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January 30, 2019

Medical Ethics Can Only Be Restored With a Single-Payer System

by David Penner

Originally published at Dissident Voice, on Jan. 28, 2019.

A recruiting poster for Australian nurses from World War I.

It is the year 2019, and American health care is in a state of profound crisis. While oligarchic parasites from the pharmaceutical industry and health insurance companies make enormous profits, bankruptcy and the fear of being denied care hang over the American people like a sword of Damocles. This diabolical order, predicated on greed and placing profit-making over human life, has stripped doctors of their autonomy and given birth to an inhuman and deeply unjust multi-tier system.

Unless we are able to disenthrall ourselves from the tyranny of privatized health care, Americans will continue to die as a result of avaricious insurance companies denying coverage for needed drugs and procedures, and from treatment which is delayed due to requests for “prior authorizations.” Moreover, medical students and residents are being taught that good health care is a privilege and not a right, and that the oath to do no harm applies, but only to a privileged few. In a world turned upside down, doctors in training are being inculcated with the pernicious notion that the job of a doctor is not to listen to the patient, perform a comprehensive physical, respect the patient’s privacy, get an accurate history, diagnose, treat, and follow up; but rather to help their employer maximize the greatest possible profit. Indeed, the number of patients doctors are expected to see each day has become increasingly unwieldy, and this has gravely undermined their ability to practice good medicine.

Are we to continue to buy and sell health care as if it were a consumer good? The wealthiest can buy a Ferrari, the upper middle class a Lexus, the working class a Toyota, and the poor a used car. The very destitute cannot afford a car at all and have to take the bus. Clearly, it is barbaric to run a health care system in such a manner, and yet this is precisely what we are doing.

From their very first day of residency, doctors in training are being indoctrinated with the following code of dishonor: “This patient has a right to privacy, while this patient doesn’t. This patient has a right to informed consent, while this patient doesn’t. This patient has a right to linger following their surgery, while this patient has to leave immediately following their procedure. This patient has a right to their own room with a view, while this patient will be crammed into a room with a stranger.” The idea that medical ethics can coexist with such an ideology is inane and deeply delusional.

Many institutions have established multi-tier systems which are so egregious that it has resulted in the implementation of a Jim Crow health care system. Indeed, these institutions often place the “humans” and the “subhumans” in physically separate facilities. In this internationalization of the third world model, patients with inferior insurance are regularly arm-twisted into being clinical guinea pigs and used as laboratory animals with which to teach impressionable residents and fellows. This railroading of the “losers” into resident clinics magnifies the innate power imbalance inherent in the doctor-patient relationship a hundredfold, and constitutes a violation of patient privacy, informed consent, confidentiality, and patient dignity all of which fall under the umbrella of the physician’s oath to do no harm.

In an article in Annals of Emergency Medicine titled “Observers in The Medical Setting”, by Joel M. Geiderman, MD, the author posits that:

Privacy is treasured by citizens in free societies around the world, and any infringement on it is considered by many to be an affront to personhood. In the United States, the right to privacy runs deep in the American soul.

Residents that have no qualms about observing office visits without the patient’s consent are likely to go on to violate the privacy of their patients as attendings, and may very well spend their careers mindlessly violating and debasing their fellow human beings, only to periodically vent their frustrations on the Internet over all the “self-entitled” patients that don’t appreciate their diligence and divine wisdom. And while there are undoubtedly some residents that may have misgivings over participating in a clinic which coerces patients with unglamorous insurance plans into being medical models, as we have largely become a nation of careerists, the apelike majority will blindly follow orders.

Geiderman writes:

In addition to informational privacy, or protection of their personal health information, patients are also entitled to physical privacy, that is, a zone of personal space where access is under the patient’s autonomous control. Closely linked is the right to one’s modesty, a human value that is expressed in the Bible in Genesis, as Adam and Eve wished to shield their nakedness even from their Creator.

Should a physician order countless tests and prescriptions which are subsequently vetoed by the insurance companies, assuming they are not vehemently opposed to single-payer, they are unequivocally not to blame for this. However, once a doctor has knowingly participated in a clinic which is predicated on coercing patients with inferior insurance into being clinical guinea pigs for residents and fellows to practice on, they have stepped into a void beyond which lies a wasteland devoid of honor, dignity, integrity and morality. Any participation in such an egregious multi-tier system on the part of a physician threatens the survival of the doctor-patient relationship and constitutes unbridled and unmitigated heresy.

This descent into barbarism is glaringly on display in many dermatology departments, which are able to choose from the crème de la crème of our nation’s medical graduates, dermatology being one of the most competitive and sought-after specialties. These departments often assign patients with inferior insurance to a resident, who in turn has to be supervised. And so through artifice and trickery, the patient is duped and arm-twisted into being a medical model without their consent. The attending arrives and spews platitudes such as “The more eyes the better,” “There’s nothing we’ve never seen before,” and “We’re all professionals here” as if this can mitigate the fact that they are teaching their residents that the have-nots deserve neither privacy nor respectful care. That neither the attending nor the resident would even think of seeking care in such a clinic underscores the fact that in the innermost recesses of their addled brains they are cognizant of the fact that what they do is unethical. To gain admission into MS-13 one would likely have to commit murder. When doing a dermatology residency at an elite Manhattan medical institution, violating the privacy of hundreds of patients is the price of admission into this rather alarming society.

In conjunction with this uncivilized behavior, doctors in training are duly inculcated with the idea that informed consent is a privilege and not a right. Many of these creatures will go on to do practice pelvic exams on anesthetized patients, or even perform forced cavity searches at the request of law enforcement. Indeed, doctors that have no respect for informed consent are a danger to themselves, and a danger to those who place their trust in their care.

Reactionary physicians at elite institutions take for granted having the finest insurance, and delude themselves into thinking that patients go to resident clinics of their own volition, and not because their insurance dictates that they go there. Few realize that if a Medicaid patient sees a doctor out of network they can actually lose their insurance. Restoring physician choice to the American patient is absolutely vital if we are to restore any semblance of democracy to our health care system. For as long as a vast swath of American society is forced to work with doctors that they do not wish to work with, all talk of “patient-centered care” is farcical and absurd.

If a woman with good insurance needs a prescription for birth control, she can leave a doctor who insists on doing a pelvic exam prior to ordering the prescription, whereas a patient with inferior insurance can be bullied into submitting to the unnecessary exam due to the lack of gynecologists that take their insurance. While the pharmaceutical companies, health insurance companies, and hospitals grow fat with the lucre sucked from the blood of their patients, not a day goes by when the underinsured do not experience such indignities. And while the government continues to abrogate its social responsibility to implement a single-payer system, many patients that do have good insurance are a cancer diagnosis or car accident away from losing their job and their superior insurance along with it.

In non-union jobs employers often change insurance plans every year, perpetually searching for the plan which is most affordable. This in turn forces patients to constantly change doctors, and if a patient has a complex medical condition, the consequences of perpetually denying such an individual continuity of care can have disastrous consequences. Indeed, even if a patient is healthy, this can result in reduced health care outcomes over the long-term. And just as the multi-tier education system has come to be accepted without question by millions of our countrymen, the multi-tier health care system has likewise left its mark on the consciousness of millions of Americans, and is increasingly accepted as “normal” by the insouciant and the knavish alike.

Patients that freelance can also see their insurance change while their income fluctuates, and this can likewise force a patient to change doctors. Like a marriage, the doctor-patient relationship is predicated on a sacred trust, and being forced to constantly change doctors disrupts, destabilizes, and destroys these relationships.

The takeover of the medical decision-making process by insurance companies – essentially criminal gangs – has stripped doctors of their autonomy and is a driving force behind physician burnout. For after every treatment plan agreed upon between a doctor and a patient, doctors’ orders are increasingly countermanded by the patient’s insurance company. Not a day goes by without a doctor prescribing a drug which a patient’s insurance refuses to cover. The doctor then calls in a second drug – a variation on the first – and the insurance company may refuse coverage for this as well. Then a third drug is called in – perhaps not even of the same class – and this too may be rejected. Meanwhile, the patient has been examined by their doctor, not by an MD working for the insurance company. Should a physician order a PET or CT scan to determine whether a patient has metastatic cancer following a needle biopsy that has revealed a mass to be malignant, it is not uncommon for the patient’s insurance to declare this request as requiring “prior authorization.” This pervasive undermining of a doctor’s authority is without precedent in American health care, and these delays have caused people to die.

In addition to living paycheck to paycheck, millions of Americans are under the illusion that their health insurance plan is much better than it is, incognizant of the fact that they are a health problem away from financial ruin. The insouciant among us who ask where the money is going to come from should consider why they failed to ask this question prior to the invasions of Iraq and Afghanistan. The money will come from demilitarizing our society and transferring to a peacetime economy. Are the underinsured not victims of terrorism?

As their entire raison d’être is anchored in maximizing the greatest possible profit, hospitals ruthlessly exploit their residents, many of whom work eighty hours a week or more. In an article on KevinMD titled “The secret horrors of sleep-deprived doctors,” by Pamela Wible, MD, a doctor speaks of their training:

I did my internship in internal medicine and residency in neurology before laws existed to regulate resident hours. My first two years were extremely brutal, working 110 to 120 hours/week, and up to 40 hours straight. I got to witness colleagues collapse unconscious in the hallway during rounds, and I recall once falling asleep in the bed of an elderly comatose woman while trying to start an IV on her in the wee hours of the morning.

It is not uncommon for young doctors to accidentally kill patients as a result of being so exploited and sleep deprived, and this has undoubtedly played a role in making hospital errors the third leading cause of death in this country. Wible quotes another physician:

I have made numerous medication errors from being over tired [sic]. I also more recently misread an EKG because I was so tired I literally couldn’t see straight. She actually had a subarachnoid hemorrhage, and by misreading the EKG, I spent too much time on her heart and didn’t whisk her back to CT when she came in code blue. She died.

This is the inevitable result of exploiting residents as if they were fast food workers. Moreover, as has transpired with education, health care is simply becoming unaffordable. In an article for KevinMD titled “The demonization of socialized medicine,” by Matthew Hahn, MD, the author writes, “It’s almost become a ritual now where a patient (who usually has health insurance) is diagnosed with cancer, and then we attend their community fundraiser to help them with the costs of their care.”

Many doctors are compelled to spend countless hours each month filling out electronic medical records which have been foisted on them by the insurance companies. To assist with this onerous task, doctors increasingly employ a nurse or medical scribe to type the required information into the computer during a patient’s office visit. This destroys any semblance of confidentiality and undermines the physician-patient bond. It can also result in the doctor failing to obtain a comprehensive history.

Some physicians feel that the way to regain autonomy is to not take insurance at all, but by doing this they are denying care to patients with low income; i.e., the majority of the country. In theory, doctors take an oath to do no harm. In reality, they are in thrall to rapacious corporate power and are more likely to spend a lot of time violating patients’ privacy, doing mind-numbing data entry, and failing to disclose the risks of extremely dangerous drugs such as opioids and psychiatric medications.

Liberal saints Obama and Hillary had an opportunity to make a push for single-payer, but instead chose to spend trillions of dollars murdering large numbers of people in Ukraine, Iraq, Afghanistan, Yemen, Libya, Honduras and Syria while maintaining nearly a thousand bases all around the world. How many more patients will be forced into bankruptcy? How many more souls will be debased and defiled? How many more human lives will be lost?

David Penner has taught English and ESL within the City University of New York and at Fordham. His articles on politics and health care have appeared in CounterPunch, Dissident Voice, Dr. Linda and KevinMD.