The Oates Journal (ISSN: 1098-1446) is a publication of the Wayne E. Oates Institute addressing issues related to spirituality, ethics, and healing from the perspective of pastoral care and counseling.

The Uninsured and Other People without Access to Basic Health Care

Central to any discussion of the problems of health-care delivery is the problem of people without any access to basic health care. This problem is complicated by the fact that it is multi¬dimensional. Beyond that, there is a theological consideration. And over-arching these areas of concern, there is the political dimension. These areas of activism are frequently at odds with one another in terms of the concept of reality they espouse and the data that are adduced to define the limits of the problem. In this country above all these factors are complex issues that are in a word the concerns of capitalism. These concerns include the rights of the venture capitalist to realize a profit and to subsidize absence profits to upper-level executives and the erection of monumental buildings to dramatize the success of the entrepreneur.

Counterpoised against these interest groups, which insist on being heard and heeded, is the average citizen aspiring to nothing more than living the normatius American dream. These are the people who work, vote, pay taxes, and raise families. They understand the necessity of providing education and moral guidelines to succeeding generations. These average people are patriots, devoted to their home and way of life, impelled by a sense of duty, and in general subscriptive to the Golden Rule.

It is the divergence of these streams of thought concerning the rightness of things that has produced American medicine. This enterprise is a technological marvel that elevates us above Darwinian survival of the fittest to a degree unimaginable even fifty years ago.

Another characteristic of American medicine is that it spares no expense to carry out its mission. This fact is beneficial to those who need long term renal dialysis or bone marrow transplants. However, there is not enough money available to provide this level of care to everyone. The result is that some people can have a level of care that stretches the limits of human knowledge and skill, while others have no access to health care at all. It is the inequality of access that is having such a stultifying effect on medicine as a whole. The same inequity is driving a relentless and probably soon-to-be successful drive toward a single payer system.

Most of the socialized medicine schemes in the industrialized nations pay obeisance to the principle of a single tiered system in which everyone is treated alike. In theory this would indeed seem to be a desirable goal. But in none of the countries with a single payer system is this goal achieved. There is de facto stratification in all of these systems. To turn attention to our nearest neighbor with “universal health-care” there is wide-spread age discrimination. In effect the elderly are walled off from expensive care such as coronary artery bypass grating because the cost-benefit ratio is not considered to meet the needs of the fiscal well-being of the system. Elective surgery, which is truly only elective if it is not your renal colic or cholecystitis that is being considered, faces a waiting period of many months. Sophisticated technological tools such as the MRI and PET scan are so few in number that the waiting period to enjoy these imaging devices often exceeds the wait the disease process allows. As a result, older, less precise and more invasive diagnostic procedures have to be employed.

To arrive at a scientifically valid number depicting how many people have no means to access the health care system is impossible. One reason for this is that there is a distinctly political reward to be gained by either over-estimating or under-estimating the number. The federally enacted EMTALA regulations simply stated provide that everyone regardless of ability to pay can be seen and stabilized in any emergency department. This fact means that many people use these emergency rooms as their primary care encounter. This fact leads to care that is inordinately expensive (for reasons which we will see later) and not at all comprehensive. Once the patient leaves the ER, there is frequently no follow-up to the disease with which he/she presented. Also, in the event the patient has no means to pay for this care, it is the hospital that must bear this deficit. To illustrate, in Denver, Colorado two hospitals have become bankrupt and are going to close their doors because of a large influx of illegal aliens in that city who use the emergency department of the hospital as their family doctor and not only is it illegal to refuse treatment to anyone in the ER setting, regardless of ability to pay, the care must be pushed to the limits of medical possibility in order to forestall negligence claims. As an example of this situation, a patient presenting with a headache cannot be told “take two aspirins and call me in the morning." At a minimum, this patient will have a thorough history and physical, as well as a cerebral CT scan and possibly a lumbar puncture.

If the problem relates to the uninsured, as well as the under-insured, what sort of numbers are we talking about? The number fluctuates and varies wildly according to what person, or agency is doing the estimation. One hears from 30 million to over 100 million. There is obviously a political agenda behind these estimates, and the numbers vary in relationship to whether the estimator is occupying an elective office, or is hoping to become an occupant of an elective office.

It should be borne in mind that government currently bears more than 40% of the health
care delivery costs in this country, i.e. close to $400 billion. This is a line item figure in our national budget that exceeds most of the total budgets of our industrialized group of nations. With Medicare, Medicaid, military personnel (and dependents), Veterans hospitals and clinics, USPHS hospitals and clinics that serve Native Americans; our government is very involved in health care. Beyond these examples of outright direct assumptions of health care, the government employees in addition to their salaries, are given health insurance, thereby injecting many more billions of dollars into American medicine. If all of these people whose health care is the direct or indirect responsibility of government are added up, the total comes close to 100 million.

The glaring problem that mitigates against the “working poor” obtaining medical insurance is the federal tax code. Simply put, if a business pays for health insurance for their employees, the expense is a tax deductible item. If an individual buys health insurance for his/her family it must be paid for with after-tax dollars. There is little wonder that millions of the “working poor” opt to gamble on not having a catastrophic illness and to spend their money in other ways.

The Nursing Shortage: A Shift from Clinical to Academic Training

Nursing shortages are becoming increasingly important factors in the need to change our current structure for delivering health care. If present trends continue, this need will very soon become a necessity. There are several major factors that are driving this problem. And it is doubtful that most of them can be remedied.

Nursing education has transformed itself from an enterprise largely funded by non-profit or academic hospitals to an activity that has been co-opted by the academic world. By the time student nurses trained under the older system graduated, they could run an operating room, a delivery suite, or a patient unit with an amazing degree of expertise. From the day of their graduation they were fully competent to fit into any nursing niche in the hospital. The intensive three year, 36 month program that was a mixture of didactic classroom instruction in the necessary academic subjects such as chemistry and physiology and extensive exposure to hospital-based on-the-job training, is no more.

For a lot of reasons, most of which were economic in nature, hospital based nursing programs began to disappear in the later quarter of the Twentieth Century. Universities and colleges took up the task of training nurses. The focus of training shifted to filling classroom chairs from bedside training, the minimum of a baccalaureate degree became the gold standard for nursing graduates. The immensely powerful influence erected by academicism ensured that the need of the universities, i.e. the renting of classroom desks, superseded the needs of the hospitals.

This shift in the training of nurses has resulted in the new nursing graduate who has minimal or no skills in the care of needy people who are ill. A prolonged orientation period is necessary for each newly hired nurse before he/she can be given independent responsibilities for patient care. The shift in methodology in nursing education has also produced a shift in the mind-set of people who are considering entering nursing. In the era of hospital based nursing schools young people entered the profession with a sense of mission, of ministry. Now, the considerations tend to be more mundane (who pays the highest salary, which provides the best benefit package, which pays the highest signed bonus). The sense of mission is largely a forgotten anachronism.

A second factor that contributes to the nursing shortage, i.e. the shortage of nurses working in direct patient care is the multiplication of job openings available to nurses that do not entail giving enemas or holding emesis basins. In 2001 it was estimated that the nursing shortage nation-wide amounted to 180,000 nurses needed above and beyond the available supply. Statistics governed by organized nursing also estimated the number of nurses engaged in jobs that entailed no direct nursing contact amounts to 180,000 jobs. In response to a Bob Dylan like plaintive question, “Where have all the nurses gone?” these statistics supply the answer.

On morning hospital rounds, each nursing station is filled with nurses, most of whom are engaged in chart review of some sort. Most of them are unrecognizable as nurses, since they wear whatever the mood of the day dictates. None of the patient charts are in the chart rack, but are scattered all over the desk tops. The actual nurses engaged in direct patient care are in a pronounced minority. Moreover, since any academic enterprise, including that of training nurses, requires graduate nurses, many are recruited into masters and doctoral degree programs to become nursing professors.

Financial Compensation

The pressure by nursing organizations and individual nurses to increase the payment and benefits package to nurses comes into conflict with the shrinking reimbursement package available to hospitals. No one would seriously agree that professional nurses are not entitled to a standard of living commensurate with other jobs requiring comparable preparation such as secondary school teaching. But the sad fact remains that the ceiling can not be raised appropriately because of the diminished amount of money paid by insurance, whether by government or corporate sources. This ratio creates added tension between the hospitals and the nurses they can not function without. Two of the leading hospital corporations in our community are approaching a debt load of $800 million, all of which will have to be repaid or the hospitals will face the prospect of bankruptcy. None of the other hospitals has a bottom line that would gladden the heart of an accountant as a stock investor. It must be borne in mind that hospitals cannot respond to economic pressure by raising prices. They are in a rigidly price-controlled industry. This pressure produces some odd results that will be discussed later.

Loss of a Hierarchical Organization within the Nursing Unit

The traditional model of a hospital nursing unit was clearly understood and intensely hierarchical. The organization table tended to look like the following:

1. Head Nurse
2. Staff Nurse (GN or RN)
3. Licensed Practitioner Nurse (LPN)
4. Nursing Assistant
5. Ward Secretary or Clerk

Several factors have emerged to change this logical and efficient organizational scheme. Many of the Staff Nurses are graduate nursing personnel awaiting their registry examinations. They are probably in an orientation status. The latter fact means that at this level there is less than full productivity.

With the Licensed Practitioner Nurse (#3) is the emergence of an academic rather than a trade school (or Clinical?) approach to nursing education that has had the net effect of devaluating the LPN. As a result, the number of LPN training programs has declined and hospitals are having as much trouble finding and recruiting Licensed Practitioner Nurses as they are Registered Nurses. This intermediate skill level, between the nurse aides and the RNs provides a yeoman’s service to the nursing unit, freeing the Registered Nurse from many of the mundane tasks that are clustered around patient care.

The Roles of the Nursing Assistant and the Ward Secretrary/Clerk (Levels #4 and #5) are also difficult slots to fill. The nursing assistant is capable of doing the majority of the bedside chores. Therefore, these people are the “nurse” in the perception of the patient. This job requires a great deal of hands-on assistance, e.g. helping the patient with positioning, cleanliness, hydration, nutrition and grooming. They take and record vital signs and routinely draw the attention of the nurse regarding any variance in these signs. These people are key to the patients and their families’ satisfaction.

It is difficult to over estimate the value of a good Ward Secretary/Clerk. This person does the scheduling for the unit’s patients; their lab tests and procedures to establish a diagnosis or to treat a condition. The Ward Secretary/Clerk also serves in the communication function of the nursing unit, receives and charts the complete diagnostic results, keeps track of the whereabouts of the unit personnel and the unit patients.

Concerns regarding the staff functioning at levels #4 and #5 are several, and they are urgent: 1.) training people at this level is not academically enticing for a degree program. Therefore, it is not easy to persuade a college to provide the necessary training, 2.) on-the-job training is inefficient and expensive and it seldom produces a well-trained employee., 3.) the exigencies of hospital economics mean that people serving at this level in the organization cannot be paid what they are worth, and 4.) the work ethic of young, poorly paid workers is frequently execrable. These employees tend to call in ill or just do not show up for work and this creates chaos on the unit.

Finally, the phenomenon of the agency nurse needs to be explained. The acute nature of the nursing shortage is not lost on anyone. Entrepreneurs have lapsed into the niche of opportunity that this shortage provides. Agencies have sprouted up to supply hospitals with temporary duty nurses for a fee. Nurses have flocked to enroll in these agencies, preferring an itinerant variegated work environment rather than a long-term commitment to a single area. As must be obvious to everyone, the staffing of nursing units by agency nurses is a poor, but necessary, compromise for the following reasons: Agency nurses are very expensive. The hospitals must pay not only the salary (and benefits) of the nurses, but also the fee charged by the agency for the services. Acquiring these necessary soldiers in the war against disease is at best a psychic victory for the hospital. Agency nurses fill in where and when needed. Their frequent unawareness of the patients in a given unit, the mission of the hospital, and the ethics and rules of behavior that govern the actions of the regularly employed nurses, puts them, their patients, and the system at a disadvantage.

Nurses employed by a hospital quickly develop sensitivity to the needs of the community of patients with whom they deal. It is not over reaching to affirm that they develop a sense of mission or even of ministry in their job. Agency nurses often lack that type of sensitivity, though some agency nurses are more effective than others. In the end agency nurses are filling an organizational slot for a given period of time for the purpose of a paycheck. They are not connected to a system that contributes to the overall well-being of the patient through the mission and accountability of that organization.

In summary, the nursing shortage is a reality. At present this short-fall has the appearance of being insoluble and health care delivery is adversely affected and moving toward permanent change. Already in some hospitals it is not safe or prudent for the one who is ill to be unaccompanied by family members who can see that the patient is being assisted to do the things they cannot do for themselves. For one example, meal trays for bedridden patients are often placed on a table or dresser across the room. If no one is there to make the food available, the patient goes without a meal.

Physician Availability

After perusing the physician listings in the yellow pages it would be understandable to conclude that we have enough, if not too many doctors. However, there are a number of circumstances that make that impression overly simplistic.

In these days of star helicopter flights and super highways to almost everywhere, the geographic inequality of the distribution of doctors is less pressing than it used to be. Urgent medical emergencies can be shipped off to the nearest medical center, usually in time to protect life. These sorts of adrenaline-packed situations so beloved by television producers represent a very small segment of medical practice.

In order to safeguard the maintenance of the optimum health of a community, on site medical professionals must be available. But this sort of outpost medical practice is lonely, usually underpaid and over-worked. For many years Dr. Paul Maddox in Campton, Kentucky was the busiest doctor in America. His clinic building never closed; his living quarters were upstairs. He literally never took a full day off (his idea of a day off was to stop work at 5 pm). He had three delivery rooms for delivering the babies of the mountain mothers. He also pushed for a clean water system and for other improvements in his town. Needless to say, Dr. Maddox was very highly respected to the point of reverence. But it must be clear to everyone that such extreme dedication is a rare commodity.

Many work situations abound among physicians. My mother, among her other irritating aphorisms, had one that went, “The Devil finds work for idle hands to do.” In the face of what is basically a doctor-glut in more heavily populated areas, fueled by too many U.S. medical schools and an immigration policy that allows foreign medical graduates to pour into the country, there is not enough community doctoring to go around. So, needless or excessive medical procedures are proliferating. If that statement seems over-the-top, consider the following:

Plastic Surgery

True plastic reconstructive surgery is an artistic wonder that has huge benefits to offer the community. Repairing nature’s mistakes or correcting the horrible disfigurements caused by trauma requires the highest blend of science and art that exists anywhere in medicine. But the ethics of putting redundant foreign material into the chests of normally configured teenagers is a distortion of the very arms of medicine. It is a frightening commentary on our culture that breast enhancement operations are considered to be suitable high school graduation presents for barely post-pubescent young women.

Pain Management

When the first clinics were dedicated to the diagnoses and treatment of pain-producing illnesses, the primary goal was to relieve pain, restore a normal optimistic view of life to the patient and to return the person to work. These goals require a multi-disciplinary team, consisting at a minimum of physical and occupational therapists, psychological therapists, chaplains for spiritual therapy, and physicals to provide diagnostic and pharmacological support to the effort. The first of these appeared in Lacrosse, Wisconsin under the guidance of Dr. Norman Sheely. They began to spread from these, but only slowly. The expense of this intense, but usually fairly brief, period of treatment was not a service that insurance companies were willing to pay.

Spinal surgery

It is difficult to overestimate the damage done to the physical well-being of the public occasioned by the extremely radical procedures done to remedy frequently simple back complaints. Not only are such operations physically destructive of normal physiology; they are also consuming vast amounts of public money. This occurs every time someone with a one-level disc herniation gets a massive spinal procedure and winds up as a result on social security disability. The cost to the public treasury lasts for the lifetime of the patient. The latter fact does not even take into account the initial cost of the surgery which is often in the mid five figures.

Now the emphasis has shifted to enrich the new “certified pain management specialists,” many of whom became certified by a no more ominous process than paying a fee to the certifying agency. The aim now is to get the patient onto disability as soon as possible and then to zonk the pain with opiods. Many of the clients of these "specialists" come from the spine specialists. The following will illustrate the cost of this frequently larcenous enterprise:

1. A series of three epidural blocks, which have become so common place as to be ludicrous, costs more than spinal surgery. In most cases, these blocks are beneficial only temporarily, if at all.
2. The indwelling spinal stimulator, which emits small electrical shocks to the spinal nerve, is very costly and prone to failure. The stimulator device in itself cost upwards of $20,000.00. The cost to the doctor and the operating room cost which boost the total cost to approximately $30,000.00 and the devices are prone to malfunctions and frequently have to be removed (and often replaced).
3. Drug pumps, which were initially devised for terminal cancer patients as a pain control measure, are now used for chronic non-malignant pain. The costs and drawbacks are similar to the process utilizing the indwelling spine stimulator.

Oncology

The sub-specialty of Oncology deals with the treatment of cancer. This horrible disease is the leading cause of premature death and the second leading cause of all deaths. Consequently, the diagnosis of cancer carries an enormous amount of emotional freight with it. The result is likely to be a plea to "everything that can be done" to fight the disease. And a great deal can be done.

1. Surgery is sometimes curative and that is a wonderful blessing. But where a cure cannot be affected, the tendency is to keep on operating after all reasonable hope has been exhausted.
2. Radiation is resorted to after surgery has failed. As an honest palliative procedure it can also be a blessing, but carried beyond all reasonable hope of recovery, it can be very painful, very disfiguring and lead to severe loss of functioning, swallowing for example.
3. Chemotherapy is the administration of highly toxic (poison) substances in the hope they will kill the tumor before they kill the patient. These toxic drugs are unbelievably expensive and often not covered by insurance. While most oncologists are very caring people who deeply empathize with the patient, administration of these drugs in the office setting is subject to finagling by unscrupulous people. As a result of the sins of a few, Medicare and Medicaid are moving toward requiring the move of the administration of these drugs from the office to the hospital. This is a bit of a paranoid reaction in that hospitals are no less concerned with the bottom line than are individual or physician group practices.
4. The overall cost of medical delivery is hugely pumped out of any normal cost-plus configuration by the influence of the malpractice insurance industry and the trial lawyers who represent medical plaintiffs. There are a number of reasons why these hand-in-glove enterprises hugely dilate the cost of providing medical care but first, the question must be posed, i.e. who pays for all the litigation with often lottery-size awards? The entire cost for medical litigation is borne not by the insurance industry and not by medical providers. The entire cost is borne by the patients. The cost has escalated to the extent that doctors are simply bailing out, often at the height of their experience and skill. There are reasons for this gross escalation in costs that the public apprehends only dimly, if at all.
5. The first evil in our American tort system is the contingency-fee-system that lawyers enjoy. In brief, they get 30-40% of any judgment before any of the plaintiff's losses are paid out. To provide a bit of perspective on this evil, it should be realized that the contingency fee is outlawed in every other industrialized nation of the world. In these other countries, the lawyer and the client agree to a fee up front. This fee is paid win or lose.
6. In other industrialized nations, e.g. Canada, if I sue the doctor and lose, I must pay all the court costs and the cost of defending the suit. This fact tends to reduce the number of frivolous suits greatly.
7. The fees that malpractice insurance carriers charge health care providers are not based on loss experience. Instead they are based on potential losses. For example, neurosurgeons are charged a much higher premium than general surgeons despite the fact that general surgeons get sued several times more frequently, primarily because a big lottery-sized judgment is more likely in the neurosurgical field.

A second factor that drives malpractice premiums has nothing to do with medical negligence. The insurance companies have stockholders who must be paid a return on their investments. So, when the stock market portfolio of the insurance companies fell as a result of 9/11 terrorist attacks, for instance, the loss was passed on to the public.

Very few physicians or other health care providers would deny that the monetary loss to the patient as a result of a mistake should be paid, along with a reasonable bonus for pain and suffering, but the latter should have a limit. A figure of $250,000 is the consensus amount for pain and suffering in those jurisdictions that cap the settlement for non-monetary losses.

The second factor that is in place to protect the public in some jurisdictions even in our own jackpot obsessed nation, is a mandatory arbitration process to decide whether a suit is appropriate. Typically, this is non-binding arbitration. But if the panel decides that a projected suit is justified by the facts, that suit is very difficult to win in court. Conversely, if there is a finding that a suit is justified, there is serious reason to try to arrive at a just settlement without the cost of a lengthy court battle. If the case goes to court, just like in a disease case or a probate of an estate, the lawyer gets a very large chunk of any judgment.

Shield Heath Professionals

Allied health professionals form an increasingly large and important segment of health care providers. Like the nursing profession, many kinds of allied health professionals are now trained in an academic setting, rather than a hospital based job-training setting. Included in this group are radiology technicians (RTs), medical technologists (MTs), physical therapists (PTs), occupational therapists (OTs),  speech therapists (STs), and clinical pathologists. These professionals add a very important dimension to professional health care management and they are more deeply trained than they once were. Their skills have increased accordingly.

The overall problem with this type of training, as with the nurses, is the number of people who are able and willing to enter into these arduous training programs is on the wane. This makes the services of these professionals difficult to access and the cost of their services is spiraling.

Most hospitals require that before a health professional can join the hospital staff they must be covered by someone’s malpractice insurance policy. These specialized providers are being included in malpractice torts in increasing numbers and the effect of this phenomenon has the same problems as are associated with suits against physicians and hospitals. The net result is the creation of a gulf between realistic patient needs and the realistic availability and cost of services.

Problems from within the medical profession have changed dramatically over the past few decades and outside pressures influence these factors to a greater or lesser degree. However, the problem must be laid at the feet of professional standards of care.

James Gustafson, the great Theological Ethicist, teaches that the task of ethics is to balance what God enables us to do against what God requires us to do. In many cases the ability we have been permitted, far out-strips the necessity or even the logic in terms of what we should do. Some of our insistence on pushing methodologies as far as we are able is clearly based on the economics of health care processes. Some of this drive, however, is to see how far the envelope of knowledge, technology and ability can be pushed. In driving a high-powered car it is sometimes irresistible to blow the roof off the posted speed limit. So it is in health care. It is apparently unavoidable that newborn intensive care units want to be able to boost the world’s record for the lowest birth-weight survivor.

Cost distribution, in terms of cost-benefit ratios; in terms of personnel utilization and in terms of a need for strict intellectual honesty, all influence this area; which, is not an inconsiderable portion of our medical costs. Cost distribution in terms of utilization of resources are rather badly irregular and intuitive in nature. Thirty percent of all dollars spent on health-care are consumed during the first and last months of life. Truly the spark of life is beyond any sort of calculus we can suggest, but the above figures suggest that the seventy odd years of life between these two extremes is short changed.

Futile care, or care that is given although it cannot prolong the term of quality of useful life is sometimes difficult for families of the sufferer to grasp. As professional care-givers it is our responsibility (and ability) to discern the point at which we should that the dying process has an unyielding hold on the person. Not only is it fiscally irresponsible to persist in treatment beyond this point; it is unkind to the patient to an extreme degree.

The 2003 statement by the Pope John Paul II regarding the provision of nutrition and hydration beyond the possibility of recovery has some powerful arguments. I would agree with others that the term "vegetative state" so beloved by the media is dehumanizing and should be replaced. My own candidate for a replacement term would be "irreversible coma." However, the Pope seems to go beyond traditional catholic ethics in declaring hydration and nutrition to be an invaluable comfort measure rather than a medical treatment. If made official doctrine of the Catholic Church, it would not permit cessation of hydration and nutrition in prolonged coma for any reason.

There have been anecdotal incidents of recovery after a very long period of time and this fact seems to feed the fear that if treatment is stopped at any point, the miracle might be foreclosed upon. However, we now have available CT scans, MRI scans and PET scans that allow us to actually see the state of the brain within its bony confines. Therefore, in most cases of persistent coma, we can say for sure if the brain has undergone such damage that recovery is indeed impossible. In such cases the lack of dignity of the patient and the emotional burden on the loved ones by prolonging inevitable death is ethically unjustifiable.

On the other end of the human biography is the immediate post-partum period of life. To cover this very important period of life, more and more sophisticated technology has been poured into the neonatal intensive care unit. The result is that many babies have been saved.

Here again, the principle of natural selection has been studied. The great expense of this form of treatment, frequently exceeding $250,000 is money well spent if a healthy child is the result. On the other hand, the survival of a severely damaged baby with multiple genetic and developmental deficits, to the point that independent life will never be possible, is a tragic result for the baby, the parents, and the public.

How can the viable children be separated from the severely damaged ones? That is the question for which we do not have a satisfactory answer at this time. Therefore the benefit of the doubt need be given as long as a spark of life is evident.

As in all medical research, the blind spot is in the evaluation of outcomes. Thus this leaves us with many urgent questions to which we have no answers. For instance: 1.) Is morbidity and mortality improved because of the huge number of cardiac catheterizations that are done today?, 2.) Is it logical that the neonatal ICU is the standard of care wherever babies are delivered?, 3.) Have obligatory CT scans of the head in the emergency department for all who sign in with head trauma reduced the incidence of potentially lethal epidural hematomas?, and 4.) Is the survival rate any better following heart attacks than it was before we had coronary intensive care units? Although these are basic questions, we do not have an answer to these medical standards. Every new procedure that comes down the pike should have a long-term outcome study built into the research protocol.

Resource Consumption

Physicians and other healthcare professionals have fallen into the habit of profligacy with expensive medical resources. Some of this is for personal gain, as outlined above. But the majority of this profligate behavior is the result of habit. Some of this is engendered in the process of training physicians that every diagnostic possibility is to be vigorously pursued; no laboratory test is left unordered. With experience this tendency lessens but does not disappear. And as we have previously alluded the Damocletean threat of a lawsuit leads to massive over testing. Some of these tendencies are also driven by corporate ownership of hospital procedures and an unshakable thirst for making money. These companies urge a widespread increase of testing beyond that which is necessary. No one argues that solid organ transplants should be abolished, but the famous Oregon voter referendum rejected such procedures because of the problems inherent in solid organ transplants. Not everyone needing a transplant can get one. The demand outstrips the supply. However, the specter of harvesting organs from healthy donors for profit is the subject of persistent urban legend in this scenario, e.g. the tourist awakens after a night of drinking to find a scar on his flank, and in subsequent testing is found to be missing a kidney. This plot is not as far fetched as it sounds. Since the numbers of solid organ donors do not meet the demand the question arises as to who will get the organ. We all read articles in the newspaper, or see a story on the television about "a bake sale and chili supper to help baby Jessica, born with biliary atresia, to get a liver transplant."  The transplant is seldom if ever curative, though it may prolong life with a greater or lesser quality of life.

Age related issues have been touched upon before, but these issues go far beyond the last month of life. Our society is no longer able to care for our aging relatives (mainly, 1 would argue, out of selfishness). To relieve this problem we have invented nursing homes; which are more or less benign albeit hideously expensive prisons for those who have exceeded their three-score and ten Biblical allotment of years.

To help assuage our collective conscience we have invented Alzheimer's (frequently mispronounced as old timer’s disease). Dr. Alzheimer in his classic paper describes a pathological form of dementia that was pre-senile and caused by a pathological condition of the brain cells. Most of what we now call Alzheimer's is perfectly predictable senile dementia caused by gradual decrease of the cerebral blood flow because of aging blood vessels.

The cost of these anile prisons is staggering. The term "nursing home" is laughably inaccurate in that almost no professional nursing care is done there. Most of us would not sign a lease on a one bedroom apartment costing 3- $4000.00 a month.

There are diagnosis-related issues, almost amounting to fraud, that have come to be standard. Moreover, other diagnoses, notably sexually transmitted diseases, have been so barricaded by privacy issues that they cannot be treated by normal epidemiological procedures.

A hospitalized patient who admits to having smoked is coded out at the end of their stay with an additional diagnosis, i.e. tobacco abuse syndrome. Likewise a patient who has taken synthroid for the past ten years because of a low level thyroid function, and has had normal thyroid functions on the medication will be coded out with the diagnosis of hypothyroidism although this did not contribute in any way to the need for a hospital stay.

These seemingly "harmless" coding practices are unfair to the public. All medical costs eventually are paid by the citizenry of any nation, regardless of the payer. Thus the hospitals and laboratories may not be able to survive without artificially inflating their price lists. But it seems the public would be better served by condemning this type of fraud.

Another seemingly harmless practice is to charge patients for post-operative visits to their surgeon after the first post-op visit, despite the fact that the fee the surgeon receives is a global fee.

These examples may not seem to elicit a "ta-da" response, but when one considers that medical costs have escalated many times faster than the inflation rate and the cost-of-living index, it is clear that we are being nickled and dimed (and dollared) literally to death.

CAM, or Complementary Alternative Medicine, currently costs the public very nearly as much as allopathic (traditional) medicine. And almost all of these dollars come out of the individual person's wallet. Some forms of CAM are useful and should be embraced by the allopathic community. Other forms of CAM are pleasant, but not helpful in health maintenance. And still others are harmful and dangerous. And yet as a nation we are spending hundreds of billions of dollars on an example unregulated industry. For example, one can do acupuncture in most jurisdictions with backgrounds that vary from a highly trained doctor of oriental medicine to one who decides acupuncture looks like a good scam and opens for business. In fairness, some states license CAM practitioners. Most, however, do not.

Overall, the subject of why people of the United States are paying an almost unbearable percentage of their income (gross national product or GNP) for health care has the many roots to which this paper has alluded. But the details are simply staggering in their volume and multiplicity. There is no one villain; all participate in the problem, including the public, which demands unreasonable and unattainable results from their medical care professionals.

The Hippocratic Oath forbids that I criticize my teacher or my brother physicians and most of us have a deeply ingrained impulse to follow this oath. There is also the Biblical injunction: "let he who is without sin cast the first stone." But it has become so easy and so profitable to hoodwink the public that there is a large-scale betrayal of the public trust in many areas of medicine.

Robert Sexton, MD, is a neurosurgeon in Louisville, Kentucky, and Chair of the Medical Ethics Committee for the Greater Louisville Medical Society.

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