Sarah Palin, Meet Hippocrates

Sherwin B. Nuland: `Death Panels,' Medical Ethics, And the Nefarious Critics Of Health Care Reform

(The New Republic)  As if you hadn't heard, a gaggle of American conservatives is stridently charging that pending health care reform legislation will institute a mechanism for euthanizing selected members of the handicapped and elderly populations--that it would, in Sarah Palin's formulation, establish "death panels." It's true that H.R. 3200, the bill that will eventually come before the House of Representatives, is still a work in progress. It has already been amended by three separate House committees, while two Senate committees are working on drafts of their own. All of the provisions to be included in the final bill are not yet known, but one thing is certain: There is not a single statement in the voluminous number of pages under study that contains the slightest consideration, no matter its remoteness, of death panels, euthanasia, or any such fearsome concept.

In reality, the legislation simply calls for the reimbursement of physicians who counsel patients on end-of-life decision-making--counseling that is already required by a 1990 law and that is now covered by many insurance plans. But the specifics of the present bill are irrelevant to the loony conversation the right has sparked during the August recess. After all, even if there were some provision before Congress that could conceivably be interpreted as establishing a "death panel," centuries, if not millennia, of established medical ethics (in addition to existing U.S. law) would prevent its actualization. In the midst of this crucial debate on the future of health care, somehow, the proponents of the euthanasia talking point seem to have forgotten everything we know about the practice of medicine in America.

Even putting aside the Judeo-Christian morality upon which the Constitution and our nation's culture are based, the notion of forced euthanasia would contradict the long-held body of medical ethics to which all American doctors must adhere. At times, morality can be dismissed as a matter of personal conscience, no matter how widespread its acceptance. Ethics, on the other hand, arises from societal or group commitments to principia of behavior. A formulated code of ethical precepts--whether philosophical, legal, or religious--is a statement of commitment that the group has a right to insist upon from its members, even to the point of punishing breaches.

Since its origin in the works authored by followers of Hippocratic teaching, the ethics of Western medicine have forbidden any action that might harm a patient, hence the famous injunction: "[H]ave two special objects in view with regard to disease, namely, to do good or to do no harm." That principle has been reiterated again and again through the ages, as, for example, in the words of the Geneva Convention Code of Medical Ethics, adopted by the World Medical Association in 1949, which states, in part, "The health of my patient will be my first consideration," and elsewhere, "I will maintain the utmost respect for human life . . . I will not use my medical knowledge contrary to the laws of humanity." I know of no source that permits anything else.

Moreover, as the modern discipline of bioethics has evolved since the 1960s, there has been universal acceptance among its authorities of four principles that are considered fundamental: autonomy, beneficence, non-maleficence, and justice. The principle of autonomy, which refers to the autonomy of the patient, directs that every individual has the free-willed authority to make well-informed medical decisions for himself and that the physician must never dictate such decisions. In the words of a highly regarded textbook of bioethics, "This implies a respectful and broadly rational dialogue between doctor and patient, in order to combine the patient's values and the doctor's expertise to produce benefit. For this to happen, the patient and the doctor must be prepared to listen to each other, think about what is being said, and be responsible about their respective roles." As for beneficence, non-maleficence (the "do no harm" of antiquity), and justice, the words speak for themselves. Death panels indeed! Euthanasia indeed!

The growing professional disciplines of medical ethics and bioethics have had a profound impact on researchers, bedside doctors, associations of physicians, and government. The President's Council on Bioethics, a carefully chosen committee of some of the field's most eminent members, was created to advise the executive branch on any and all issues for which guidance is needed. Furthermore, the much-maligned American Medical Association, a strong supporter of H.R. 3200, has urged President Obama to publicly recognize the code of ethics that governs the actions of physicians.

Even if some wild-eyed legislator, special interest group, or purposeful troublemaker were to ignore the personal ethical behavior that has long been among individual and organized medicine's strongest influences, no bill could legally include any deadly provision of the kind being bruited about. In 1990, responding to several high-profile court cases--notably, those of Karen Ann Quinlan and Nancy Cruzan, two young women in deep and irreversible comas who were kept on life support for unconscionably long periods, even as their families petitioned for cessation month after month--Congress mandated that any health care institution receiving Medicare or Medicaid funding (which means all but a very few acute and chronic care hospitals) must, on admission, provide patients with three statements: one outlining their right to accept or refuse any type of treatment; another laying out their right to issue advance directives to ensure that their wishes about continuing life-sustaining therapy be carried out; and a third explaining any policies that govern the institution's withholding or withdrawal of life-supportive treatments.

Though the purpose of the 1990 legislation was to ascertain that hospitalized patients would not be maintained on ultimately futile therapies, such as ventilators or feeding tubes, against their stated wishes, it also forbids anything resembling forced euthanasia, since the patient (or, in the case of incompetence, his or her legally authorized surrogate) by definition would not have requested it. Regardless, fulfilling such a request would be illegal if it were made in any of the 48 states that do not have an assisted-suicide law. And, even in the other two--Oregon and Washington--assisted suicide would certainly be viewed by the authorities as quite a different thing than forced euthanasia.

In order for patients to make knowledgeable decisions under the 1990 law, it is essential that they thoroughly discuss with their physicians the implications of the directives they are choosing, such as "do not resuscitate" orders. H.R. 3200 would, for the first time, legislate that the physician receive a fee for these discussions, making it more likely that they will take place and that they will be of real substance. From these provisions of the bill, the ignorant, the nefarious, and the just plain stupid have extrapolated that the purpose of the periodic consultations is really to determine life or death, with government officials and even physicians--heaven forfend--taking on the role of Dr. Mengele. It is ironic that the very legislation designed to protect patient autonomy is that from which Sarah Palin and her ilk have derived the fantastical notion that her son, Trig, who has Down syndrome, would be euthanized if H.R. 3200 were passed.

Even if such a gruesome threat were real, the combination of morality, ethics, and the law would stop it early in its malodorous tracks. The entire issue--or non-issue, which it surely is--contains the ingredients of travesty unworthy not only of the attention of the bioethics community, but of the general public as well.

Sherwin B. Nuland, the author of How We Die, is Clinical Professor of Surgery at Yale University and a member of the Executive Committee of The Yale Interdisciplinary Center for Bioethics.

[cameraphone]

I wonder how the GOP will ever top this lie about there being Death Panels .... but they will.

[Danfromhere]

Everyone should have noticed that over time society?s attitude about things change. This process once took a considerable amount of time. Today with the internet and world communications, it goes much faster. The Obama health plan may not specifically state that there will be ?death panels?, but? When abortion was found to be a constitutional right of women, attitudes started changing until today we have horrific but acceptable things happening like a botched abortion and the stranding of the newborn to cry out its life until ?natural? neglect kills it. And why, because it was the intention of the mother that the child dies by abortion and therefore it should die even if it continues to live pass the efforts to kill it. How can we trust Obama on healthcare when he has this type of thinking going on in his head?! How will our attitudes change in 30 years, and they will change? Will we become as heartless over our elderly as we are about abortion? I may not be an intellectual, but I do have a vote and I?m not afraid to use it.

[kmccdoc]

Check out this link to youtube - some of sarah palin's friends are on it:

http://www.youtube.com/watch?v=defXnFJpBYM

[klps302]

Everyone has the right to have health care coverage. While this bill may be flawed, the right wing seem to like to distract the American public with Cold War propaganda and complete misinformation. As an American living in England, I can tell you there are NO death panels in the NHS and no "rationing" as is being represented in the American media. While the NHS isn't perfect, it still means that a hotel cleaner doesn't go bankrupt just because their child has needed stitches in the hospital. What the US could really use is the best parts of the NHS mixed with the best parts of the US system. Basic coverage for all would in the end cost less than the strains the current health care system is having to deal with. How to pay for it-by taxing an extra few percent of people making over $250,000 a year (less than 5% of the US population). The super rich might not be so against this if they suddenly found that they had to clean their own office bathrooms, make their own coffee, and drive their own subways to work because the population they are denying health care coverage to are all dying due to lack of proper medical coverage.

[justamomm]

Sherwin B. Nuland, Meet Reality
WIth all due respect to the author, this article was penned by "the ignorant, the nefarious and the just plain stupid". The Geneva Code of Ethics and the mantra for the medical community "I will remain the utmost repect for human life" does not apply to children diagnosed in pregnancy with down syndrome.

The medical community has gone on a search and destroy mission to be sure that these children are detected in the womb and then destroyed. The race to find more effective and less harmful tests to weed out the extra chromosome continues today, as Sequenom stock price fluctuates with the advance of it's work. ACOG recommends that all women test for down syndrome because 80% of children born are to those mothers under 35. There is an estimated termination rate at diagnosis of 90%. The medical community and insurance community are striving for 100% termination.

The medical community recommends testing without real knowledge of down syndrome... the abilities and gifts that these children have and bring to their families. There was recent legislation sponsored by the late Ted Kennedy to be sure that parents were given more ACCURATE information at diagnosis. This had to be legislated by the government because it is no routinely given by the medical community.

The author of this article believes Sarah Palin should reflect on the work of Hippocrates, I do believe it is most hypocritical . Sarah Palin speaks from true knowledge, true experience.

[sarrab-2009]

she's smarter than Obama

[myth1958]

We only have to look as far as the real financial losers of the new legislation to see where most of the organized opposition is coming from. Pharmaceutical companies; health-care for-profit companies; insurance companies. Not very many doctors care how they get paid: they actually want to heal people. All the rest of the afore-mentioned players see their exclusive turf being invaded and profits from the golden calf reduced (or eliminated). People just want access, they want treatment. What is the fairest means of bringing it to all? Right now all Americans contribute toward Social Security, Medicare and other well-run caretakers of our elderly, infirm and indigent. Why not, I ask? we are the greatest nation in history. Let's take care of our own. If little old Canada demonstrates to us daily that it can be done, the United States sure can.

[longkat]

This whole issue about death panels makes as much sense as the moon being made of green cheese! Sarah is a hoot. As the hockey mom, or pit bull with lipstick, she ought to know better than to disregard health care. Kids need good health care when they play contact sports. Forget the elderly and their needs. She was the governor the state that had their home care services shut down for the elderly (a first in federal history). Great leadership and care of older adults! What is utterly fantastic is the extent to which Sarah and gang have taken this opposition to the bill. What would she say to families who cannot afford basic health care? Take a powder? I cannot fathom how anyone with half a brain can believe this garbage that is spewing forth. Even if a health care plan is flawed, then let's work out the details and get it right. It is frightening that this woman could have risen to the position of anything above her well-touted hockey mom position

[noloyalisti]

Failin' Palin" Quaylin is a complete joke. The very fact that she has an audience just shows how very stupid and dumbed down Americans have become. God forgive us and save us from ourselves.

[robo1415]

Sarah Palin is looking smarter and smarter while Obama is looking more and more like the over-rated buffoon he always was.

[noloyalisti]

Sarah Palin and smarter in the same sentence? OMG, what happened to our brains.

[robo1415]

Barack Obama:The Half-breed Holehead from Harvard and his ignorant army of serfs are about to fix American Healthcare liked they fixed the economy and ended the wars NOT!!!

[robo1415]

thank goodness for sarah Palin!obama is a dunce!...does he actually think that there will not be rationing of healthcare when you have high demand and limited resources?The woman is only stating the obvious ...too bad the dummies that elected obama can't even figure this one out!

[cs4466]

The Witch of Wasilla: Professional victim, leader of the ignorant, the misguided, the spiteful and the simply uninformed.

[John_Merritt]

Dr. Nuland EXCELLENT article. You are right that people have a tendency to lock into some quote, or grouping of words and construe their own meanings. The universal law of humanity as you noted within your article states what? I guess it all depends on the culture it which one resides?

However, I believe this HC bill, as is, may be flawed beyond belief. I am a firm believer that people (physicians) should be recompensed for their knowledge, abilities, and education. I have a problem with 'brokers' of health insurance, the industry itself. I have problems with a CEO who makes $1 million + per year telling you and me how I should be treated; and how you should conduct your practice. I have a problem with brokers who are paid more for telling you what you can do, and when you do it, paid miniscule when YOU did all the work. Do you agree? What is wrong with this picture?

This bill and the entire science of health care delivery needs to be over hauled and the physicians and medical community should be able to what is necessary in providing quality health care to THEIR patients in an affordable and effective way. Whenever obstacles lie in the road of that concept, you can either go around, run over it or sweep it to the side. The health insurance industry is more than a barrier, it is becoming an obstacle that prevents you from doing your job and me from trying to get the best at the lowest possible price.

Since you and I have been part of the 'system' in various ways, you will have to admit your job has become appreciably harder because of the constraints of others demands on you. Would you agree? It is time the AMA and other organizations including pharmacy and medical device companies demand the impediments of health care delivery be streamlined and made to allow all, patients and organizations, to move forward and remove the obstacles in our path that deters us from what God intended for you and.

Great article and have a good day.

[steeepe]

Palin is not fit to serve in public office. She is an unapologetic and intentional liar, whose mischaracterizations bring further disrepute to the GOP. Time for the GOP to find a few reasonable intellectuals in their ranks, instead of trying to appeal to ignorant Americans representing the lowest common denominator.

[briannorwood]

Let's face it. Sarah Palin is an intellectual lightweight. Why she continues to garner national attention is beyond me. Can't we just do the right thing and ignore her?

[hologram5]

One simple word, MILF. That is the ONLY reason this mental midget could stay in the news so long.

[ClarkeGrissom]

blah blah blah...tldr.

The bill is still flawed beyond belief. You've picked one ambiguous portion to argue your point. So ambiguous that they have decided to pull this specific legislation out, your points are moot. Now, how about addressing the fact that under the bill 10 million illegal aliens are going to receive health care? Or how there is actually very if any little 'reform' at all, but instead its just another big entitlement program to grow our nanny state government into making decisions that will affect both our standards of living and our well being. How the bill is really going to get funded? How the government plans to extend better healthcare to more people without spending a fortune? Or even better why the government employee unions, SEIU and UAW have to be excluded from the mandatory healthcare being shoved down our throats and why our tax money will be used to subsidize their unions health plans?