Monday, November 7, 2011

Death Panels--Turning Patients into Algorithms

Over two years ago, in the heated discussions leading up to the passage of Obamacare, Governor Palin rightfully categorized a key aspect of the legislation--the "death panel".  More and more evidence of such rationing continues to become evident day-by-day. In her initial post, Governor Palin rightfully highlighted President Obama's healthcare adviser, Ezekiel Emanuel and his advocacy of a "complete lives system" that would ration care to those who are capable of being productive in society (i.e. those who are disabled, have special needs, or who are elderly would be less likely to receive needed care). Controversial former Medicare commissioner nominee Donald Berwick willingly admitted that he considered rationing to be necessary component of healthcare. Congressional Democrats have even recognized that the Medicare Independent Payment Advisory Board is an effect a rationing board that essentially redistributes the health of Medicare recipients. The FDA has also skirted the thin line between being a regulatory agency and a rationing board when they took cost into consideration in their approval process for a breast cancer drug, rather than sticking to their role of evaluating safety and efficacy of drugs.

Eyebrows have been raised also with reports released in the past few years from the US Preventative Task Force suggesting changes to the normal breast cancer and prostate cancer screenings. Those who disagree with the task force's findings are critical of the fact that they do not include radiologists and oncologists as part of their group as this may indicate that the appropriate expertise is not being utilized. Supporters of the findings think that this is beneficial as it removes the potential of bias from those who may benefit professionally from the status quo or increased frequency in screening recommendations. Those on both sides of the issue are addressing the wrong problem.

Dr. Richard Ablin,the physician who developed PSA testing for prostate cancer, is now saying that routine testing is "a public health disaster". Yes, PSA screenings can detect cancer when it is treatable, but that also must be weighed against unnecessary treatment and surgery if the test results in a false positive. The psychological effect must also be taken into consideration for those who tested positive, but were actually negative. Sometimes very old patients are treated for cancer with treatment regimens that are very painful and uncomfortable in and of themselves, and some would have likely have died of natural causes prior to the cancer itself killing them. Similar issues can occur with breast cancer. There is a concern that too frequent of mammographies has the potential to cause cancer itself. There's also the psychological concern that arise with the worries of yearly examinations among other problems.

The true problem is the burgeoning influence of the government in these screenings and the shrinking influence of individual patients and physicians. The recommendations of such a government commissioned panel as the US Preventative Task Force has the potential to create a precedence for influencing what both private and public insurers cover and at what ages and frequencies they cover screenings such as mammograms. In the United Kingdom, their universal health care covers mammography for women aged 50-64 years of age every three years. Prior to the most recent US Preventative Task Force recommendations, women in the United States were recommended to receive mammograms on a yearly basis from age 40 and up, which is still what is generally adhered to. In the UK, breast cancer  mortality rate of 26.2 per 100,000 while it was 23.5 per 100,000 in the US for an 11% difference in mortality. Although not all factors can be effectively evaluated, earlier and more frequent screening likely played a role in making survival better for American women than UK women.

In addition to the potential for task force  recommendations to turn into government regulations, the influence of comparative effectiveness research provides a potential threat to the patient-physician relationship. When applied on the micro level, comparative effectiveness research is needed and welcomed. Patients and doctors alike want to ensure they are either receiving or administering the most effective treatment for their condition. No one wants unnecessary, ineffective procedures to be performed. However, when the results of such research is applied on the macro level through government regulations, it has the potential to turn patients into algorithms where a patient's demographics, symptoms, and disease are placed into an equation to spit out what is deemed the appropriate treatment.  This is the kind of healthcare system that has been implemented in England through the National Institute for Health and Clinical Excellence  (NICE) which has lead to increased rationing of care, increased wait times, and non-coverage of cancer treatments often basing decisions on a quality of life equation. To be sure, quality of life is important and often more favorable than an increased quantity of life of just a short time. However, the problem lies with who makes this determination. Does a government panel make this decision? Does the influence of government applied comparative effectiveness research play too large a role? Two of the key tenets of bioethics are autonomy and beneficience. When decisions are made by government panels and government implemented algorithms rather than by patients and their doctors, it flies in the face of both of these tenets.

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