Opinion: House Approves Bill that Defies Basic Standards of Medical Ethics

by Michael S. Dauber

On May 4th, 2017, the Republicans in the U.S. House of Representatives voted to pass the American Health Care Act, an Act that, if enacted into law, would repeal and replace many central elements of the Affordable Care Act, commonly known as Obamacare. The measure has received widespread criticism from many Democrats and from professional medical associations such as the American Medical Association and the American Cancer Society. Many people have questioned various parameters of the bill. This article questions it from an ethical perspective, and in particular, the potential consequences of abandoning health care protections designed under Obamacare to ensure that the most vulnerable people in society receive the care that they need.

The American Health Care Act would strip away protections that have facilitated access to care for pregnant women, patients with disabilities, patients that cannot otherwise afford health care, and patients with pre-existing conditions. While any attempt to discriminate against the sick and needy is unjustifiably wrong, the Act appears to directly target members of groups that are defined as most vulnerable and in most need of protection under most formulations of ethical practice.

For example, the Act would allow states to opt out of Obamacare requirements that prohibit insurers from charging patients with pre-existing conditions higher premiums for health insurance. It further classifies pregnant women, women who have had C-sections, and victims of domestic violence and sexual assault as patients with pre-existing conditions. It also targets elderly patients by allowing insurers to charge elderly patients up to five times as much as members of younger age brackets. Currently, under Obamacare, insurers cannot charge the elderly more than three times the amount they charge younger patients. The Act also includes plans to gradually eliminate $880 billion in Medicaid funding over the next ten years, funds that could have otherwise been utilized to extend coverage to low-income families.

In short, the Act specifically targets some of the most vulnerable members of society who might suffer immensely without health care and who may not be able to afford to pay the costs that many insurers may demand, or may be unable to pay for other essential expenses after paying their insurance premiums. Ahead of the vote in the House of Representatives, Senator Bernie Sanders called the Act “an abomination” and, in a CNN interview with Anderson Cooper, Sanders said, “thousands of Americans would die because they would no longer have access to health care.” Proponents of the Act argue that it is engineered to reduce the burdens of health care cost on the government and on insurers. Yet, the overall effect will be a higher cost for patients. Many patients will suffer and will lose their access to care because of circumstances beyond their control.

In this regard, the Act conflicts with basic principles of contemporary bioethics.  For instance, the Belmont Report (1979), as a blueprint for ethics in human subject research, stresses the importance of respect for the “dignity of persons” while ensuring protections in accordance with justice. The Belmont Report, though focused on ethics in human subject research, has become a defining document in the history of medical ethics, establishing a system in which patients must be respected and special protections must be given to members of vulnerable populations. If a patient falls into a protected class, health care providers have an ethical obligation to ensure that the patient receives the care he or she needs and that the patient is not denied care solely on the basis of disability, economic status, or prejudice against specific medical conditions.

There is an apparent conceptual link between commitment to protecting vulnerable populations in the clinical and research context and commitment to ensuring that vulnerable populations have access to care. The American Health Care Act has not yet become law. It must first obtain approval in the Senate and be signed by the President. Most recently, the Senate decided to modify the bill before voting on it and, as a result, the bill must be sent back to the House for a second vote. As the Senate prepares its own version of the bill, government officials should recognize that a policy that effectively precludes access to health care for members of vulnerable populations is unethical by virtually every principle of medical ethics.

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How Long is Too Long? Medical Interns Soon to Be Working Much Longer Hours

The current rules state that medical interns cannot work longer than 16 consecutive hours. This rule is in place to prevent accidents and mistakes as a result of fatigue. Recently, The Accreditation Council for Graduate Medical Education has proposed a change that would allow interns to work almost twice as long, for 28 hours without a break. The Council argues that this change would help expose interns to real-life practice. However, opponents of the rule argue that allowing these long hours is a severe risk to patients.

From npr.org, “Medical Interns Could Work Long Without A Break Under New Rule”

Excerpt from article:

“For years, medical interns have been limited to working no more than 16 hours without a break to minimize the chances they would make mistakes while fatigued. But that restriction could soon be eased.”

Read Full Article

 

 

First 3-Parent Baby Born in Mexico, Setting Off Regulatory and Ethical Concerns

According to an article published by CNN, dated September 28, 2016, on April 6, a baby was born with DNA from three people by using a new technique called “spindle nuclear transfer.” A team of doctors from New York went to Mexico to conduct the procedure since the Food and Drug Administration has not approved spindle nuclear transfer in the United States. Some are saying that this baby is the first to be born through this procedure, but critics state that the procedure produced children in the “1990s/early 2000s before the FDA” began to regulate it.

From Cnn.com, “Controversial 3-parent baby technique produces a boy”

Excerpt from article:

While in the past, the procedure was used to help women conceive and give birth to healthy babies in cases of infertility, the new version was created to tackle a specific problem: mitochondrial mutations.

Read Full Article

 

Editing Embryos: Scientist Begins Research Involving Modifying Genes of Human Embryos

In an article dated September 22, 2016, it was revealed that a Swedish scientist has become the first known researcher to begin attempts to modify genes in healthy human embryos—a practice which has been, and for many still is, considered “taboo.” Critics are concerned that people will begin to use such technology to create “designer” babies, or that such research could unintentionally create a new genetic disease; however, the scientist involved says he plans to use the embryos for no more than 14 days, in which time he may be able to discover new ways to treat infertility, prevent miscarriages, and use stem cells to treat various diseases.

From NPR.org, “Breaking Taboo, Swedish Scientist Seeks to Edit DNA of Healthy Human Embryos”

Excerpt from article:

“Lanner is planning to methodically knock out a series of genes that he has identified through previous work as being crucial to normal embryonic development. He hopes that will help him learn more about what the genes do and which ones cause infertility.”

Read Full Article.

 

To Treat or Not to Treat? The Debate on Incidental Medical Findings

In an article dated August 29, 2016, doctors and researchers debate whether they should disclose to patients minor abnormalities that are incidentally found during an imaging procedure (such as an MRI or CT scan). On the one hand, researchers say that doctors are going “overboard” on disclosing low-risk findings that lead to overtreatment and unnecessary worry by the patient.   However, on the other hand, a decision not to follow up on an incidental finding can have serious consequences. For one patient, kidney cancer was incidentally found and led to early treatment that arguably saved his life. Although the professionals disagree on whether to treat or not to treat, most agree that guidelines are needed to help doctors make the difficult decision.

Excerpt from article:

Often there is “little benefit” to patients knowing about minor, low-risk findings, and it can have significant financial, psychological and clinical consequences, they say.  Failure to follow up incidental findings can come back to haunt some patients, other experts say. . .

To read full article: When a Medical Test Leads to Another, and Another

FDA Takes the Advocates’ Advice: Approves Drug from Muscular Dystrophy

In an article dated September 19, 2016, Muscular Dystrophy patients and advocates, with the help of select members of Congress, celebrated the FDA’s approval of Eteplirsen, a drug manufactured by Sarepta Therapeutics for treatment of a type of muscular dystrophy that predominantly affects boys in their childhood. Advocates fought heavily for the approval even though there are limited clinical trials to confirm the drug’s effectiveness. While the drug may help up to 12,000 Americans affected by the disease, critics worry that the FDA has set a “dangerous precedent” by its decision.

From NYTimes.com, “F.D.A. Approves Muscular Dystrophy Drug That Patients Lobbied For”

Excerpt from article:

[I]t was taken as a deeply troubling sign among drug policy experts who believe the F.D.A. has been far too influenced by patient advocates and drug companies, and has allowed the delicate balance in drug approvals to tilt toward speedy decisions based on preliminary data and away from more conclusive evidence of effectiveness and safety. . .

To read full article:   F.D.A. Approves Muscular Dystrophy Drug That Patients Lobbied For

 

 

The Link Between C-Sections and Obesity

This article reports on a study showing that the method of childbirth might affect that child’s weight well into adulthood. Babies who were delivered by caesarean have a 15% higher risk of being obese than babies who were delivered vaginally. The article suggests causative links, but the study did not prove that a caesarean section is a cause of obesity.

From TheGuardian.com, “Babies born by caesarean more likely to be obese as adults, study suggests”

Excerpt from article:

“Birth by caesarean was linked to a 15% higher risk of obesity in children compared with vaginal birth.”

 To read full article: Babies born by caesarean more likely to be obese as adults, study suggests

Legalization of Marijuana Reduces Teenage Use

According to the results of a biannual poll conducted by Colorado’s Department of Public Health and Environment, teenage marijuana use has not increased since the state legalized the use of recreational marijuana for adults over the age of 21. The poll surveyed about 17,000 high school students in Colorado, of which 21.2 percent responded that they used marijuana in the preceding thirty days. This is a slight decrease from the 2011 results of 22 percent. The 2015 survey also indicated that the nationwide average for teen marijuana use is slightly higher than Colorado’s at a rate of 21.7 percent. Yet, contrary to the results of Colorado’s survey, a survey by the U.S. Department of Health and Human Services placed Colorado at the top of the list of states which the highest rate of marijuana use in teenagers between the ages 12 to 17.

Advocates for legalization of marijuana believe that the results in Colorado’s survey prove that the “fears of widespread pot use by minors” in states with legalized cannabis are unwarranted. Yet, others are skeptical about the results. SMART Colorado, an organization that lobbies for stricter marijuana regulations, believes it is “‘deeply concerning” that according to the survey, only 48 percent of students in Colorado view regular marijuana use as a risky behavior.

Source: http://www.scientificamerican.com/article/colorado-s-teen-marijuana-usage-dips-after-legalization/

“Extreme Overvalued Belief” or Mental Illness?

Society and courts of law often find themselves struggling to understand what causes someone to commit a violent act. Mental illness is often cited as the motive for such crimes.  However, Dr. Tahir Rahman, an Assistant Professor of Psychiatry at the University of Missouri’s School of Medicine, has concluded that in some cases, violent crimes are not the result of mental illness but rather an “extreme overvalued belief,” a term Dr. Rahman uses to classify the cause of criminally violent behavior when psychosis can be ruled out.

Dr. Rahman conducted a case study on Andres Breivik, a Norwegian terrorist who claimed to be a “savior of Christianity” after detonating a car bomb that killed 77 people in 2011. A psychiatric team concluded that Breivik was not psychotic and instead diagnosed him with personality disorder. Dr. Rahman suggests, however, that Breivik’s criminal acts were a result of his extreme overvalued belief.  An extreme overvalued belief is “a belief that is shared by others and often relished, amplified and defended by the accused.”  This intense emotional commitment to a particular belief is what causes the accused to commit a violent act.  Dr. Rahman hopes that his study can help forensic psychiatrists properly identify the motive for a crime in courts of law when a defendant’s sanity is in question. Although more research must be done to fully understand the concept of extreme overvalued beliefs, Dr. Rahman also hopes that future research will enable mental health professionals to identify early signs of such extreme beliefs and intervene before violent behavior occurs.

 

Source: https://www.sciencedaily.com/releases/2016/05/160523130806.htm

Texas Abortion Law Struck Down by Supreme Court

On June 27, 2016, the Supreme Court invalidated a Texas law that limited women’s access to abortion. The law required physicians performing pre-viability abortions to have hospital admitting privileges. It also required women’s health centers that offered abortion services to abide by certain surgical center requirements, causing many centers to close.

Proponents of the law claimed that it was an effort to maintain safety standards for women. However in a 5-3 vote, the Supreme Court concluded that the legislation imposed an undue burden on women attempting to obtain an abortion. Justice Breyer explained in his opinion that with the majority of clinics that offered abortions forced to close, the law would require women to travel long distances to the only “crammed-to-capacity” compliant facility. He further stated that nothing in the legislation provided any benefit to women’s health. Justice Ginsburg echoed this conclusion in her concurring opinion by explaining that complications from pre-viability abortions are rare and not life-threatening.

Justice Samuel Alito, Jr. wrote the dissenting opinion, which did not directly speak to the constitutionality of the law. Instead, he focused on the doctrine of res judicata, which prevents recurring litigation on a matter that has already been resolved. Justice Thomas affirmed this argument in a concurring dissent, claiming that the majority has repeatedly “distorted” the law and given preference to pro-choice arguments.

This is the first case the Supreme Court has decided regarding abortion rights in nine years, and while it was by no means a unanimous decision, it affirmed that the undue burden test established in Planned Parenthood v. Casey in 1992 continues to control the constitutionality of abortion laws.

Source: http://www.nytimes.com/2016/06/28/us/supreme-court-texas-abortion.html?_r=0; Marcia Coyle & Tony Mauro, High Court Strikes Down Curbs on Texas Abortion Clinics, N.Y. L.J., June 28, 2016, at 1–2.