherwise. My rebuttal would be that we can already live self-destructive lives with drugs and alcohol if we so choose. Alcohol is legal and drugs are not that hard to come by, if one wants to find them. If we can, as a society, manage alcohol abuse with enough success that the buses and trains run on time, why not marijuana and opium?

The last group that would be helped is the desperately ill. One problem with the FDA, according to Nobel-winning economist Milton Friedman, is their tendency to overregulated medications. Estimates on how much it costs to get a drug approved range between $200 million and $2 billion, a process that takes about 10 years to accomplish. To put it in perspective, if a drug has the ability to save 10,000 people a year, and it is ready to go in 8 years, if it takes 10 years to get on the market, 20,000 people died in vain. Instead, is it not more respectful of a patient and their rights to give them the knowledge that they may be taking a drug that hasn’t been fully tested and to let them decide? Currently, that’s not how our system works. We would rather let desperate people who want to live die or continue being sicker than they need to be than let them take a chance with their own lives. Of course, with this would have to come an implicit understanding or an explicit law passed that made litigation against unintended effects prohibited.

A final point I'd like to make and a contention to answer. In considering the poor and reckless, what should be done about information on drugs? While I have not fully fleshed this out in my own conception, the internet is now a powerful tool for self-directed medicine. It is now within a person with average intelligence to find the relevant knowledge of many diseases for little or no cost online. Much of our medical care could be scaled back with people who learn to self-educate themselves on their own diseases. Another argument against my plan would be on how we handle people who take a drug, say a pain pill, and they commit a crime while under the influences of that drug. My argument would be we should treat it like any other chemically induced crime and punish it under our legal system.

Conclusion; or, My Libertarian Spiel

Going back to my first criticism, what if people just go crazy and become drugged-out junkies? Ought not society to curb that behavior? I can’t help but ask, Do you not feel a bit like a child when that’s government’s role in our lives? Do you really want to say no to everyone because a few people will abuse something, to hurt only themselves? I’m sure that most doctors want to help their patients and have their best interests at heart. But remember that physicians and politicians share one thing in common: they delight themselves on controlling you. They want to tell you how to live, and will gladly take a pound of flesh and say “you’re welcome” for the service. Doctors want to tell you what to eat, how long to exercise, and what you should and should not put in your body, in large part “advised” by a well-paid representative from the “drug-pusher” of the pharmaceutical industry. Lord Acton was right, and the only thing a doctor likes more than helping people and getting paid six-figures is having their thumb over your day-to-day affairs. It’s not called “playing God” for nothing.

Freedom is not empowerment. Empowerment is what the Serbs have in Bosnia. Anybody can grab a gun and be empowered. It's not entitlement. An entitlement is what people on welfare get, and how free are they? It's not an endlessly expanding list of rights — the "right" to education, the "right" to food and housing. That's not freedom, that's dependency. Those aren't rights, those are the rations of slavery — hay and a barn for human cattle. ~P.J. O’Rourke

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