Friday, September 6, 2013

Blog Post: some general observations about care



September 6, 2013

Last spring, the Quebec National Assembly suggested a Bill to allow their province’s doctors to perform euthanasia on terminally ill patients.  There are places in the world where killing patients is ‘legal’ after a fashion.  Holland is one place, and depending on whom you read or talk to,   Belgium is another place, and their law is based on Holland’s.  Washington and Oregon are two other places where medically provided death is ‘legal’.  The reason I have qualified those statements is because there is a question in some research I have done which says that these positions might not be legal after all.

It’s not about the money.  It’s about world-class patient care.

Yet our medical care, as technologized as it is, is highly controlled and very expensive.  It is commonly said that health care in the US is the most expensive – and dollar for dollar – the least effective – in the world.  And there are still people who are not covered for care.  The alternative is to make people pay vast sums out of pocket.  In Canada, this past summer, the Ontario provincial government quietly delisted diabetic test strips being paid for with a prescription.  Seniors were agitated about this move; but a few weeks before there were articles discussing the delisting of occupational therapy for certain procedures.

That development led to a possible court challenge to this situation on the part of professional occupational therapists, to keep that funding alive.  This is what I would personally call privatization by stealth: quietly one test or procedure here and there is privatized.  For instance, this past summer [2013], the Ontario government de-listed diabetic blood test strips for seniors.  Seniors’ groups are now fighting this, but the de-listing happened overnight.  In the same way, the association of physical therapists of Ontario fought the de-listing of physio services for seniors and their court case was dismissed. (both sources Toronto Sun articles)

When these services have been privatized, the stance becomes that it will never be made public: the tradition is now that we have never done things like that; and it will make a bad precedent.  If we make public the care of this disease, then we will have to fund that ailment.  I argue that this is not a cost-cutting measure, but, rather, at a theoretical level is part of a neo-conservative ideology of minimalist citizen care. Why else would a government not trumpet what it is doing when it comes to health care, and why else would there be a silence over the impeding health care talks coming up in 2014?  Remember that we are hearing of more and more patients and families who have to go to the US to get care for ‘rare’ or ‘uncommon’ diseases and ailments, and OHIP is refusing funding for them…

This could be happening because Harper wants it that way.  Because there are a host of people in the background pushing the ideology, message and appearance of issues.  As well, journalists have been effectively muzzled in Canada, as in when Harper now only answers in one official language not both.  [August 20, 2013, Toronto Star]  Why else would you do that, unless it served your agenda?

This is the same apparent rationale with which we see the Senate scandals.  Harper’s platform was to create a triple-e senate: one of the ‘e’s in that was elected.  So is it really a scandal that we should find out about the nefarious dealings?  Or is it part of a larger rationale that just happened to fit in with the ideology?

So if we have seen how there is a push on toward legalizing medically provided death, and if we have seen that there is a deathist agenda in the offing, and we can see that safeguards, as in place in schools, are not effective in protecting students from harm – and that is the paramount mission of teachers and administrators, even before teaching students effectively.  And it’s not working for the students; just ask Rehteah Parsons, Mitch Wilson and others who have died as a result of apparent bullying.

So if there is an agenda of cost-cutting, and we have ineffective safeguards for something as simple as bullying, what makes us think that we can effectively protect patients from harm in a medical setting?  As in the case in New Brunswick, we have seen that mistakes will happen, and currently there is very little that patients can do about it.  So what makes us think that patients, or families, can resist doctors who are determined to take a life, especially if those same doctors have administrators telling them to cut costs as mandated by the provincial governments?

I remember coming to after an operation in 2010 and vaguely asking why someone was shouting.  Later I learned it was the administrator of the unit, who was yelling that the patients were not being moved out of recovery fast enough.  That did happen; and I heard, although I have not been able to confirm, that hospital administrators at that level get a bonus based on how much money they save the hospital they work at.  At this point, that is a hypothetical assertion, but if that is true, it would go a long way to show that there is a hidden agenda of money in our socialized medicine.

Now, if there is a push to cost-cutting, and there is a social push toward legalizing medically provided death, and administrators get money for cost-savings, how much more pressure will there be on doctors to provide, and patients to accept, medically provided death for economic convenience?  And given that doctors are not required to tell you what is on your chart, how easy would it be to place a quiet kill order on your chart when your family goes home?

This happened in Holland, by the way.  There was evidence that a doctor stated of a patient that, if this certain patient was alive on Monday when the doctor got back from the weekend, there would be hell to pay.  That’s not a hypothetical situation: that happened.  And in science, one anomalous result is enough to put a theory in doubt.  In euthanasia, it’s a hiccup, and means that we can carry on.

My main argument about euthanasia as it is presented and practiced is that it creates a medical star chamber.  People will never know what has happened; patients get abandoned by friends and sometimes, sadly, family.  There are tight silence orders in employment contracts which cover everything from talking to the wrong family member to whistleblowing when something is really wrong.  That last makes everyone in an organization legally complicit if anything goes wrong and there’s a cover-up, when you think about it: if you can’t speak to the police or authorities when a crime is committed without losing your job, how likely are you to say something?

From the point of view of someone who is suddenly bumping into health provision services, these changes will come as a stealthy surprise.  Patients and families are not likely to know what is going on their charts, even less will they know that there are cutbacks which tie the hands of the medical service providers.  Those providers are also working with tied hands: cutbacks and government regulations will ensure that they can do so much and not more.  I would even venture to say that there is an invisible triage based on how patients present themselves.

So for instance, if you are considered a ‘medical hulk’ – let’s say that you are ‘identified’ as a drug addict (whether this is proven or not) then you will fall under the regulations which say that people with damaged lives – alcoholics, drug addicts, smokers – will not get as high a treatment rating than those who are considered ‘not’ to have done those things.  So how you present visually and what you say at the emergency department will impact how you are seen and what type and velocity of care you get.

And you will never know that this is happening, because it is not required that you know this under law.  In addition, consider the following:

“In the fall, I attended a public bioethics talk at the hospital where Annie died about discharging, planning and community services.  The speaker, who is a physician and policy strategist, explained to everyone how the government makes funding decisions and how the bottom line is that there will be no more money for community services for disabled children.  She suggested that it was important to “think critically about the quality of life versus salvageable life” and questioned whether 24-week preemies should be resuscitated.  I was disturbed by this because I think these are societal decisions that need public and parental input.”

(Susan McIver, p. 13, “A child like Annie” in the book After the Error: Speaking out about Patient Safety to Save Lives, essay written by Barbara Farlow)

So this policy analyst was creating policy from the podium, and had the imprimatur of professional ethics, and this would now be in the minds of the policy wonks who were in the audience hearing this speech.  Given that we are facing fiscal cutting, and given that preemies need care and that we have technology and technique to save children 24 weeks and older, we are choosing to eliminate through denial of medical care a subset of humanity based on membership in that subset.   I think that the word we are looking for here is genocide.  It will start with these hard cases, and then it will become easier and more acceptable to deny care to others based on difference and ‘defined difficulty’ of care.

And thanks to the silence from medical providers, iron-clad gag contracts and the complicity of mainstream media posing these situations as heroic choices, we will never hear about this state of affairs.  It’s hard enough having a voice in this time when you are disabled in any way, this silence of care and lack of social commentary by those who provide care will doubly silence those who need another voice to speak with them.  Yet, this will be seen as a heroic thing when someone chooses death to donate their organs and such a person will be held up as an example for all to follow.

The pressure, conformity and horror stories will come later, if we ever hear of them at all.  So we are gradually dehumanizing the fragile, starting with those who have a special claim, and moving to those infants who truly have no voice.  We will end by silencing anyone who criticizes and then eliminating those critics.  And the whole while we will think that we are doing the right thing because those who are killed will be ‘better off’ in comparison to ourselves.  Until we end up needing help and then our help will come from…oh, wait…

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