Abortion at 33

This past week marked the 33^rd anniversary of Roe v. Wade. Thirty-three is not a landmark year in the typical way we mark anniversaries (10^th, 25^th, 50^th, etc.), but it does have an oddball resonance. In the Christian tradition, 33 was Christ’s age when he was crucified.

Though I consider myself an anti-abortionist, I do not hold that abortion is murder. Murder is the intentional, unjustified, malicious killing of a human being. Even law recognizes that a person can justifiably kill another person in certain circumstances. Substitute a 6 week old fetus for “person,” and “certain circumstances” becomes a murky question.

But not too murky. Many people justify their tolerance for abortion by arguing that it is not knowable when life begins. This is foolish talk. A fetus may not be a full person, but it is not dead. Not by any biological definition of life I have heard of. A rock is not alive; a single cell is. A fertilized egg is a cell. Not fully human as we understand it, but a living, functioning cell.

One of the interesting features of anti-abortion arguments is that they tend to be very biological. They focus on things like when the heart starts beating, when the organs form, and when the fetus starts to suck its thumb. Anti-abortion arguments are very factual, perfused with statistics and blood and gore. Pro-abortionists tend to argue about rights and the imposition of morality upon others. It is an irony of the abortion debate that the side most concerned about morality (anti-abortion) argues biological facts, and the side most concerned about health issues and the mental health of mothers argues the legal ethics. Shouldn’t it be the other way around?

Many people have wondered aloud if the issue of abortion will ever be settled in public life. I don’t think so. Abortion is about pregnancy, which is about sex. As long as humans have lived in societies there have been fundamental disagreements over who should be having sex with whom and when. One side says sex is about pleasure, and that people should do it whenever and wherever they want. The other argues that sex carries the attendant responsibility of reproduction and emotional attachment and that people should do it only with the confines of committed relationships. Or to simplify it, one side considers pleasure the goal of sex, and the other places primacy on reproduction and social structure.

I do not think pleasure should be excluded from discussion about sex by any means. But neither should the potential of reproduction. One of the things that riles moralists most about pro-abortionists is that they seem willing to make sexual intercourse a free lunch. If one drives drunk and kills someone, it is not possible to pay a cash sum for a replacement person and go back to work on Monday. In almost all ethical situations, when a person behaves recklessly, that person must take responsibility for a bad outcome. With sex, a person can behave recklessly ( not use birth control or use it improperly) and still get away from taking responsibility for an undesirable outcome via abortion.

As I see it, this pleasure/reproduction conflict is at the center of the abortion debate, and explains why the battle is likely to go on and on. The pleasure side is willing to jettison the consequences of sexual decisions; the reproductive side is not. Since this difference in views is as old as human civilization, it is hard to see why it should be resolved any time soon.

We all know that the main use for abortion in this country is birth control. There are 1.3 million abortions a year in the U.S., and there is no way the condom broke all those times, or that all those pregnancies are from rape or incest. The vast majority result from women (and men) who simply did not use adequate birth control, and now want a “do over.”

Pro-abortionists argue that a woman’s right to emotional well-being supersedes the rights of a clump of cells to continue to live. In other words, a woman’s right to happiness gives her the right to kill. Note I did not say murder, I said kill. It may be debatable whether abortion is murder, but I do not think it is debatable that abortion is killing. Some have argued that a life form must exist independently from its parent to be considered alive, but I know of no biological concept that supports this. Parasites are dependent on their hosts, completely, to exist, but no one argues that they are not alive. You have to kill a tapeworm to get rid of it.

At the very least, pro-abortionists should have the honesty to admit that abortion is not an absolute, but rather a relative right. It is dishonest to argue that abortion is not killing; instead, the more honest argument is utilitarian: abortion is the greater good trumping the lesser. I versus a cockroach. Both have some right to live, but one clearly is more valuable than the other, and there is no way both can live together. (I will not live with a cockroach. So it goes.)

Of course, abortionists shrink from this argument because they know as soon as they admit the fetus is alive they have opened themselves up to being tagged as killers. In the interest of fair play, anti-abortionists can ease the pain of this admission by making the counter-concession that abortion is not murder. If both sides could at least come that far, there might be a way for us to tolerate each other.

If we could just come to agree that abortion is killing, and that it is undesirable, we could start to make progress. It bothers me a little that abortion is considered a civic right, but what really bothers me is that it happens 1.3 million times a year. If pro and anti people could agree that abortion is killing but not murder, we could get to the important part – getting that 1.3 million number down.

Would I like to see Roe v. Wade overturned by the Supreme Court? Actually, I am indifferent to that. Many people think that if Roe v. Wade were overturned abortion would be illegal in the U.S. Not so. Roe v. Wade made it illegal for states to write laws banning abortion. But if Roe is overturned, all that means is that states can ban abortion if they want to. Many, including California, New York, and Massachusetts are almost certain make abortion explicitly legal if Roe is undone. Others, like Utah and Louisiana, are just as certain to restrict or ban it. Conservatives, who think they are winning a great battle by packing the Supreme Court with conservative judges, will find the abortion question thrown to each state legislature. There will be a state-by-state battle for abortion, and pro-abortionists will win some and lose some, creating a patchwork quilt of abortion laws nationwide. Then abortion will become like gambling is in this country – banned in most places but available within a 2 hour drive from almost anywhere. Only Alaska and Hawaii are remote enough to have a realistic chance of eliminating abortion access for their citizens should they choose to do so.

If this sounds like further politicization of an already over-politicized issue, it is. No matter what the law says about abortion, one side or another will always be rallying to defeat the other. If the Supreme Court recuses itself by abandoning Roe, the national battle will balkanize into 50 state battles. This will never forward the cause of morality.

In the case of murder, every state has laws against it. For the average citizen, this means the problem of legalities is settled, leaving individuals to get down to the more substantial work of creating a society in which no one wants to commit murder. Good schools, good jobs, a fair legal system, and so on. We ban murder, but it still happens. The hardest work is not banning it, it is getting the numbers down.

Perhaps we could all agree to set aside the legal issue and concentrate on the numbers. If anti-abortionists and pro-abortionists would just agree that abortion is killing but not murder, and that it is not a desirable form of birth control, we could skip over the legal wrestling match and start teaching people to behave responsibly.

As a doctor, I have never turned down a request for birth control unless it was medically contraindicated, which is a very rare situation. I feel every birth control prescription I write potentially saves an abortion, and with that mentality I would write for it all day every day until my fingers bled, if necessary.

Abortionists say that women must be allowed the right to choose it because they have the right to their own bodies. I am not willing to concede that women have the freedom to kill under for any reason whatsoever, whether it be because the pregnancy is life-threatening or because the woman is going to the Bahamas in 3 months and doesn’t want her stomach to pooch out in a bikini. Certainly anyone can see that those two situations are completely different and that completely different ethical standards apply.

If there were only 10,000 abortions a year in this country, the question of legality would be important. In that case, abortion would be rare and only carried out for serious reasons. The battleground would be over hard cases, like 14 year olds who had been raped by their fathers, or women with cancer who need chemotherapy immediately. The more cases there are, the more safely we can assume that abortions are being performed for convenience rather than necessity.

Who are you to decide what constitutes convenience or necessity, some will ask. Well, I guess I am nobody. It has never been my desire to tell people how to live their lives – I have my hands full living mine. But if we can agree that abortion is killing in some form, then we can agree that there is some moral value in preventing it. Certainly if two people go to bed together thinking, “Well, if she gets pregnant we’ll just go for the abortion,” something is amiss. There can’t be that many people around who consider abortion a form of birth control ethically on-par with condoms, or even abstinence.

It is also reasonable to argue that if abortions are moral in all cases then we should also legalize euthanasia for people who are depressed. After all, the justification of abortion is that the suffering the mother would endure in having the child is greater than the harm done in killing a fetus. This implies that killing may be justified to relieve emotional pain. Hence, a deeply depressed person should be put down if that is his choice.

Laws, if enforced properly, might prevent almost all abortions. Or they might engender distrust and hatred and put society in the uncomfortable position of having to imprison doctors and formerly pregnant teenagers. (Those arguing that only abortion doctors need be prosecuted are fooling themselves. How do you ban something and then let the person who makes the choice to violate the law go free?) As for me, I would be satisfied with preventing as many abortions as I can and leaving the most painful decisions to the people making them.

Before I close, I want to tie up two loose ends. First, the problem of exceptions. A friend of mine once criticized my anti-abortionism by saying that my readiness to consider exceptions for rape and incest is a flaw. I don’t think so. Society recognizes exceptions to killing in other contexts, such as the person who shoots an intruder in his home or the soldier who kills an enemy. I am not above saying that killing is sometimes necessary. My way out with abortion is that I do not consider it murder, but rather killing. Killing can be justified. Although I am dubious about rape and incest as a justification for killing, I am willing to admit that not everyone sees things my way and that many consider the emotional pain of bearing the product of a rape of greater importance than the life of a fetus. Again, I want to reduce abortions, and if an agreement to exceptions brings both sides together and lays the groundwork for a concerted effort to prevent abortions, then is a concession I am willing to make. Better that than having the pro-abortionists banging the table and demanding full moral amnesty for all abortions no matter what, as they are doing now.

The second loose end: the reader may have noticed that I do not use the words “pro-life” and “pro-choice.” These are silly phrases that obscure the real issue at hand. I support life and I support choice. I want more women to choose not to have abortions, or even better, to choose the medical means we have to keep from ever getting pregnant in the first place. I am not against choosing. I am against abortions.

Katrina #8: Severe ER Shortages in New Orleans

Of all the national media outlets, National Public Radio has done the best job of covering the post-Katrina story. Today it has an excellent story about the crippled ERs of New Orleans. To wit: Katrina shut down so many facilities in the city that there is now a critical shortage of ER beds. The 4 existing hospital ERs are running at way over capacity, and any sudden spike in ER need (a flu epidemic, or Mardi Gras, for example) could mean disaster.

In a previous post I noted that 10 hospitals in the New Orleans area were destroyed in Hurricane Katrina. That includes 3 that I used to work at. Those 3 facilities are all owned by one company, Universal Health Services of King of Prussia, PA. Unfortunately, UHS has no intentions of refitting two of the facilities it owns at this time. The third it may open again in 5 years.A quick visit to the UHS website supports my impression that UHS intends to do nothing -- the page discussing the status of the facilities has not been updated since September.

Only 4 years ago, the three hospitals in New Orleans East were owned by three different organizations, but since then UHS came in and bought up all three, later closing one of the three as an acute care facility.

While it is understandable that UHS, as a for-profit company, would want to wait until it is assured of a steady income before re-investing millions in a ruined hospital, I think the patient load in the surviving ERs in the city strongly suggests that any reopened ER would be extremely busy. Hospitals are more than just profit centers, though. Anyone who owns a hospital license (and UHS has three) has a responsibility to its community to try to operate, especially after a major natural disaster, even if only on a limited basis.

But UHS is doing nothing, holding its cards, perhaps looking to sell out later when the value of its holdings go up, perhaps waiting until its truly profitable investments, like outpatient surgery and cath lab, can come back. Meanwhile New Orleanians suffer.

I think UHS has a responsibility to the city to either sell to anyone who will develop the hospitals now or to try to get some kind of temporary services going. But all it does is sit and sit. It has already laid off all of its staff, meaning any recovery effort is months away from even getting underway.

What a shame.

On a brighter note, I would like to wish Wolfgang Amadeus Mozart a happy 250^th birthday. In celebration, I will be listening to Wolfie all day in my office.

The Medical Paradox

Kevin, MD comments on the state of health care in this country. He says "we can't have everything," which I take to mean that he feels the American public wants high quality healthcare but is unwilling to pay the price tag. All of the commentators on his site seem to agree with him wholeheartedly, and think that patients need to pay more and shoulder more of the burden of healthcare. I respectfully disagree.

I have been a doctor for 8 years now and I know I am in the minority when it comes to healthcare reform. In a previous post about HSAs I spelled out my position. Here I will emphasize a few points. First, all workers already do pay the full bill for their health care. Health insurance premiums are deducted from paychecks, and employers who offer health insurance factor in the cost of healthcare when they set the salaries of their employees. It has been proven in multiple economic studies that companies that offer health insurance pay lower salaries than comparable  companies that don't. No one should think for a second that the typical worker gives up nothing for health insurance. Anyone who thinks employees get a free ride on insurance should confront a worker and tell them that.

Take nurses. In a typical hospital, there are two types of nurses, staff employees and agency nurses. Agency nurses work for a nurse staffing agency that leases their services out on an hourly basis. Agency nurses are not hospital employees, and are paid strictly on an up-front cash basis, one shift at a time. They are essentially independent contractors, and are paid much more money per hour than staff nurses -- sometimes $10 an hour above staff nurses, or even more. Yet every staff nursem, if asked, will tell you that she chooses full-time employee status over the better money of agency nursing because she wants the benefits. She knows exactly how much money she is giving up in the trade. Yet most nurses choose staff-employment over agency nursing.

But the key point I want to make is that when it comes to health care reform, doctors are not often very consistent in their opinions. The typical doctor (such as those posting in Kevin, MD, and the site Kevin was quoting, Medpundit) is completely against nationalized health care. I know very few doctors who want the government to finance insurance for everyone. And yet . . . .

If you look at the activities of the AMA, you will find that one of the AMAs highest priorities is lobbying Congress for increased Medicare funding. Each year, Congress tries to cut reimbursement to doctors under Medicare. And every year, doctors furiously lobby Congress to get the cuts restored. I have never met a doctor in my life who thinks physician reimbursement under Medicare should be reduced.

Think about it. If doctors really and truly believe that big government is bad, shouldn't they be lobbying for a smaller Medicare? Shouldn't they be arguing the Medicare should be cancelled, and that Medicare patients should be forced to pay cash for their care? In Kevin, MDs blog entry, he quotes Washington Post columnist Robert Samuelson: "Medicare recipients should pay more of their bills." That means Samuelson, and presumably Dr. Kevin and Medpundit, want Congress to cut Medicare payments to doctors. That is exactly what they are saying. I know of no way to make patients pay more of their bill except to cut the Medicare payment.

That is the paradoxical attitude of many doctors have towards health care reform. On one hand, they are against government involvement in health care. On the other, they are against any cut in physican reimbursement. Since Medicare is a government program, they are  both in favor of and against the growth of  Medicare growth of Medicare payments.

If the doctors who support shifting more financial burden directly onto patients get their way, there will be fewer patients who can afford to go to the doctor. This is economics 101. When you raise the price of something, fewer people will be able to afford it. Demand goes down. In the end, this so-called beneficial shift will save taxpayers money, but it will also deny health care to millions of seniors. And yet, check the AMA website, even as some doctors push to decrease government payments for their patients,  they are working at this very moment to increase government payments to themselves.

I want to say parenthetically that I do not oppose the AMA's efforts to increase Medicare physician payments. But then, I am not the one calling for decreased  government involvement in health care.  

Conservatives often make good points when they argue that private businesses can provide services cheaper and more efficiently than the government. But in the case of health care, I do not believe it is so.  Private enterprise has had every opportunity in the world to provide cheap, efficient health care. What we have as a result is millions of uninsured, millions more unhappy with the insurance they have, and the medical community arguing that public health spending needs to be cut for the patient's own good.

I ask you: Is your health care cheap? Is it efficient? Do you trust it to be there for you for the rest of your life?

Katrina #7: Scorecard

The Associated Press is reporting this complete assessment of Hurricane Katrina’s damage:

                                                    Louisiana                             Mississippi

Deaths                                         1,100                                             200

People Displaced                 786,000                                     110,000

Destroyed Homes                217,000                                      68,700

Destroyed Schools                   835                                               263

Destroyed Hospitals                 10                                                   2

Businesses Closed                 18,800                                         1,900

Jobs Lost                                 240,000                                     46,000

I cannot find a list of the destroyed hospitals, but I can make a good guess on the 10 in Louisiana: Chalmette Medical Center, Methodist Hospital, Bywater Hospital, Lindy Boggs Medical Center (formerly Mercy Hospital), Lifecare-Chalmette, Lifecare-Memorial, Memorial Medical Center, Charity Hospital, University Hospital, Tulane Medical Center.

Of all these hospitals, only Tulane is currently being renovated for reopening. I was on staff at Chalmette Medical Center and Methodist, and worked at all the others (with the exception of Bywater) as a resident.

I will post pictures of my old neighborhood on my website soon, for the curious.

HSAs, Part I

The Health Savings Account, or HSA, is the centerpiece of conservative health reform today. Much as the new Medicare prescription benefit has descended on seniors, the HSA is a latest healthcare wrinkle that will probably find you whether you want it to or not.

An HSA is a personal savings account that can be funded tax free. The money in the account can then be invested, if the owner prefers, for growth. Any money, whether deposited or interest made on prinicpal, can be applied to healthcare expenses, again tax free.

Sounds pretty benign, but here’s the catch – to qualify for such an account, you have to enroll in a health insurance plan with a high deductible, what the government calls a Qualified High Deductible Health Plan (QHDHP). This means a plan with a minimum deductible of $1,100 for an individual and $2,200 for a family.

High deductible health plans have been around for a long time, and the can make sense for young, healthy individuals who do not see the doctor much. For a cut in premium of several hundred dollars a month, the insured assumes the cost of routine visits. Insurance only kicks in when there is a serious expenditure, such as an appendectomy or orthopedic surgery for a torn knee ligament.

Advocates say HSAs will help patients in several ways. First, they offer a tax break to those who are willing to assume some of the cost of their healthcare through higher deductibles. Secondly, HSAs will allow employers to offer health insurance to more employees, because the premiums employers pay for high deductible plans are so much lower. Finally, they argue that consumer driven healthcare, that is, healthcare in which the patient decides what to buy and how much he wants to pay for it, will drive healthcare costs down. A patient who has to pay for a tetanus shot out of his own pocket, for example, will shop around to find a good price. The weakness of the current system, HSA fans argue, is that patients never see the entire bill. They are not aware of the full cost of their care, and so have no incentive to shop around, or to dispute unnecessary expenses.

As a practical scientist, I am not against giving the HSA idea a whirl. HSAs will probably reduce healthcare expenses a little and will likely make insurance more affordable for some people. I am in favor of trying anything that will improve healthcare. The problem is, I think the benefits of HSAs are limited, and that this concept is only a temporizing measure that may slow but will not prevent the long term healthcare problems this country faces. In the interest of brevity, I will not tackle every concern I have with HSAs now, but will spread them out over several articles. I will spell out my biggest concern here and now.

HSAs will not extend healthcare to everyone. If we assume for the moment that HSAs will in one way or another reduce health costs (which is not proven), it follows that the savings can be used to insure more people. This is a good thing, but “more people” is not everyone. Though HSAs will make it easier for workers to afford insurance, it does nothing for the unemployed. The insurance may be cheaper, but you still have to buy the it, or get it from an employer. Let’s say a full policy costs $600 a month and a high deductible plan costs $350 a month. A premium of $350 a month, or $4200 a year, may be an affordable option for someone who drives trucks for a living, but for a cashier at Denny’s who makes minimum wage, it may still be unaffordable. Extending healthcare coverage to a greater number of people is a good thing, but not at all the same as extending healthcare coverage to everyone.

Here I think is the greatest disconnect in the healthcare debate. There are some people who think health insurance is a personal right that should be extended to everyone, regardless of their ability to pay. There are others who think it should be available to everyone as a choice, but it should not be legally mandated. The choice people believe that our only responsibility is to make access to healthcare inexpensive enough so that everyone has a fair shot at getting it. The rights people think as long as someone is left out, for whatever reason, that injustice is being committed.

I am a rights person.. As a doctor, I spend most of my life’s waking hours helping people overcome the scourge of disease. The care system I am part of can help anyone and everyone, and I am opposed to any approach to healthcare that would leave anyone out. It does not make sense to me that a system dedicated to helping people should select who it helps depending on his or her ability to pay.

Purists like to look at the Constitution and the Bill of Rights and say there is no mention of healthcare as a personal right. No, there is not. But our country is built on the assumption of equal opportunity and social mobility. The freedom to compete on equal footing with others and rise out of poverty is the very heart of the American Dream. We do not consider it just that a child who grows up in the ghetto should be required to go to a terrible public school while one who lives in a wealthy suburb gets to go to a good one. This does happen in America, but that is not to say that we endorse it as right.

In the same way, access to quality healthcare is very important if individuals are to compete on a fair playing field. Why would it be fair that a man from Upper West Side New York can have his asthma properly treated, allowing him to continue to work, while a minimum wage earner in the Bronx goes untreated, resulting in missed work days and eventually in the loss of his job?

From a Constitutional standpoint, it is not obvious that everyone should have healthcare insurance. But from a moral standpoint, it is. Allow me to turn the question on its head: If everyone is not entitled to health insurance, who should be excluded? Should the lazy, or the uneducated, or the immoral, or even the downright evil be excluded? In out country even imprisoned murderers have access to doctors. It is one thing to say that a lazy unemployed man should be denied luxury housing, or a car, or a steak dinner. But how long, in the richest nation in the history of the world, should he be allowed to cough up blood before he gets an X-ray? If the U.S. can’t afford to care for everybody, then hang it up – no one can. The problem is, poorer nations can afford it, and they do.

Giving everyone the opportunity for good healthcare isn’t just good ethics. It is good business. As I noted above, a large part of the American Dream is about giving everyone who wants to try a fair shot. Good health is a basic possession that frees people who want to better themselves to go out and do just that. By giving everyone healthcare access, we unloose the full creative force of America. A healthy workforce is a productive economy. I think even the staunchest conservative would have to admit that our economy would benefit from a work force that is medically fit.

And that is the problem with the HSA. It offers healthcare to more people, but not all of them. Both morally and economically, it falls short.