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April 16, 2014

Leonard Fleck: Using a medical ethicsope

April 16, 2014

Leonard Fleck, a professor of philosophy and a faculty member in MSU’s Center for Ethics and Humanities in the Life Sciences, is among the foremost experts on the ethical dimensions of American health care.

A woman died Dec. 23, 2013 at age 53. The immediate cause of death was a fatal heart arrhythmia. The ultimate cause of her death was lack of health insurance. Her cardiologist had told her two months earlier that he had detected a dangerous rhythm in her heart. He strongly recommended that she receive an Implantable Cardiac Defibrillator. But she had no way to pay the $40,000 cost of that device and the surgery.

Did the cardiologist do everything possible to address this woman’s heart problems? We should assume this cardiologist was completely competent and caring. But his ability to effectively meet her health care needs (and prevent a premature death) was limited by the policy environment outside his office door that increasingly intrudes into the examining room.

The woman lived in Texas, a state that has refused to expand Medicaid to 138 percent of the poverty level, which is where her financial circumstances placed her.

In the College of Human Medicine, students are educated for twelve weeks about health care policy. Some students complain that this is time that should be spent on learning pure medicine, as if that were the whole of their professional responsibilities. But, as the story above makes clear, the policy choices made by our government, insurance plans or local hospitals intrude substantially into the practice of medicine and a physician’s ability to actually carry out their responsibilities to patients.

If an insurance company refuses to insure a patient with a pre-existing condition, then that patient is at risk of being denied costly, but effective medical care. If an insurance company is allowed to sell patients “barebones” insurance with $5,000 deductibles or 30 percent co-pay requirements, then those patients too will be at risk of denying themselves costly, but effective medical care.

Physicians are supposed to be just and caring advocates for the best health interests of their patients. But that advocacy must extend beyond the examination room and into the boardrooms and legislative chambers where decisions are made regarding financing and access to needed health care.

Integral to the practice of medicine today should be both a stethoscope and an ethicscope—a capacity to recognize injustices in the system, such as the 22,000 premature deaths each year in the United States associated with being uninsured. If medical students, our future physicians, have not been trained to engage thoughtfully and effectively in the health policy debates that increasingly shape the practice of medicine, then political interests or economic interests will dominate and potentially corrupt the values that are supposed to be central to the practice of medicine. That would be professional negligence, even if physicians were never sued for it.