Can there be an advocate who hath no sin? Who can speak out without producing controversy? No one…
How then does society address the challenge of confronting difficult modern technical and ethical issues in regard to truth, science, and patient care? How do we approach death with dignity and who receives organs and new technology? For example: with the development of highly effective implantable heart pumps, particularly of the totally implantable type, ground-breaking, and less controversial approaches to these issues has now been made possible by the creation of self-reliant patient advocacy councils. A pioneering example, established by AbioCor, is intended to provide each patient with a independently funded (irrevocable blind trust) advocacy group consisting of a qualified mentor and other council members. No council member, surgeon, or anyone else connected with the council may have a financial conflict of interest.
Perhaps this patient-related example may begin our excursion toward dealing, in a more productive manner, with other challenging clinical issues, (particularly those of death with dignity), in a manner more consistent with truth, consideration, as well as the scientific merit.
In the area of surgery and special procedures there are always those which are well-established, safe and efficacious for patients which have not been popularized because of lack of a profit motive and need to be better utilized. For these the term “Back To The Future” seems to be appropriate. In spine care some excellent examples are:
- Strut Stabilization (“Feathered Fusion”) first performed in 1911
- “Chip Posterior Interbody Fusion (PLIF)” first performed in 1978
- Autogenous Fat Grafts first performed in 1916 Percutaneous Radio-Frequency Nerve Blocks first performed in 1973
As our longevity increases and we become more prone to the progression of geriatric disease we begin to think more about quality of life issues. The saddest occurrence is to be afflicted with an agonizing and disabling condition which does not shorten life expectancy. The advent of many remarkable therapies has done a great deal to improve the quality of life for many conditions which, in the past, were poorly, if at all treatable. When any medical intervention, particularly surgery, is recommended it is the patient who must carefully weigh the risks against the possible benefits before making a decision. The risk versus benefit ratio applies in all cases. The understanding of these risks is the basis of informed consent.
Behavior does not change unless there are consequences for it. If the consequences for poor behavior are not sufficiently adverse, poor behavior is enabled and will continue. In the United States today the most significant consequences likely to change medical transgressions of outrageous behavior are (sadly) legal cases where high awards help to assure that such behavior will be discouraged in the future. It is unfortunate that this role falls mainly on the shoulders of the legal profession. Even so, lawyers advise their brethren to avoid populating juries with jurors possessing keen senses of personal responsibility when their clients could have avoided the injury by exercising better judgment in the first place (Wenner DA:ATLA’s Litigating Tort Cases, American Trial Lawyers Assoc.). The medical profession itself needs to take a more prominent role in promoting higher qualities of care. Punitive liabilities must be such that they can not then become only “the cost of doing business.” A meaningful advantage of a courtroom trial for society is that the results become documents in the public domain rather than proceedings hidden from public view by “gag” orders.
The success of any future health care plan in the United States will directly depend on the ability of patients to regain control of their destinies and get back into the driver’s seat. In order for this to happen many of the present perverse incentives for patients and physicians in managed care and the continued demeaning of physicians will need to be eliminated. A dramatic paradigm shift away from the present system’s disrespectful attitude toward patients (which assumes them be incapable of understanding health care issues) is required. In the final analysis it is only the patient who can best determine which options reflect their best interests (rather than abrogating this privilege to the best interests of shareholders and executives of alien corporations).
In addition to corporate entities not only acting in the patients best interests we have also been beguiled by the recent revelations that major corporations don’t always act in the best interest of their own shareholders. If there were any common sense in health care the patient should be the only shareholder. The well-informed patient is also the very best unpaid watchdog for the health care system in assuring that cost-effective quality care continues to survive as part of a free-enterprise system. Just think of all the money presently being spent on fraud and abuse enforcement alone which could be saved by the patient being in charge of spending their own money to treat their illnesses.
“You can not do the right thing unless you know what it is”
“When you can’t ethically live with an organization it’s time to move on”
“The Navy in the years before the second world war….More than the manners of polite society distinguished the life of a naval officer….An officer must not lie, steal or cheat-ever. He keeps his word, whatever the cost.”
McCain J, Salter M: Faith of My Fathers, Random House: New York, 1999
The science of changing what is presently considered to be “normal” and, by the process of knowledgeable intervention, to extend or enhance it beyond the vista of “normal” is what “Eugonomics” is all about. Ergonomics is the science of achieving maximum utilization of “normal.” Eugonomics represents the next step beyond Ergonomics. Ergonomics is the science of designing work and home devices intended to potentiate functionality of effort and to minimize associated health problems and injuries. Eugonomics is the science of designing the means of making the body better and lasting longer. The prefix eugo- means “good” and has come to denote “normal” in medical syntax. It is the intent of the field of eugonomics to break the barrier of “normal” and to create a new paradigm of “normal.” Nanomedicine, technology of the future (devices measured in nanometers) such as implanted miniature monitoring and drug delivery devices have the capability of being eugonomic. We only know what we are aware of. Fortunately, these limits are constantly expanded by science and inspired insight.
Why would any person in their right mind voluntarily allow their health care to be held hostage by some third party not primarily interested in their own personal welfare? The only individual not having a significant conflict of interest in the patient’s welfare is the patient. Health Savings Accounts (HSAs) now represent the best new paradigm for placing informed patients into the driver’s seat. Onerous legislation has forced, what used to be a free health care market to respond to destructive and perverse influences. By basing reimbursement and payment on specious concepts as “usual and customary” and by being procedure oriented (rather than quality oriented) managed care has increasingly subsidized medical incompetence and encouraged the performing of procedures not in the patient’s best interest while also denying procedures clearly <in the patient’s best interest. HSA’s are limited only by our ability to innovate and create. The possible variations on this theme are endless. With HSA’s the patient’s best interest is always paramount. HSA’s are needed to encourage a more rational health care system in the United States other than the one we presently have to deal with.
The maintenance of good health requires a continuing commitment to good nutrition (with appropriate supplementation), being a non-smoker and drug free, maintaining reasonable body weight, and exercising, on a regular basis to improve muscle strength, tone, and flexibility. An added dimension in the area of spine health is counteracting the deleterious effects of our existence on a high-gravity planet by daily anti-gravitational body traction/ distraction in order to counteract deleterious compressional and rotational forces. In this manner individuals can readily achieve increased longevity and improved quality of life through eugonomic principles.
We live in a “now” society where today is not soon enough. With the myriad of modern “inconveniences” available to speed up our lives and almost instant gratification through the internet and companion fast-delivery services there still appears to be less, rather than more, time available to us. Maintaining good health and a good quality of life require good decisions (which can be only based on good information). Time to slow down and collect this information. It is not unusual for patients to spend more time selecting a nutrition bar in a health food store than in choosing a surgeon. There needs to be some change. Start by slowing down and carefully perusing the Burton Report®.
The greatest strength of medicine is its conservative nature. The greatest liability of medicine is its conservative nature. Conservatism does not excuse indifference, ignorance, or disrespect. Too often the medical profession is not current in regard to important information. Today’s era of electronic communication appears to have reached out to the patients more than their physicians. Part of the responsibility of being a patient today is to keep one’s health care professionals up-to-date. An important responsibility of the health care community is to listen to their patients.
How does one measure integrity? Integrity is an inherent guide as to the worth of an individual. Integrity is something not immediately evident to the beholder. In the world of medicine, there are a myriad ofadverse external influences acting against the provision of good health care directed to the patient’s benefit. These undesirable pressures seem to multiply each day. The result is a most frustrating and demoralizing situation. The challenge to each health care professional is to maintain the ethic of their profession, their integrity and sense of humor, and not simply give in or take the “easy” way out despite the great temptations to do just this.
This section has been written to honor the memory of Swedish diplomat Raoul Wallenberg (1913-1947?). The plaque shown above is on the “Path of Remembrance” at the Yad Vashem Holocost Memorial in Israel. Mr. Wallenberg, through the use of bribery, threats of postwar retribution and sheer nerve, saved over 100,000 Hungarian Jews from certain death at the hands of the Nazis during World War II. The icon of Raoul Wallenberg stands as a symbol of all that is brave and good in the world. His name continues to serve as a lighthouse beacon in exhibiting that there are some who will not compromise their integrity no matter how great the adversity. In what must be one of the most perverse episodes of modern history Raoul Wallenberg was kidnapped and imprisoned by the Soviets on January 17, 1945, in Budapest, on his way to meet with the commanders of the Soviet troops occupying the capitol. Despite torture, he did not “cooperate” with the Soviets and was “eliminated” in 1947 (at age 34) because he had been an unwilling witness to Soviet depravity. The enduring interest in Raoul Wallenberg has been reflected by the continuing inquiry by the world community, as to his exact fate.
Kati Marton (author “Wallenberg”, “Wallenberg: Missing Hero “) has pointed out that Raoul Wallenberg created a particular societal debt for all of us by his remarkable example of not bending before the murderous machinery of both the Nazis and the Soviets, two of the 20th century’s most brutal totalitarian regimes.
On November 27, 2000 Aleksander Yakolev, chairman of a Russian Presidential Commission (considered to be Russia’s most authoritative voice on Soviet-era repression), indicated that Russia might finally be on the vergeof confirming Wallenberg’s fate. “We do not doubt that he was shot at Lubyanka” (Soviet secret police headquarters and prison in Moscow). Yakolev indicated that the former Soviet KGB secret police chief, Vladimir Kryuchkov, told him in a private conversation of this execution”. He was executed because” “First of all he knew too much, and second, he refused to cooperate with our people.” On December 22, 2000, a two-page statement was issued by the Russian prosecutor’s office which indicated that all documents related to Wallenberg had disappeared from the archives. “The archives were simply purged, and all the files were destroyed to hide the evidence,” said Leonid Troshin, spokesman for the Prosecutor General’s office. (Los Angeles Times, December 23, 2000).
Wallenberg clearly paid the ultimate price in order to maintain his integrity. There were also other diplomats during World War II who attempted to maintain their sense of humanity despite the madness surrounding them. In this regard Hiram (Harry) Bingham, United States; Aristides DeSousa Mendes, Portugal; Carl Lutz, Switzerland and Georg Duckwitz, Germany are also identified by the Burton Report® as being due our respectful homage.
The great actions and thoughts of the concluding millennium have often reflected acts of inspired insight based on observation and thought rather than the scientific process. The existence of germs and the associated concept of antisepsis entered medical consciousness because of the insight provided by the German-Hungarian obstetrician Ignaz Philipp Semmelweis (1818-1865). The “discovery” of x-ray by Wilheim Conrad Roentgen and of the sewing machine needle by Isaac Merrit Singer represent only some of the many examples of inspired insight.