Ethics presentation 2-b

AMONG ALL THE WEALTHY
COUNTRIES ON EARTH, THE UNITED
STATES HAS THE MOST INEFFECTIVE,
UNJUST, INEQUITABLE AND
UNETHICAL MEDICAL SYSTEM and
the 2009 health reforms made
matters worse.
Jeoffry B. Gordon, MD, MPH
paradocs2@hotmail.com
Originally presented May 1, 2011
Updated August, 2015

Part 1 – The BIG PICTURE & VALUES

“Seniors 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 they are worthy of
health care."
Sarah Palin on Friday, August
7th, 2009 in a message posted
on Facebook
.

"I'm still trying to find the first American to talk to who's in favor
of the public option, other than a member of Congress or the
administration" said Representative Boehner, whose sole recent
foray into a public discussion of health care reform was a tea-
party-style event in Ohio a few weeks back. "I've not talked to one
and I get to a lot of places," he told reporters at his weekly press
availability. "I've not had anyone come up to me -- I know I'm
inviting them -- and lobby for the public option. This is about as
unpopular as a garlic milkshake."
John Boehner, elected to represent the Eighth
Congressional District of Ohio for a 10th term in
November 2008, is a national leader in the fight for a
smaller, more accountable government.
Throughout his time as a small businessman, state
legislator, and Member of Congress,
John has been a straight-shooting and relentless
advocate for freedom and security.

Critical Letter By Catholics Cites Boehner On Policies
By LAURIE GOODSTEIN THE NEW YORK TIMES Published: May 11, 2011
More than 75 professors at Catholic University and other
prominent Catholic colleges have written a pointed letter to
Mr. Boehner saying that the Republican-supported budget
he shepherded through the House will hurt the poor, the
elderly and the vulnerable, and that he therefore has failed
to uphold basic Catholic moral teachings.
“Mr. Speaker, your voting record is at variance from one of the
church’s most ancient moral teachings,” the letter says. “From the
apostles to the present, the magisterium of the church has insisted
that those in power are morally obliged to preference the needs of
the poor. Your record in support of legislation to address the
desperate needs of the poor is among the worst in Congress. This
fundamental concern should have great urgency for Catholic
policy makers. Yet, even now, you work in opposition to it.”

Peter Singer, NEW YORK TIMES, July 15, 2009
PUBLIC
HEALTH
INSURANCE
SHOULD PAY
UP TO $_____
FOR A
TREATMENT
THAT WOULD
EXTEND A
PATIENT’S
LIFE FOR ONE
YEAR

Texas Futile Care Law: “Death Panels” Signed Into Law… By Bush
Advance Directives Act
The Texas Advance Directives Act (1999), also known as the Texas
Futile Care Law, describes certain provisions that are now Chapter 166
of the Texas Health & Safety Code. Controversy over these provisions
mainly centers on Section 166.046, Subsection (e), which allows a
health care facility to discontinue life-sustaining treatment against
the wishes of the patient or guardian ten days after giving written
notice if the continuation of life-sustaining treatment is considered
medically inappropriate by the treating medical team.
The law was signed by George W. Bush, when he was governor of
Texas.
Life-Support Stopped for 6-Month-Old in Houston March 16, 2005
Yesterday Sun Hudson, the nearly 6-month-old at Texas Children's Hospital in
Houston, diagnosed and slowly dying with a rare form of dwarfism (thanatophoric
dysplasia), was taken off the ventilator that was keeping him alive. A Houston
court authorized the hospital's action, and Sun died shortly thereafter….
This is the first time in the United States a court has allowed life-sustaining
treatment to be withdrawn from a pediatric patient over the objections of
the child's parent.

Hammurabi’s Code and U.S. Health Care
By Uwe E. Reinhardt, The New York Times, April 6, 2013
I recall addressing a group of New Jersey State legislators on this point a few
years ago as follows:
"I teach my students that the price a buyer is willing to pay for a thing signals to
suppliers of that thing the monetary value the prospective buyer puts on it. It is a
basic tenet of economics. Leaning on that tenet, I conclude that the value you in
your role as state legislators put upon the professional work of, say, a
pediatrician, if applied to a poor child on Medicaid, is less than a quarter of
the value you put upon that same professional work it applied to your own
commercially insured children.“ Physicians clearly understand this relative
valuation being signaled to them. According to a recent estimate, almost a
third of American physicians are unwilling to accept any new patients covered by
Medicaid. Naturally, New Jersey’s legislators were not well pleased by my
comment. Perhaps these legislators believe that the Hippocratic Oath, sworn to
by all physicians at the onset of their careers, compels that egalitarian approach.
In fact, neither the ancient nor modern version of the oath imposes on healers an
obligation to treat patients at a monetary loss.

Nursing facility providers in the United States (1997)
1,813,665 total nursing facility beds;
16,995 total nursing facilities;
83 percent nursing facility occupancy rate.
Nursing facility ownership in the United States
66 percent for profit;
27 percent not-for-profit;
7 percent government.
Nursing facility reimbursement in the United States
8 percent Medicare;
68 percent Medicaid;
23 percent private pay.
Medicaid in the United States
1,031,364 Medicaid only beds;
400,122,716 Medicaid nursing facility days;
1,667,319 total Medicaid nursing facility residents;
$85.05 per diem Medicaid nursing facility rate.
Medicare in the United States
53,138 Medicare only beds;
1,113,237 total Medicare stays;
$234 average per diem Medicare rate;
There are nearly nine million people, representing
one in five Medicare beneficiaries, who are eligible
for services through both Medicare and Medicaid
-- often called “dual eligibles.” They are the poorest
Providing tools for those who are eligible for Medicare
and Medicaid would save money and make the
programs work better for the elderly. They consume
about 25 percent of Medicare’s spending and nearly
half of Medicaid’s -- more than $250 billion in 2008.

Patients Are Not Consumers
By Paul Krugman, The New York Times 21 April 11
Earlier this week, The Times reported on Congressional backlash
against the Independent Payment Advisory Board, a key part of efforts
to rein in health care costs….
But something else struck me as I looked at Republican arguments
against the board, which hinge on the notion that what we really need to
do, as the House budget proposal put it, is to "make government health
care programs more responsive to consumer choice."
Here's my question: How did it become normal, or for that matter
even acceptable, to refer to medical patients as "consumers"? The
relationship between patient and doctor used to be considered
something special, almost sacred. Now politicians and supposed
reformers talk about the act of receiving care as if it were no different
from a commercial transaction, like buying a car - and their only
complaint is that it isn't commercial enough.
What has gone wrong with us?

The Inverse Care Law
JULIAN TUDOR HART The Lancet: Saturday 27 February 1971
Glyncorrwg Health Centre, Port Talbot, Glamorgan, Wales
The availability of good medical care tends to vary inversely
with the need for the population served. This inverse care law
operates more completely where medical care is most exposed
to market forces, and less so where such exposure is
reduced. The market distribution of medical care is a primitive
and historically outdated social form, and any return to it
would further exaggerate the maldistribution of medical
resources.

VALUES IN HEALTH CARE:
THE MORAL AND ETHICAL
IMPERATIVE
The Values of a Healthy Society
(1) MAXIMIZE HEALTHY STATES (provide good,
quality medical care)
(2) COMPASSION and CARING (relieve individual
pain, suffering and anxiety)
(3) SOCIAL and ECONOMIC JUSTICE (provide for the
vulnerable )
(4) CIVIC RESPONSIBILITY (society as a
commonwealth)
(1) MAXIMIZE HEALTHY STATES (provide good,
quality medical care)
(2) COMPASSION and CARING (relieve individual
pain, suffering and anxiety)
(3) SOCIAL and ECONOMIC JUSTICE (provide for the
vulnerable )
(4) CIVIC RESPONSIBILITY (society as a
commonwealth)

MALE LIFE EXPECTENCY AT AGE
65 BY YEAR OF BIRTH
SOCIAL SECURITY DATA

. Adult Admissions for Uncontrolled Diabetes Without
Complications per 100,000 Population, by Race

FIGURE 10 Cancer Survival by
Insurance Status*

Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer.
Smith AK1
, Earle CC, McCarthy EP., J Am Geriatr Soc. 2009 Jan;57(1):153-8. doi: 10.1111/j.1532-5415.2008.02081.x.
Epub 2008 Nov 21.
OBJECTIVES:
To examine racial and ethnic variation in use of hospice and high-intensity care in patients with terminal illness.
SETTING:
Surveillance, Epidemiology, and End Results-Medicare Database from 1992 to 1999 with follow-up data until December
31, 2001. 49,960 non-Hispanic white, non-Hispanic black, Asian, and Hispanic fee-for-service Medicare beneficiaries
aged 65 and older with advanced-stage lung, colorectal, breast, and prostate cancer.
RESULTS:
Whereas 42.0% of elderly white patients with advanced cancer enrolled in hospice, enrollment was lower for black
(36.9%), Asian (32.2%), and Hispanic (37.7%) patients. Differences between white and Hispanic patients disappeared
after adjustment for clinical and sociodemographic factors. Higher proportions of black and Asian patients than of white
patients were hospitalized two or more times, spent more than 14 days hospitalized, and were admitted to the intensive
care unit (ICU) in the last month of life and died in the hospital
CONCLUSION:
Black and Asian patients with advanced cancer were more likely than whites to be hospitalized frequently and
for prolonged periods, be admitted to the ICU, die in the hospital, and be enrolled in hospice at lower rates.

2. ECONOMICS:
THE MEDICAL
MARKETPLACE
(1)CONSUMER CHOICE
(2) PROVIDER INCOME
(3) ECONOMIC EFFICIENCY

Health Care Costs Concentrated in Sick Few—
Sickest 10 Percent Account for 65 Percent of Expenses
Source: Agency for Healthcare Research and Quality analysis of
2009 Medical Expenditure Panel Survey.
Distribution of health expenditures for the U.S. population,
by magnitude of expenditure, 2009
1%
5%
10%
50%
65%
22%
50%
97%
Population Share of Health Spending
25

Medical loss
ratio
2Q 2008 2Q 2009
Aetna 81.9% 86.8%
Cigna 86.0% 86.7%
Coventry 85.8% 86.4%
Health Net 85.3% 86.2%
Humana 85.8% 83.6%
WellPoint 83.3% 82.9%
UnitedHealth
Group
83.6% 83.6%
Source: Securities and Exchange Commission

•Among medical debtors, hospital bills were the largest medical expense for 48% drug costs for 19%,
doctors’ bills for 15% and insurance premiums for 4%. In 38% of cases, lost income due to illness was
a factor.
•Out-of-pocket medical costs since the onset of illness averaged $17,943.
•For the privately-insured, out-of-pocket costs averaged $17,749.
•For the uninsured, out-of-pocket costs averaged $26,971.
•Patients with neurologic disorders such as multiple sclerosis faced the highest costs, and average of
$34,167, followed by diabetics at $26,971.
•Illness and medical bills were linked to at least 62.1% of all
personal bankruptcies in 2007. Based on the current bankruptcy
filing rate, medical bankruptcies will total 866,000 and involve 2.346 million
Americans this year – about one person every 15 seconds.
•Using identical definitions in both years, the proportion of bankruptcies attributable
to medical problems rose by 49.6% between 2001 and 2007.
•Most medically bankrupt families were middle class before they suffered financial setbacks. 60.3% of
them had attended college and 66.4% had owned a home; 20% of families included a military veteran
or active-duty soldier.

Nigerians Receive First Payments for Children Who Died in 1996 Meningitis
Drug Trial
By DONALD G. McNEIL Jr., THE NEW YORK TIMES, August 11, 2011
The first payments were made Thursday to Nigerian families who lost children during a 1996 trial of an
experimental meningitis drug, and Pfizer, which had tested the drug, a new antibiotic, said it was
“pleased” that payments were finally being made under a settlement reached two years ago. Four families
received $175,000 each from a $35 million fund created under the settlement between Pfizer and
Nigeria’s northern Kano State, where the brief trial of the experimental drug, Trovan, took place. The four
families had DNA evidence proving they were related to children who died during the trial.
In all, 11 children died in the trial: five after taking Trovan and six after taking an older antibiotic
used for comparison in the clinical trial. Others suffered blindness, deafness and brain damage.
Although Pfizer said that only 200 children had been given Trovan or the older antibiotic, 547 families
sued.
Despite having settled the case, the company still contends that meningitis, not its drugs, was responsible
for the deaths and injuries, a Pfizer spokesman said Thursday. The company also said that Trovan had
first been tested in 5,000 Americans and Europeans. Pfizer said Trovan saved lives in Nigeria, because
94 percent of the Nigerian children who received the drug survived — more than normally do if no
medicine is administered. Nonetheless, according to a 2006 Washington Post article, the trial’s certificate
of approval from a hospital ethics board was forged, and Pfizer said its own investigation had proved that
the certificate was “incorrect.” Families of children who died or were injured while on the second antibiotic
contended that Pfizer had prescribed low doses of the drug to make the results for Trovan look better.
The distrust of Western medicine that the dispute engendered was one of several factors that led
many families in northern Nigeria to refuse to let their children be vaccinated against polio.
Northern Nigeria is still one of the world’s last remaining epicenters of polio.
Trovan was introduced in 1998 and became a lucrative product for Pfizer, but it was later withdrawn in
Europe and restricted in the United States after the drug was blamed for cases of fatal liver damage.
Last year, a secret 2009 State Department cable exposed by WikiLeaks said that a Pfizer official in
Nigeria told American diplomats that the company had hired private investigators to “uncover
corruption links” to Nigeria’s former attorney general in order to pressure him to drop the Trovan
lawsuits.

PUBLIC GOODS
• Medical services and a person’s state of wellness
itself are “Public Goods” in a technical economic
sense. A “public good” is a product or service
which benefits everyone in the community and
has “externalities,” that is, it has benefits and
value to people who do not purchase it.
• Medical services and a person’s state of wellness
itself are “Public Goods” in a technical economic
sense. A “public good” is a product or service
which benefits everyone in the community and
has “externalities,” that is, it has benefits and
value to people who do not purchase it.

PUBLIC GOODS
• EXAMPLES OF PUBLIC GOODS
• Police and Fire Departments
• Interstate Highways and Bridges
• The Internet and GPS systems
• Public Schools
• Water distribution and Sewage treatment
• ? ALL MEDICAL SERVICES ?
• EXAMPLES OF PUBLIC GOODS
• Police and Fire Departments
• Interstate Highways and Bridges
• The Internet and GPS systems
• Public Schools
• Water distribution and Sewage treatment
• ? ALL MEDICAL SERVICES ?

It was Ronald Reagan who
said “freedom is always just
one generation away from
extinction. We don’t pass it
to our children in the
bloodstream; we have to
fight for it and protect it, and
then hand it to them so that
they shall do the same, or
we’re going to find ourselves
spending our sunset years
telling our children and our
children’s children about a
time in America, back in the
day, when men and women
were free.”

3. THE RECENT HEALTH REFORM IS
MOSTLY
A GOVERNMENT SUBSIDY OF
COMMERCIAL
HEALTH INSURANCE

Congress Passes Socialized Medicine and Mandates
Health Insurance - In 1798
RICK UNGAR POLICY PAGE FORBES Jan. 17 2011 - 9:08 pm |
The ink was barely dry on the PPACA when the first of many
lawsuits to block the mandated health insurance provisions of
the law was filed in a Florida District Court. The pleadings, in part, read -
“The Constitution nowhere authorizes the United States to mandate, either
directly or under threat of penalty, that all citizens and legal residents have
qualifying health care coverage.” State of Florida, et al. vs. HHS
It turns out, the Founding Fathers would beg to disagree.
In July of 1798, Congress passed – and President John Adams signed - “An Act
for the Relief of Sick and Disabled Seamen.” The law authorized the creation
of a government operated marine hospital service and mandated that
privately employed sailors be required to purchase health care insurance.
Keep in mind that the 5th Congress did not really need to struggle over the
intentions of the drafters of the Constitutions in creating this Act as many of its
members were the drafters of the Constitution…. But those were the days when
members of Congress still used their collective heads to solve problems – not
create them. Realizing that a healthy maritime workforce was essential to the
ability of our private merchant ships to engage in foreign trade, Congress and the
President resolved to do something about it.

85 percent: The percentage
of all enrollees receiving tax
credits for their insurance
premiums — 8.7 million
people.

As originally envisioned, the ACA would have extended Medicaid coverage
to everyone below 133 percent of the federal poverty level, regardless of
previous Medicaid eligibility. The Supreme Court, however, ruled in June of
2012 that the provisions proposed in the ACA to enforce state compliance
with Medicaid expansion were too coercive, and that states could choose
not to implement Medicaid expansion. Since the Court’s decision, only 26
states have chosen to expand Medicaid coverage. The split of states on this
question has largely followed political party lines, with most blue states
choosing expansion and most red states rejecting expansion.
Since Medicaid expansion has gone into effect, the number of individuals
receiving Medicaid has increased by 6 million, roughly a 10 percent
increase in Medicaid enrollment overall. The increase in Medicaid
expansion states is 15.3 percent, compared to 3.3 percent for non-Medicaid

Supreme Court Justice Antonin
Scalia’s dissent in the same-sex
marriage cases, June 26, 2015:
“Four of the nine are natives
of New York City. Eight of
them grew up in east- and
west-coast States. Only one
hails from the vast expanse
in-between. Not a single
Southwesterner or even, to
tell the truth, a genuine
Westerner (California does
not count).”

GOP Governors' Obamacare Opposition Is Denying The Poor Health Care
Nonelderly Poor Uninsured Adults
in the Coverage Gap in States Not
Expanding Medicaid by
Race/Ethnicity
Total, United States:
4,832,000 - All races/Ethnicities
2,248,000 - White
1,327,000 - Black
992,000 - Hispanic
265,000 - Other
2,584,000 - People of Color

Preventable Deaths from Heart Disease & Stroke

Hobby Lobby 101: explaining the Supreme Court's birth control
ruling
By Warren Richey, Staff writer, The Christian Science Monitor, July 10, 2014
The US Supreme Court ruled on June 30, 2014 that the owners of closely-held, profit-
making corporations cannot be forced under the Affordable Care Act to provide their
employees with certain kinds of contraceptives that offend their religious beliefs.
The decision arose from litigation filed by the owners of the national chain of craft stores
called Hobby Lobby, and the owners of Conestoga Wood Specialties, a cabinetmaker in
Pennsylvania.
It has sparked a heated debate about the scope of religious liberty in the United States
and whether bosses are now empowered to impose their religious beliefs on their
employees. It has also raised concerns that female workers will now be denied access to
contraceptives.
Both Hobby Lobby and Conestoga Wood are controlled by family members with shared
religious beliefs. Those beliefs hold that life begins at conception and that any birth control
method that may result in the destruction of a fertilized egg is a form of abortion and killing that
is forbidden by their faith. They also believe that supporting and financing their company health
care plan in a way that provides their employees with the means to destroy a fertilized egg
makes them complicit in a sinful and immoral act. Their objections were to four of 18 methods
required to be provided to female employees under the Affordable Care Act’s contraception
mandate. They objected to paying for two forms of the emergency morning-after pill and two
kinds of intrauterine device (IUD).They did not object to providing their employees cost-free
access to the most common forms of birth control, including daily birth-control pills.
Women have a constitutional right to access to birth control and abortion, but there is no
constitutional right to have someone else pay for it. The question in the Hobby Lobby case was
whether the government can force someone else to pay for a woman’s contraceptives even
though that person has religious objections to doing so.

4. “HEALTH CARE IS A HUMAN
RIGHT”
HAS REAL MEANING
OPTIMAL HEALTH
OUTCOMES DEPEND
ON SOCIAL and
ECONOMIC JUSTICE

Pope Francis called for renewal of the Roman Catholic Church and attacked unfettered
capitalism as "a new tyranny", urging global leaders to fight poverty and growing
inequality in the first major work he has authored alone as pontiff. The 84-page
document, 'Evangelii Gaudium' known as an apostolic exhortation, amounted to an
official platform for his papacy. In it, Francis went further than previous comments
criticizing the global economic system, attacking the "idolatry of money" and
beseeching politicians to guarantee all citizens "dignified work, education and
healthcare".
He also called on rich people to share their wealth. "Just as the commandment 'Thou
shalt not kill' sets a clear limit in order to safeguard the value of human life, today we
also have to say 'thou shalt not' to an economy of exclusion and inequality. Such an
economy kills," Francis wrote in the document issued on Tuesday( Nov 26, 2013) "How
can it be that it is not a news item when an elderly homeless person dies of exposure,
but it is news when the stock market loses 2 points?"

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