Following in this post is the text of a talk I gave at Bethlehem Baptist church on 11/16/09. I had the honor of speaking with Twila Brase, RN, who started an organization called Citizens Council on Health Care (cchconline.org). She and her group advocate for patient privacy and no interference with the doctor-patient relationship, topics near and dear to my heart. She is also an expert on the proposed health care reform bill, which will change the practice of medicine forever in this country–and not in a good way. Please access her site and learn. Donate to her organization if you can.
Here is the text of what I said.
I would like to talk tonight about two issues primarily. One will be about morality and ethics in medicine and how straying from the Christian and historic underpinnings of medicine have allowed changes that no one expected, changes which will become national with passage of the health care reform bill and the other will be about “cookbook” medicine, eugenics, euthanasia and how it affects doctors and also the medical care you receive.
Let me start with a question. What percentage of new doctors just out of medical school take the Oath of Hippocrates, the Hippocratci Oath? What would you think, 100%, 70%, 30%, 5%? Well, according to a study done in 1993, the number is less than 1%. So the Oath that nearly every lay person thinks we take—we don’t. What do we take? We take a watered-down version that ignores the main thrust of the Oath of Hippocrates.
I’ll go over why that is, but first I want to give an overview of this oath and there are six main tenants of the oath, all of which are important.
The actual oath of Hippocrates was written by maybe Hippocrates, we’re not sure. But it was written around the time he lived and so it was named after him. The actual oath is not Christian. It swears to some the ancient Gods of the time, so Christians maintain the essential points of the oath but make it Christian.
The first point is transcendence, which means submission to a higher authority, in our case, the God of the Universe who created us and sustains us.
The second identifies medicine as a fundamentally moral activity, not just a technical activity.
The third is respect for life, meaning no abortion or euthanasia.
The fourth is a covenant for care between a patient and physician, not just a code of conduct or a contract.
The fifth requires physician honesty and integrity, holding in confidentiality what he is told and not using his power to take advantage of the weak and helpless.
The sixth deals with collegiality between like-minded physicians.
How did we find out about the watered-down version of the Oath?
A study of 157 deans of medical schools done in 1993 found that only one school used the text of the classical Hippocratic Oath, but 68 reported they used other “versions” of the traditional oath. When researchers examined the contents of all oaths in current use, they discovered that although 100% pledge a commitment to patients, 86% to teaching, only 43% vow to be accountable for their actions, only 14% include a prohibition against euthanasia, only 11% invoke a deity, only 8% foreswear abortion, and only 3% retain a proscription against sexual contact with patients. So what new doctors recite now ignores important parts of the original oath. I’d like to go through how ignoring transcendence and life issues affects medical practice today.
Let’s look at transcendence, or the accountability to God for our actions, accountability we will answer for one day when we stand before him. Accountability is a humbling thought. We will be judged by God on our actions. Think of it. Doctors will be judged for their actions as doctors. But modern medicine has a different view of accountability. Modern medicine works off a bio-psycho-social model, a model which totally denies we are spiritual beings. I remember when I was on my psychiatry rotation as a medical student. We were learning about schizophrenia, which is a mental illness characterized by paranoia, delusions, losing touch with reality. My professor said such behavior was always abnormal, except when it came to religion, because that is a normal, acceptable delusion.
Modern medicine uses the ethic of utility, which means whatever gives the most good to the greatest number is OK as long as it increases happiness. And the situational ethic, which says love is the only ethic, that love and justice are the same and that right and wrong are determined individually in each situation and the end always justifies the means if it increase happiness.
So medicine no longer holds to responsibility to God, but medicine replaced that with ethical views are unpredictable. Neither has a solid foundation, and since there is no foundation to either one, one can never be sure that the patient is the primary consideration when receiving care from a doctor. It could be the economist dictating medical decisions, or the administrator, or the bureaucrat or even the doctor himself who is paramount in the medical equation. If there is no absolute truth, which the utilitarian and situational ethics hold—if there is no God-defined morality on which to base the doctor-patient relationship, then there is no protection for the patient. It is God’s truth and God’s morality followed by a committed physician that protects a patient from harm, not an economist or bureaucrat or administrator. So I hope you can see the value of a doctor realizing that he or she is ultimately accountable to God, not the corporation, not the government, not the economist, not the bean counter. We have had such a long Christian tradition in our country that we still operate with the shell of moral medical care. But that is changing. The Oath of Hippocrates is an Oath because it recognizes accountability to God. The best modern medicine can come up, since God is not part of the equation, is a code—a code of conduct for physicians.
Let me give you an example of doctors ignoring accountability to God. You all remember, I am sure, the holocaust in Nazi Germany in WW2. What a horrible time. Six million Jews lost their lives. 9 million total when one counts the gypsies and other undesirables. But the cultured, sophisticated nations of Europe knew about the beginning genocide early in the war and did nothing to protect those being gassed—they did not even protest the genocide and, in fact, some cooperated with the Nazis. Why? Why? Why would they do that? Why would the Germans not blink when this was going on. Because early in the 20th century, the idea of eugenics had taken root. Margaret Sanger, the founder of Planned Parenthood, wanted birth control and abortion to stop the Irish, the Negroes, the poor, the vermin of society from reproducing. Eugenic thinking was very avant garde. Eugenics, of course, means improving the human race through better breeding and eliminating the retarded, feeble, the old, the disabled and other undesirables. So what the Nazi’s were doing was not protested. In order to justify the killings, the Nazis turned to the doctors of Germany. The psychiatrists, you see, designed the gas chambers. German doctors in the killing camps did a sham “medical selection” of those to be killed. Medically, eugenically, they viewed Jews, gypsies and other groups as inferior, so their elimination was progress for the human race, not a blight on humanity. Germans were the best, the super race, so they were just fulfilling their natural role. They just extended the logic of eugenics to these groups. Physicians had lost their way, had ignored the tenants of the Oath of Hippocrates and, instead of preserving life at all costs, eliminated the lives they wanted to eliminate—for the betterment of humanity, of course.
How many of you know that we practice eugenics in our country today? At every university hospital, every medical school (with a few exceptions) We are eugenicists. We are trying to design a world of “perfect people,” where no one is born with a disability and no one has an increased risk of any genetic disease. And we do that of course through prenatal genetic testing. And we just yawn.
Genetic testing is done now, even by Christians. The doctors who do the genetic testing always say they are neutral on abortion. With a wink and a nod. But when a baby with a handicap is found, the push is always to abort the child. 70 to 90% of babies with Down syndrome now exit this world through the abortuary. Other handicaps are equally at risk. The incidence of cystic fibrosis has declined 30% since testing became available. They now even have a test on embryos call Prenatal Genetic Diagnosis in which an embryo is created in a dish, then one tiny cell is removed, and the genetic material tested for problems. One couple had a strong family history of breast cancer and they wanted a daughter, but didn’t want her to have the gene that increased breast cancer. So they made lots of embryos for testing. Each embryo was tested until an embryo was found without the gene. That one they let grow. And they had a brand spanking new little girl. And they were so proud that they had not “inflicted’ that gene on their daughter. But what about those many embryos that didn’t pass muster? Well, they were rinsed down the sink. Easy. One doctor in the United States, one of our countries major abortionists, David Grimes, even admitted in a weak moment that without abortion, genetic testing would disappear as a procedure.
How long before an insurance company says to a young couple, we will give you very cheap insurance on any children you have until they are 15 years old. The only requirement would be that you have genetic testing and abort the baby if any of the problems we may be concerned about are found. Or, with the government in control, they could say, we will give you an extra, say, $5000 dollars cash for each child you deliver provided you have genetic testing and abort a baby we don’t think is good enough. Or they could just make it law that everyone have genetic testing.
Oh what a wonderful world it would be! No people with disabilities clogging up the system, no cystic fibrosis, no Down syndrome, no spina bifida—none of the more than 6000 known adverse gene mutations! Why, just think! When they come up with a gene for those with an IQ of less than 90, only smart people could be born. And, you know, if your political party were in power, your party could decide what inferior meant. Why, it could include races, or religions, or height or weight. The sky is the limit!
That chuckling you hear in the background is the spirit of Margaret Sanger and Adolph Hitler and all other eugenicists from ages past quietly laughing as their ideas resurface, ideas of elimination of undesirables and a world with only perfect people.
Back to where I was. In response to the holocaust, the nations got together and developed a physician code of conduct. A code that they thought would prevent a holocaust in the future. They did a physician code because doctors were so closely involved in the genocide. But since their code was based on behavior and not an oath to an all supreme God, it missed the mark. The code was based on rationalism, but rationalism depends on whose rationality is in power. An Oath to God meant the doctor was responsible ultimately to God, not just himself and not just man. This change from an Oath or Covenant with God to Code or Contract for behavior was like turning the Ten Commandments into the ten guidelines.
As our world has become more secular, more humanistic, more based on rationalism, situational ethics and utilitarianism, we now no longer all inhabit the same story. What do I mean by that? For centuries, the Bible was the main book taught—to everyone. Everyone knew the stories from the bible. Everyone understood the morality of the bible. Now, not so much. I’ll give you an example of how things have changed just since WW2. When the British were being chased off the continent of Europe by the Nazis, their troops were in Dunkirk, trapped between the Nazi war machine and the sea. The British made a daring rescue of the troops with nearly every boat England sailing the channel to bring the soldiers home. But when they were first trapped, when they didn’t know if they were going to be rescued or killed, the British commander at Dunkirk sent a message to England and this message was only three words. His three word message was understood by everyone in England and told of their plight and their resolve. Those three words? “But, if not…” It’s a Biblical quotation. Can anyone tell me where it is found and the context? In Daniel 3:16 Shadrach, Meshach, and Abednego answered and said to the king, “O Nebuchadnezzar, we have no need to answer you in this matter. 17 If this be so, our God whom we serve is able to deliver us from the burning fiery furnace, and he will deliver us out of your hand, O king. 18 But if not, be it known to you, O king, that we will not serve your gods or worship the golden image that you have set up.” Everyone knew what it meant. That they would fight if need be and not give in to the Nazis, even if it meant death.
So we no longer hold to the same story, the belief in God that defined medical ethics for thousands of years. As a result, the Oath has changed; our commitment to patients and to life has eroded or disappeared. The trust patients have in their doctors will soon, if not already, be on the decline.
Sanctity of life is another tenant of the oath. “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly, I will not give a woman an abortive remedy,” it reads. This statement of the sanctity of life is probably the main reason the oath was jettisoned in the 1970’s. No one says that part anymore. The oath stands against abortion and euthanasia.
Why did Hippocrates put that phrase in the Oath? Why the commitment to life in 400 BC? Because, so many thousands of years ago, doctors could not only heal, but also kill. Their power and status in society allowed them to take advantage of the weak and helpless. You never knew if someone was paying the doctor more for your death than you were for your life.
But Hippocrates changed all that. By protecting life at all costs, patients knew they could trust their doctors to never kill them, no matter what. Margaret Mead, the libertarian anthropologist and not a Christian, may have said it best, believe it or not. She said,
For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. … With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect – the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child. . . . [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer – to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. . . . [I]t is the duty of society to protect the physician from such requests.
As a result of this Oath, patients knew they could trust their doctor to protect their life, no matter what. That they would be safe in their doctors hands, that doctors would always put them first, that they would be responsible to God, not the emperor for the care they gave, that they would always do their best to heal. This was truly revolutionary thinking. So, people voted with their feet. Those who did not take the oath soon found no patients in their waiting rooms. The Oath became the standard for more than 2000 years.
But now we are governed by this new ethic. The vestiges of the Oath still persist and have given us good care. But the winds of change blow strong. So, what is the effect of this new ethic, this utilitarian, situational, rationalism, eugenic ethic? Or rather, lack of ethic on the practice of medicine today? I’m going to give you two main effects.
The first effect of this new ethic is legalized abortion and euthanasia. If a doctor does not hold to the sanctity of life and instead holds to a utilitarian ethic, a situational ethic, then anything that increases the immediate happiness of the patient is good. Since the patient may be troubled by a new life growing in her womb, abortion can kill the baby and remove the angst and the problem. I don’t agree with that of course. The literature is replete with examples of mental and physical negative effects of abortion. Things like premature birth, depression, suicide, substance abuse and even in some cases an increased risk of breast cancer. Abortion is a scourge on our world, with now 50 million babies missing from these United States because of abortion. Abortion has disproportionately hit the black race. I don’t know if you knew that. Blacks make up 13% of the population but 35% of abortions.
Dr. Alveda King, Pastoral Associate of Priests for Life and niece of the Rev. Martin Luther King, Jr., commented on these numbers, saying, “In the last forty-plus years, 15 million black people have been denied their most basic civil right, the right to life. Roughly one quarter of the black population is now missing. This hasn’t happened because of lynch mobs, but because of abortionists who plant their killing centers in minority neighborhoods and prey upon women who think they have no hope. The great irony is that abortion has done what the Klan only dreamed of.”
The Pandora’s box of abortion, when opened, now endangers the black race. Abortion in India and China results in sex disparity, with girl babies aborted more than boys. In these areas now, 150 boys are born for every 100 girls.
Regarding euthanasia, Washington State and Oregon have legalized assisted suicide which is just euthanasia. They don’t just want it legalized, however. They want every doctor to participate if asked. A Christian group of hospitalists in Oregon may be fired because they won’t participate in assisted suicide. The Dutch have assisted suicide in Holland. It was supposed to be tightly controlled, but even the government has no idea how prevalent it is. A survey of Dutch doctors found more than half of the time, they do not report when they have done someone in because they don’t like the paperwork.
The second effect of the new ethic is interference with the doctor patient relationship, placing a bureaucrat between the doctor and patient. How do they do that? Well, the government, insurance companies and big health care organizations really dislike the independence of doctors. Rahm Emanuel is President Obama’s chief of staff. Mr. Emanuel’s brother is a prominent doctor in Harvard, Ezekiel Emanuel, who often writes for the NEJM, the most exalted medical journal in the country. Dr. Emanuel has said that the Oath or Code of conduct new doctors take is the problem, because it encourages doctors to be thorough, find out what is wrong and treat it. In other words, heal. And those doctors are the ones who get good grades in school and get advanced. But he wants to change that and reward doctors who do the minimum, who save money, who manage resources. Such a statement translated into English? He wants to reward doctors who deny care.
Since Henry Ford first gave health insurance as a fringe benefit to his employees, insurance companies and the government have found doctors are a difficult group to control. Literally every cost of medicine is doctor driven. Tests are ordered by doctors, scans are ordered by doctors, therapies are ordered by doctors, medicines are ordered by doctors, surgeries are done by doctors. And on and on. Insurance companies and the government wanted to control costs so they could sell their insurance product for less money. First, they tried a review process, reviewing each chart for necessary care. But that didn’t work very well, because if a chart didn’t meet the guideline criteria, it was reviewed by another doctor and most doctors had good reasons for what they did so most medical care was found to be necessary. So, it didn’t change costs much. Then they tried HMO’s, managed care, preferred provider organizations, but again, doctors reviewed doctors regarding medical decisions, and it didn’t help much. So the hospitals realized they could better control costs if they bought the doctor’s medical practice and made the doctor an employee. Along with that, came this thing called by a variety of names: Pay for performance, standards of care, best practices, protocols and health care pathways. So, by paying a doctor to follow a set of guidelines, guidelines which apply to a group of patients, not to one individual patient you could lower costs and look good to the public. The problem with that is that there is now, between you and your doctor, a checklist, a guideline that must be followed or his pay is docked. But what if your situation doesn’t fit the checklist very well? Then, he still follows the checklist—too bad for you.
Let me give you some examples. The company I work for, Fairview, sets some standards or protocols that they want us to achieve in a year. For us, one was testing all women between the ages of 16 and 26 for Chlamydia and gonorrhea, regardless of their risk status or history. The quota we were given to achieve was 78%. The company withheld some of our pay. If we performed that test on 78% of our patients in that age group, we received our withheld pay. If not, they kept our money. Also, the testing applied to the entire clinic as a whole. Meaning if one doctor had poor numbers and cause the percentage to drop, then no one got their withhold back. So there was tremendous pressure to comply or your colleagues got less pay.
If I were in an inner city population at high risk for STD’s, I’d probably be testing more than 78%. But in my population, our percent of positives is very low. No matter. The testing has to be done. So when a 24 year old missionary home on furlough with three children and no partner other than her husband, I’m supposed to test her for STD’s. Her chance of having an STD is zero. Who pays for it? She does, of course. And the screening for STD’s is easy. My partners never tell their patients they are testing them for STD’s, they just say I’m doing a routine test for infection.
My company established a list of questions, best practice questions, all women coming to my office had to be asked by my medical assistant. One was “Do you have sex with men or women or both?” Another was, “Do you feel safe in your environment. The first was to identify lesbians and bisexual women—I don’t know why. They receive the same health care as anyone else. The second was to find out if their husband or boyfriend beat her. So I would have a 72 year old grandmother in for an exam, someone married for 50 years with children and grandchildren and my medical assistant had to ask her if she had sex with men or women or both. Oh dear. But the check box had to be filled in with something, or the visit could not be closed on the computer. Also, when she asked patients about feeling safe in your environment, most women thought we were talking about a gas leak or carbon monoxide leak or bad wiring in the house. I even had one patient come in with a lot of pain. She had been in before. She said to my medical assistant, “Look, I’m hurting too much to answer your silly questions. I just want to see the doctor.
Family doctors and internal medicine doctors face the same pressures. They have checklists for a variety of problems. For diabetes, there are certain tests that must be done and certain medicines that diabetics must be taken, regardless of their blood sugar control. For instance, all diabetics have to have a blood test for a1c every six months and all have to be on a cholesterol lowering drug. But what if your patient has been in excellent diabetic control for years and doesn’t need that blood test? And has a very low cholesterol. Doesn’t matter. The protocol dictates it, and if the doctor doesn’t follow the protocol, he and his entire clinic will lose money.
Doctors, me included, always want the best for our patients. But how does one determine what is best? Even the best studies can be in error. Two of the largest and best studies of regarding postmenopausal hormone therapy came to opposite conclusions regarding the risk of heart disease. Does a study on an inner-city population translate to a well-to-do suburban population? Do studies on one race translate to all races? Does a study based on thousands of people necessarily translate to the individual patient in the exam room? Individuals vary by sex, physical characteristics, mental capacity, emotional make-up, cultural differences, values, ethnicity and side effects to medicines just to name a few variations a doctor sees. Is what may be good for a majority the best for you in your situation? Are you really unique? Could politics influence these protocols, say, to save money? Or further a politically correct “treatment”, such as euthanasia?
The process of checklist medicine, or cookbook medicine as it is sometimes called, can cut both ways. Many unnecessary tests are done to make the insurance company or government look good. Some necessary tests are not allowed because they don’t match the protocol.
Examples of “cookbook medicine” or “check box medicine” are becoming more numerous and more frightening each day. In England a few months back, two doctors who specialize in palliative care for people dying of cancer or other serious illnesses, raised questions about a protocol that was killing people too soon. The Marie Curie Cancer charity developed a protocol, called the Liverpool Care Pathway for terminally ill cancer patients. It was adopted nationally by the National Institute for Health and Clinical Excellence, called NICE or nice. Soon they applied this protocol not just to cancer patients, but any critically ill patient. The protocol said that if the doctor thought the patient might die in the next 24 hours, then they could start the protocol, which meant no food or water (no IV’s) and constant sedation. So, they people received no food or fluids and were knocked out with sedatives until they died and guess what? All of them died. But these two doctors took several patients off the protocol and the patients woke up and lived for a longer time than anyone thought. There was some outcry when relatives realized that their loved one had not just died, but were starved, dehydrated and sedated to death. So they studied this Liverpool Care Pathway and found that fully 23% of patients were dying in this way, more than the percentage in Holland where euthanasia was legal. But this was not regarded as euthanasia. Euthanasia is still against the law in England. This care pathway was labeled as “medical care”, a “best practice”, so flies under the radar of the law against euthanasia, but euthanasia it is. One of the doctor who blew the whistle said he thought doctors has quit thinking and were just practicing “tick box” (or check box) medicine. How true. But the government spokeswoman defended the protocol as a “best practice.” As far as I know, it was not changed.
Think of this. You are estranged from your uncle who is very ill. You come to his bedside, hoping to heal the relationship and again present Christ to him. But when you get their, his is unconscious and he will die unconscious because of continuous sedation and no food or water. No chance for reconciliation. No chance for a death bed conversion. No chance to heal a broken relationship prior to death.
Another example from England. A woman delivered an extremely premature baby and begged the doctors to help her child but they refused. Why? Because according to a best practice guideline, the baby had been born two days too soon. So they stood toe-to-bed and watched for two hours and her baby struggled for life and then died. She complained and has started a movement to get the rule changed. The group that developed the protocol, the Maternal Fetal specialists, did some fast back tracking, saying what they wrote was only suggestions, not rules. But suggestions morph into guidelines, which soon become protocols, which soon become rules.
So, the ethics in medicine have changed from a Christian, caring, pro-life view of life, a story we all inhabited and agreed on, to one of utilitarian ethics (the most good for the greatest number of people to increase overall happiness), situational ethics, where right on wrong are determined on the fly and the end always justifies the means, and rationalism, rationalism that depends on whose rationalism is in power. The spin off of this change can be seen in the eugenics we now practice—eliminating the handicapped before they can take a breath, designer babies without bad genes, abortion for convenience to increase “happiness”, unbridled euthanasia in Holland, the UK, Oregon and Washington state, practicing cook book medicine, leaving medical judgment about what is best for you individually and substituting what may be best for a group.
What does all this have to do with Obama care? Everything. These best practices, protocols and guidelines are all in the new bill. I can give you chapter and verse if you would like. Because now if an insurance company provides a bad product, no one buys it and the company goes broke and disappears. But if the government decides on this type of care, which is in the Health care reform act, since Medicare and Medicaid are the driving forces behind it now, they can never lose their jobs or go out of business. And they can ultimately, with the power of law, require everyone to receive their medical care this way.