All posts by Niyeti

A System Surviving on Self-Interest

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Pellegrino makes a strong argument for our need for a moral community for doctors. In doing so he highlights the fine line faced in this profession between the ethical obligations to the sick vs. self-interest and the marketplace. As he continues his argument, he makes a clear argument for the former stating the moral and ethical obligations of a doctor to care for the sick over all else. While I morally agree with this statement, in the context of the United States I do not know that I buy this premise.

Pellegrino makes states a variety of examples of situations in which doctors would refuse patients saying, “we must feel demeaned by them and act to repudiate them” pushing for the Hippocratic oath as the ethical guide for doctors. While I completely agree that refusing to see a Medicare patient or patient with HIV is morally and ethically wrong – I want to also understand the other side of the story before agreeing to such absolute statements.

It is no shock that doctors are now making less money than they were before. Medical school costs having increased while pay has decreased leading to a significant number of doctors struggling to pay off student loans. In Escape Fire, the struggles of doctors to pay off current bills in order to stay in business are highlighted as a fault of the system. If doctors are paid by patients seen per day, it cannot be completely faulted on the doctor that slightly unethical practices (referring to the Hippocratic Oath regarding empathy) occur. Many practices are forced to fit in an increasing number of patients simply to stay in business – creating a culture of apathetic treatment as we have discussed many times in class. But is that really the fault of the doctor?

Speaking on patient rejecting, prior to Obama care a study in the Health Policy Journal Health Affairs found that 33% of primary care physicians were not accepting new Medicaid patients. Why? Low government reimbursement rates. Certain practices simply could not afford to stay in business while continually taking on new Medicaid patients while reimbursement rates were so low.

***Increasingly more ironic,  an economist with the CDC found that reimbursement rates were highest in states with high rates of physicians accepting Medicare.

Under Obama Care certain physical salaries will take a decrease depending on the federal decision to expand Medicaid. However, the doctor shortage will also be heightened leading to an increasing number of ethical concerns within Pellegrino’s quest for a moral community.

I do not condone much of the behavior that is being discussed. My position is rather that it is (in many cases) the fault of a system over the fault of a doctor. It is completely rational for a doctor to worry about paying his own bills vs. seeing one patient at times. Beyond Pellegrino’s moral community, I think we should be calling for greater government funding to offset the costs of medical school which will also allow for federal agencies to dictate specialties, etc that doctor’s choose to pursue. The change has to be more than just a call for morality, but true structural change.

 

Kliff, S. (2012, August 6). Study: One-third of doctors wouldn’t take new Medicaid patients last year. Washington Post. Retrieved , from http://www.washingtonpost.com

Matthews, M. (2013, November 25). When Will The Government Start Forcing Doctors To See Obamacare Patients?. Forbes. Retrieved , from http://www.forbes.com

Pellegrino, E. The medical profession as a moral community. PubMed, 66, 221-230.

Tyson, P. (2001, March 27). The Hippocratic Oath Today. PBS. Retrieved April 23, 2014, from http://www.pbs.org

 

3 Parent Babies

An article recently came out regarding designer babies on CNN. The FDA is considering a new method that would allow for both a mother, father and healthy woman to create a child if the mother is suffering from a genetic disorder, etc. It is an interesting article! Link Below!

 

http://www.cnn.com/2014/02/26/health/ivf-mitochondria/index.html?sr=fb022614threeparentbabies9p

Prisoners Health Care

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We have recently been speaking about access to health information and the responsibility of doctors to tell patients what they believe is important and what will cause unnecessary harm to the patient.
During this conversation I have been questioning the judgment call of doctors for certain patients. For example, if a doctor is forced to treat a patient they strongly dislike – will they give more or less care to the patient? Furthermore, would they unknowingly withhold information simply because they do not like the patient. Of course, we would like to assume that all patient treatment would be exactly the same but this of course is not true. Beyond the doctors’ control, the care will shift slightly for a patient they favor over a patient they dislike.

 

Although a bit of a leap, I began thinking about healthcare and health information in prisons in the United States. As we stress the importance of doctors’ gauge on a patients, health, needs and information; what about patients who doctors may have prematurely judged?

 

As of 2012, there were 1,517, 013 prisoners in the United States. Prisoners have the right to adequate healthcare under the eighth amendment. This means that prisoners should not be subject to cruel and unusual punishment. Clearly this is not the case. Many claims have been main regarding the “deprivation of basic elements of adequate medical treatment”, “deliberate indifference” and most importantly “abuse of discretion”.

 

Of the current inmates approximately 800,000 suffered from a chronic condition that needs regular medical attention such as diabetes, previous heart attacks and hypertension.  Furthermore the treatment rate for mental health ailments tripled for individuals after incarceration. With the Americans prison members older than 55 growing faster than the population at large, may prisons must be prepared to provide them healthcare. This will cost approximately nine times more than healthcare for younger inmates. As the prison population rises, hospitals for prisons are becoming overbooked such as in California, which currently has three hospitals. Prisons must then contract to private hospitals for inpatient care that can cost approximately $850,000 per year for one inmate.

 

It is a raising concern for many that healthcare costs in prisons are continually raising. As the U.S. healthcare suffers from severe budget crisis, prisoners are being moved to hospitals and additional forms of treatment. Doctors treating prisoners are often cited for ignoring patient needs or abusing the right of doctor discretion, a topic we have discussed at length.

 

Knowing this information, the current U.S. healthcare system and the large cost of incarceration it is crazy not to ensure that inmates get the basic care that they deserve. But is it really possible to ensure that they will be receiving ethical care? If prisoners are placed in private hospitals, will that not factor into treatment? Will they be given complete treatment, or treated like a general patient? Is it unethical to do so? How can we ensure that a doctor will be using sound discretion which treating these patients?

 

Sources:

Gardner, Amanda. “Many in U.S. Prisons Lack Good Healthcare.” HealthDay. Jan. 16 2009. Web

 

Klein, Stuart. “Prinsoners’ Rights to Physical and Mental Health Care: A Modern Expansion of the Eight Amendment’s Cruel and Unusual Punishment Clause.” Fordham Urban Law Journal. 1978.  N.pg. Print

 

Williams, Timothy. “Number of Older Inmates Grows, Stress Prisons.” New York Times. N.pg. Jan. 26, 2012. Web.

 

 

Shifting Expectations and Adding Prescriptions

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It is completely undeniable that the life of a student in the past twenty years has changed drastically. Students are expected from a young age to be receiving perfect scores, excelling creatively and athletically while holding leadership positions. Majority of children are expected to attend a four-year university and graduate with a “stable” respectable job. The only way to obtain this job, as socially preached, is to get above average grades while balancing a social and extracurricular life. Quite simply stated, the expectations for a student of any age have changed.

Dr. Diller, author of Running on Ritalin, claims that the rise to the use of Ritalin can be attributed to a variety of non-medical factors. During an interview with PBS, Diller explains how the shifting culture surrounding young people has changed the understanding of managing behavior. He attributes the increasing pressure to be above average as a young person, matched by parents working full-time and a decrease in parental discipline with the rise of Ritalin prescriptions.  Next he discusses the flaw in diagnoses, as there is no concrete test for ADHD but rather a series of rather subjective tests usually administered by a general physician. He additionally attributes the rise in Ritalin usage to general awareness. ADHD is an easily identifiable disorder. As diagnosis increase and education law changed to include services for those with ADHD simply checking for ADHD has become more popular.

Throughout the interview Diller touches on the moral aspect of Ritalin usage. He talks about how naturally any parent would want the best for their child. At times there may be a child who is excelling outside of school but simply cannot focus. Other times children can be seen as hyper or unable to pay attention. However, parents want to do all they can to help their children excel and many times this includes the addition of Ritalin. He ends the discussion by stating the ethical dilemma he faces as a doctor. For certain patients he understands that possibly changing classroom size, disciplining methods or family habits could address some of the concerns that parents have however, the solution quickly shifts to medication. Family life, parenting, temperament and learning environment are not typically taken into account before prescribing Ritalin to improve concentration.

The stigma surrounding Ritalin, I feel (especially in college) is quite small. Partially because many who take Ritalin take it for purely medical reasons but also because it is so frequently used. Many college students take Ritalin when they simply cannot concentrate, or seek a specific diagnosis to gain regular access to this type of drug.

I question this on a deeply ethical level, for isn’t this use (and possibly abuse) shockingly similar to the use of steroids? Why are athletes so widely criticized for using performance enhancement drugs when it is acceptable for college students to use similar aids? Is there a difference between the two? Should one usage be more criticized than the other? Do we deem the use of Ritalin (or Adderall)  as cheating or taking the easy route?

I personally see difficultly in drawing the line between the two. While I don’t feel as strongly about the usage of Ritalin or Adderall in relation to a performance enhancement drug, I also can’t articulate and argue the difference.

Sources:

“Interview with Dr. Diller.” PBS. PBS, n.d. Web. 09 Feb. 2014.

Parker, Harvey. “The Ritalin Explosion.” PBS. PBS, n.d. Web. 09 Feb. 2014.

Trudeau, Michelle. “More Students Turning Illegally To ‘Smart’ Drugs.” NPR. NPR, 5 Feb. 2009. Web. 06 Feb. 2014.