On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.

On euthanasia

Jack Kevorkian served 8 years in prison for second-degree murder, that is murder that is not “premeditated”, or what you may also describe as murder that is not ill-intentioned. Essentially, he was a doctor that assisted many ill patients to die; what we commonly call euthanasia. He argued that he was imprisoned for being merciful, and that his merciful acts were to procure or hasten the death of other human beings. They were merciful because he aimed through his actions to liberate the person from suffering due to illness – when this person had indicated that they wanted or needed his assistance to do just this. The law said that regardless of the intent, procuring or hastening someone’s the death equates to murder and this is illegal even if the other party consents and requests it.

Now, a lot of the issues surrounding euthanasia and death legislation are about semantics, and to a lesser degree also intent. I remember first learning about euthanasia in a bioethics class, and I will describe it briefly now as I was taught it. There were four categories of “euthanasia” described:

1) voluntary active euthanasia (where the patient voluntarily requested help in dying and another person actively helped him achieve this) – E.g. a person asking someone else to inject a fatal substance into them.

2) voluntary inactive euthanasia (where the patient voluntarily requests help in dying and another person acts by withdrawing or ceasing an action that is helping the patient stay alive),  - E.g. a person asking someone else to pull out all tubes providing life-saving support like oxygen or fluids, etc.

3) non-voluntary active euthanasia (where the patient does not actually request or oppose help in dying and he is acted upon so as to hasten his death), - E.g. a non-communicative or possibly brain-dead patient who has made no prior indication of his wishes in this situation being given a fatal substance to hasten their death.

and  4) non-voluntary inactive euthanasia (where the patient does not request or oppose help in dying but another person acts by withdrawing or ceasing an action that is helping the patient stay alive). - E.g. a non-communicative or possibly brain-dead patient who has made no prior indication of his wishes in this situation having all life-supporting measures like oxygen or fluids withdrawn.

“Non-voluntary” is used as opposed to “involuntary” because involuntary implies that it is against the person’s wishes whereas non-voluntary simply that it is not opposed nor is it specifically desired. For example, involuntary active euthanasia could be thought of as common first-degree murder where a person does not want to die but he is purposely killed. Involuntary inactive euthanasia could be akin to a person actively asking for my help to avoid death (which I can presumably prevent by some action) but I withhold from providing this life-saving thing. This is a crime similar to murder in many countries too.

In most countries in the world what the law forbids are active forms of euthanasia, and in fact inactive forms of euthanasia are quite readily accepted – and legal. Every day in intensive care units patients are non-voluntarily actively euthanized, when their treatment is deemed futile by someone other than the patient themselves. And our right to “voluntary inactive euthanasia” is hailed one of the great achievements in medical ethics when doctors were disrobed of the expectation of paternalism to have that same power handed back to the alert, competent patient, in the form of autonomy. Any patient in the world can refuse any treatment in the world even if that treatment is considered life-saving. You can even write down your wishes when you’re still able to communicate them for future reference, for those times when you are non-communicative or no longer medically-competent. But I am digressing here, I could go on for hours on medical ethics, but what I really wanted to discuss is active forms of euthanasia.

Take religion and law away from the argument for a moment and try to discuss why euthanasia is “wrong”. Well, they tell us, it’s inherently bad because it has the potential for abuse and you run the risk of evil people wanting to just kill whoever for whatever trivial reason. Reasons such as, maybe, “he’s no good to society anyway”, “I don’t like him”, “he is of this race or culture”, “he’s poor”, or “he has no family”, or “he will cost more than I am willing to spend to keep alive”, etc. etc. There are many things in medicine with potential for abuse. We often hospitalize and treat the mentally ill; we force-feed those with eating disorders; we prescribe medications with known side-effects; we terminate the lives of foetuses for whom we can’t prove either way whether they are “persons” with an independent right to life or not, etc. I even heard it once said that one of the biggest mistakes in medicine was the idea to try to keep premature babies alive at all costs. Many of these babies will have chronic health problems, and the expenditure on neonatal intensive care units is massive. Some would say we have abused the technology in life-sustaining measures by trying to apply it to each and every patient, even these tiny babies which we are potentially setting up for terrible lives. My point isn’t to argue if these tiny babies are worth it or not worth it; my point is that we do entrust health professionals with many life and death situations all the time. And we do this because we have assumed they won’t abuse their powers just to see a new technology or treatment work without thinking of the consequences.

So then, why else is euthanasia “wrong”? They say because we could make a mistake – and the consequences of that mistake is not reversible. Again, doctors face this potential every day! I think that if you were to filter it down, the real controversies with euthanasia are 1) religion, 2) law, and 3) an expectation (or perhaps misconception?) that the overriding aim of medicine is to prolong an individual’s lifespan (as opposed to other aims like preserving their dignity, ensuring quality of life, and having a social responsibility to the rest of our fellow humans). Unfortunately, like many things in life, when you use one rule to apply to everyone in every situation, you will often get it wrong. Many people do not like to think that their doctor could have the knowledge or ability to perform euthanasia, because they assume doctors are special and, like I mentioned, should only want to prolong a person’s life. However, I believe that keeping euthanasia from the scope of medicine isn’t keeping us from any evil we aren’t already at risk of committing. I also don’t support allowing the scope of euthanasia to evolve without the input of medical professionals. If you’re going to do something, do it right. This is called harm minimization, and is not a new concept to medicine at all.

But why do I personally believe that euthanasia isn’t bad (if it were able to delivered effectively and without inflicting further harm or pain)? Because I believe that every person is free and free to choose to live their life how they choose. I also think it is cruel to deny someone something, especially their freedom of choice, simply because they need someone else’s assistance to achieve their goal. Imagine being denied access to the top floor of a building because you are a paraplegic in a wheelchair and the building isn’t equipped with elevators or ramps. Now, imagine that the reason you want to get to the top floor is because on the ground level where you are there is a fire that keeps intensifying. Don’t you wish someone could help you? But no-one can because then they will be arrested and they would rather not go to prison, even if they’re your friend or relative and they love you. So you’re left to fend for yourself. No-one bans you from going to the top floor, it’s simply a shame you can’t get yourself up there – and that is your only option! Oh well, better just wait for the fire to intensify, your skin to burn, and to watch yourself helplessly, and probably painfully, die. You knew all along that upon going to the top floor you’d only fall asleep and die up there, but hey, wouldn’t it have been nicer? Apparently not. Apparently it is nicer to allow our much-esteemed friends and family members to die in pain and helplessness.

And yet, having said all this, I have to clarify one thing for fear of being called out on my inconsistencies. Fortunately or unfortunately, I am Christian first and foremost, so no, I personally would not help a patient in this way. But I have tremendous respect for people like Jack Kevorkian who were/are courageous enough to serve their patients at all stages of life. Death is simply another stage of life.

On the rules

One day I told someone that I was struggling because there was something that I really wanted to do but that I didn’t do simply because it goes against my religious beliefs. And it wasn’t a fleeting desire, either; no, it was actually a very deeply-seated desire that penetrated and marked me to the core of my being. But, yes, I had a system that I lived my life by and it is religion. People often quote this feature of religion as being one of the “bad” things about it. It’s so restrictive. It rules people’s lives and is a great evil. But everyone lives their lives with at least some rules. Some are there to protect the ego, others to protect our survival, others to keep us out of jail, others to protect our conscience, etc. But every rule serves to protect something – and we all, even the most free-spirited ones of us, obey some sort of rule or rule system. My rule system is basically Christianity.

The friend I told how I was struggling with this feeling I had but had to hide because of my religious system gave me some advice: change or leave my religion. Of course! Why didn’t I think of that?! In fact I had thought of that, but before I tell you about that, let me tell you about something else I really really wanted to do one day.

I was at a restaurant once and this woman pushed me as she walked past. I was furious! I wanted to pull this lady back and pull her hair, punch her in the face, and kick her in the guts. I felt an energy surge through me, it was so strong. My expression changed to one of absolute spite for this woman, so much so that the people around me noticed my anger. They told me to let it go and move on. Someone moved in between me and the woman so I wouldn’t make a sudden lunge towards her. I thought to myself, “Move on?! Let it go? But I feel this feeling so intensely, so deeply, so in my core.” I let it go, though. Do you know why? Because there are rules in society, and even if I don't agree with them, they still apply to me as a member of society. Of course one can always break the rules and accept the consequences of doing so.

This incident is not the only time I've really wanted to hurt someone, nor am I the only human being who has ever had this desire. We have all wanted to hurt someone for even minor spites like being cut off by another car while you’re driving, being spoken to in a rude and impolite way, seeing someone purposely abuse an animal or someone who is weaker than them, etc. All these things can irritate a person and the human instinct may kick in to react with violence to serve our own ‘justice’. Now, should you? It's something you want so why should you have to resist? Because it's against the law? Because it's against social norms? Because it would be morally “bad”? Because it’s against your religion? But none of these norms and rules were devised by yourself, so why should you comply? Do you see what I’m getting at?

I rejected my friend’s suggestion that I change religions because I don't think everything in life should be solved this way. I think this attitude of always having things your way, if not changing your environment (the physical environment/religion/political party/professional membership, etc.) comes from our society's new rules of the self as deity. Our religions, the object of our worship, have become ourselves. We worship by seeking to maximize our personal pleasure and meeting all our desires – often at the expense of... ‘whatever it takes’. And what is wrong with that religion? Nothing. But our religions are not the only rules we face in our lives. Sure you can punch that guy who pushed in front of you in line at the cinema, or you can steal that item you really want from the shop, etc. but you’ll still have to face the consequences of doing so. That’s just how life is, with every rule comes a consequence.

I’ll tell you now how I overcame my struggle. No, I didn’t change religions just so I could obey my desires. I still believe in everything I ever did about Christianity. I didn’t suddenly lose the burning desires I once had. No. The only thing I changed was I accepted the consequences. There are some things that are worth the consequences.

Only God can judge me.

J

On what we don't know

Let me propose a very sinister scenario for your consideration. I propose it only because I don’t know exactly what to conclude from it but it raises a lot of very interesting ideas.

The scenario: There’s a 25 year old man; a man who you know to be a nice guy, who is studious, who is playful and just generally a fun guy. He is a foreigner and speaks with a somewhat funny Indoasian accent. He goes to university and he likes to tell jokes. He is respectfully religious but not over-the-top with rituals. He even volunteers in a community youth group. One day this guy is joking around, playing with a boy who is 11 years old. In the spirit of the moment he makes a penis joke and makes a move towards the child’s genitals. The child pulls away, pushes him, and the day proceeds. One day this man is accused (by a third party) of indecent sexual dealings with a minor because of this particular incident.

Now, all of which I described above actually happened, the actions are exactly as I described. You can picture the man, you can picture the child, you can picture that they were having a laugh and engaging in the physical play which all children enjoy. Even the man in question clearly admits the incident occurred as described. However, the only things we don’t know are the thoughts and intentions of the 25 year old man. The matter went to court and the man was ordered to have no further unsupervised dealings with children, especially not in institutional settings like in his university studies. He was sentenced to 12 months probation and nothing else. Now, most people’s responses to this story are either 1) ‘the pedophile got away with it!’, or 2) ‘I know that guy and he’s totally a nice guy. It is such a shame that he has had his name tarnished with such a terrible accusation’.

Further from this, let’s consider one possibility. In the case it was alledged that the man meant no ill-harm because when the child pushed him away and said ‘no’, he obeyed. It follows from this that the man was acknowledging that this contact was against the child’s wishes. They added this to his character references from people who knew the man prior to this incident to conclude that he was a good man who was innocently playing with a child, joking, and incidentally happened to have made a move towards the child’s sex organs while in the course of a non-sexually intended activity. Makes sense, right? Good guy made bad move.

But imagine for a second that he wasn’t a good guy; propose he is a big bad pedophile. What would a pedophile do in the same situation? He would play a non-sexually-seeming game with the child to “groom” him, to teach him increasingly more sexually-explicit acts that the child will not associate with “bad” (or sexual) things. In the way of this grooming he will “accidently” touch the child’s genitals or allow the child to accidently touch his. The child thinks ‘we’re playing!’, meanwhile the pedophile just scored sexual contact. As I mentioned, the “play” will become increasingly more explicitly sexual, but the grooming for the pedophile involves a bit of trial and error. Sometimes he overestimates his steps; sometimes the child is more docile than first imagined. If the child were to become uncomfortable in a situation, he knows he has to slow down – because a comfortable child is much easier to take advantage of! Can you see where I’m going with this? If the child in the scenario had not pushed the man away, what would have happened? The man would could either have just been playful with the child and possibly never meant to even touch him (like a ‘normal’ person); or he could have sexually fondled the child to his own sexual gratification (like a pedophile). So therein lies my problem with judging the man either guilty or not-guilty of a sexual crime against a child: the fact that he withdrew his attempt does not prove his actions either way.

The second question this case raises for me is which is better? When this case went to court there were four possible outcomes that could have come from a verdict of either guilty or not guilty: 1) an innocent man walks free, 2) an innocent man is punished, 3) a pedophile receives deserved punishment, and 4) a pedophile goes free. All of these outcomes have an equal probability of happening. I would hate to have been a judge in this case and have to make that very hard decision. Ideally the evidence of the case helps you make the right decision (options 1 or 3 above), but as we saw in this case, judging intention is something that maybe only God can do. So now the judge has to make an even harder decision, which is the least unjust finding: set a guilty man free or convict an innocent one? Of course, the case we are considering here is not just any case, but an accusation of pedophilia. And in fact, that is what the judge based his decision on in setting the man free. He reasoned that if the man is innocent because he didn’t actually “do anything” to the child then he hasn’t been unfairly deprived of his freedom. Yet if he is guilty then his punishment will be that his name will be always be known and associated with ‘that guy that tried to touch that kid’.

Of course, to the general population this may not seem be enough (punishment to a presumed offender). After all, don’t the courts and governments also have a duty to protect the public from exposure to harm (e.g. pedophiles and other villains)? Yes, it’s in the constitution of most countries’ governments. But before I consider this last point, you have to excuse me as I recede back a step.

The man in the scenario we discussed in the beginning in fact pleaded guilty to the actions of that day as they happened (and conceded the possibility that they could be deemed to be pedophilic in nature – thought he never said that it what he intended). So the judge never even had to make the judgement of labelling the man “guilty” or “not guilty”, he just had to decide on the punishment for the man’s actions. So in a way you could say that a guilty man walked free based on the judge’s reasoning as was discussed earlier. And maybe that is what we need to focus our attentions on: setting adequate penalties for crimes against children. I know the frustration of victims and of police officers who strive to find the bad guys only to have them go to court and receive a sentence that seems to be but a mere formality and without any intention to actually punish offenders, to rehabilitate them, or even to protect the public.

(P.S. I hope the guy whose story I based my scenario on can forgive me for using his example to illustrate my point. Only God can judge you.)

On abortion

The rape of the Sabine women, Giambologna

Recently someone asked me to express my views on ‘abortion’, specifically as it relates to my role at work, my personal religious views, and my experience with medical ethics. I found it an interesting little exercise because it made me think about the different roles we play in different social spheres and also the cognitive schemas which we keep constant across these spheres. For example, the religious group to which I belong and whose view I share (or at the very least accept) has a view on abortions that is easily summarised as “it is never indicated”. Now, in my role as a doctor I am at times confronted by people enquiring about termination of pregnancy services. In this scenario you could say that I am paid to educate, to assist, and to aim for the best health outcome for my patient. But I am the same human being doing both roles of Christian and doctor. The other thing to realise is that I represent only myself, not my religion or my profession – and yet to another fellow human, I am both!

I have summarised perfectly my religion’s views on abortion as “it’s never indicated”. Before I summarise my profession’s view on abortion, I must summarise my profession’s role. Doctors have sets of clinical standards and legal standards by which we must exercise our jobs. It is not just about using the best clinical method or doing things legally, it is about using the best clinical method to do legal things that are in the patient’s best interests – as dictated by the patient himself (or a substitute decision maker on his behalf). So my profession’s view of abortion you could say has to do with the performing of legal abortions in a clinically safe manner. Of course, this is given that it is requested by the patient, and is in keeping with the general direction to minimise harm to her or to improve her wellbeing. You could very generally summarise my profession’s views on abortion as “it is indicated when the patient wants it, it is the best thing for her mental and/or physical health, and it is able to be performed in a clinically safe manner”. Now, does everyone in my religion believe exactly the same thing? No! Does everyone in my profession believe the same things as each other? No, of course not. Some of us differ even in antibiotic prescribing!

Personally, I believe whether or not a thing is bad has to be decided by the person to whom the decision directly affects. For example, if my religious belief is that eating a certain food is a sin, then it IS a sin if I personally ate that food. However, if someone else doesn’t believe it is a sin and eats this particular food, then to me that person is not guilty of a sin either in his own view or mine, and I can hold no negative judgement towards that person. The question of MY view on ‘abortion: good or bad?’ for me is redundant. To me what is of relevance is what I do in one or another context. I am both a Christian and a paid medical professional, but I am above all things, a human being. Every human being approaches life with the same basic aim: to do the thing that is best for me and minimize my discomfort (physical and/or mental). No one likes to feel guilty of not doing their job adequately, and no one likes to feel that special type of guilt our religious beliefs can make us feel. Things get even more complicated when you throw in having to act in situations that will directly (and indirectly) affect at least one other human being.

I have reached a position in my life where I don’t want to change anyone’s view to that of my religion, or to change the views of my religious associates to that of my own. I have also been lucky enough to realize that my work is just that: work. So what has all this stuff on religion have to do with my discussion here on abortion? Medically, in my job, it is never my choice to decide on a patient’s medical care if he is competent to make that choice himself, regardless of their or my personal religious or personal views. My job would be to inform accurately and with scientific fact, to ensure that the person has access to adequate psychosocial support, and to aim to protect the patient from mental and psychological harm. None of these tasks have anything at all to do with my own personal religious views on anything.

You can’t discuss abortion, though, without discussing legality. I was asked whether I believed that termination of pregnancy services should be deemed “illegal”. I believe that the main reason that the concept of legality is still introduced into discussions about intentional abortions is that it is contended on some many levels that have little at all to do with either medicine or the law. The way our society deals with such “ethical” or “moral” dilemmas is to pass strict laws or rules to dictate what should be done and where and by whom. For example, a statement could be made that an unborn person has the same human and legal rights to a person who is already born. However as a society a statement like that is not very practical because there are too many things to consider, e.g. at what age or weight is a foetus a ‘person’, what anatomical or biological parts entitle a person to be called a person, etc. So we come up with laws and rules instead, saying for example that a foetus after 24 weeks of gestational age is a person and has this and that other human right but not these other ones yet, etc. This is, you’ll notice, similar in concept to Christian ideology that says “it is never indicated’.

Personally, I believe that health professionals should not be criminally prosecuted for performing abortions that are performed safely and using standard practices when a person has consented to the procedure after being adequately counselled about it. I believe it should also be legal for patients who are intellectually competent to make health care decisions to seek adequate help from health professionals for discussion and possible subsequent performing of an abortion. I also believe that it should remain illegal to perform abortions that are not medically supervised or on people who are not capable of consenting or refusing to the procedure (unless in conjunction with a substitute decision-maker that has the person’s best interests at the forefront). I am glad that termination of pregnancy techniques have been developed in a medical context. For example, it’s better that a doctor with appropriate tools and knowledge perform an abortion than a woman attempt to have one done by someone with no specialized training. To believe that outlawing something which has such a long history of occurring is going to stop it from being done, I think is quite naive.

I do have one problem with our society’s current high rate of abortion, though, and it has nothing (or everything?) to do with either religion or law or ethics. I find it concerning that the high use rate of termination of pregnancy services, and its widespread acceptance, has led to the trivialization of what is essentially (and I think, rightly so) a big decision to be made in a person’s life. It saddens me that some people are coming to think of an abortion as an option for contraception or that it is a common/simple thing like getting a mole removed from the skin. The true and often undiscussed fact is that a lot of women do not understand the psychological impact of their decisions, and the potential for negative psychological sequelae in the years to come. Ideally, no woman should opt for an abortion without having full explanation of the medical or surgical techniques and the potential risks associated. The discussion should include explanations of the changes to be expected in her body, an understanding of the foetus’ current stage of development, an exploration of her own spiritual views, and consideration of her mental and physical health. Now, I am not saying ‘don’t have an abortion because you’ll get depression or other mental problems in the future’. I am simply saying that a patient needs to be given adequate and complete information to help them form their own decisions.