---Daniel Burnham
The last eight years have seen subtle and not-so subtle predations on the practice of medicine. Will the new administration be able to promote the kind of change we need? Let's review some of the challenges facing the Obama administration.
Ethical apocalypse
Bush's evisceration of the Constitution of the United States has affected health care professionals. For example, the military has likely always used psychologists to assist with interrogations, but the last eight years has seen a huge increase in the number of secret charges, unconsitutional imprisonment, and "forceful" interrogations. Military psychologists have been put in the position of choosing between what their country demand of them, and what their ethics and responsibilities to other human beings requires.
Additionally, the (now former) administration worked tirelessly to push through so-called "conscience clauses" during the waning days of their power. These rules allow health care providers to impose their own beliefs on patients in clear violation of the ethical precepts of patient autonomy and dignity. Given the challenges of the Mid-East, the economy, and other crises, it's hard to imagine why they would think this should be a priority, but apparently giving health care providers legal protection to advance their own needs above those of their patients seemed like a good idea at the time.
Health care justice
For both ethical and economic reasons, health care should be acknowledged as a human right.* Bush made some strides toward improving health care for seniors in giving them Medicare Part D, which helps pay for prescription drugs, but in every other way, he has failed to acknowledge our nation's health care crisis. With millions of Americans uninsured and underinsured, we are all paying a heavy price.
Ethics demand a lot of physicians, independent of our political context. We cannot of course ignore context, as only a very few will be in a position to risk their lives or livelihoods in the name of ethics, but a good government will encourage ethical behavior. Ours has not.
Ethics are embedded in culture, so universal statements are often problematic. The AMA, hardly a left-wing organization, and one clearly arising from American soil, has a 9-point statement of medical ethics which should serve as a guide to American physicians, members or not. Following ethical principles toward social justice can be made easier or more difficult with the help of the government. Let's take an example:
Principle VI: A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
Principle VII: A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
Principle IX: A physician shall support access to medical care for all people.
Doctors must be given the freedom to choose whom to treat. If I were forced to treat all-comers, I would quickly go broke an be of no use to anyone. However, my ethics dictate that I do my best to provide for good public health, and to advocate for access for all. The outgoing administration has made it perfectly clear that increasing access to health care is not a priority, and as millions have lost their jobs (and therefore their insurance) we have had to take care of more and more people for free, and more importantly have had to turn many away. As a healer, I can tell you it's a lousy position to be in.
Politicization of science
It is perhaps inevitable that government appointments will be political, but the CDC has taken a real beating over the last eight years. In one famous incident, the Bush administration significantly altered the CDC's evaluation of the effect of climate change on health. This is not a fringe issue---climate change effects public health through food, clean water, emerging infectious diseases, for example.
Moralistic inanity trumps science
The Bush administration has been praised for its efforts to fight AIDS in Africa, but many of their policies have made a mockery of medical science. AIDS activists in Africa understand the difference between faith-based and science-based medicine:
"We are now seeing a shift in recent years to abstinence only," she said. "We are expected to abstain when we are young girls and to be faithful when we are married to men who rape us, who are not necessarily faithful to us, who batter us." The women in the audience, several waiting to share their own stories of marital rape, applauded.
Were [a Ugandan AIDS activist] exhorted her audience to "denounce programs that are not evidence-based, that view AIDS as a moral issue, that undermine the issues that affect us, women's rights. I want to be very clear -- the abstinence-only business, women must say no!" (emphasis mine. --PalMD
Abstinence-only policies are not just for export. The Bush administration has made them a priority, despite their complete failure.
Politicization kills science-based medicine
When politics trumps science, medicine suffers. If we are willing to compromise our science and our ethics as physicians for political expediency, we have failed our most sacred duties. If politics can open the door to deciding what is fact and what is fiction, then invalid medical ideas can walk right in. We can hope and fight for better science policies during the next four years, but politics being what it is, we must remain vigilant. Still, I'm hopeful.
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*It has been pointed out to me that the concept of health care as an enumerated human right is problematic for a number of reasons, including imposing some rather burdensome obligations on other individuals, so perhaps "human right" is not the proper word.
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