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[Nmaro Makari]

Consider Britain's NHS. The National Health Service is an interesting model. Some prefer it, some prefer a simple single-payer system, and some, such as myself, think that Obamacare is probably worth exploring on a practical level. The NHS largely avoids the problem of people dying for lack of treatment, but the large waiting lists for electives seems to imply that this is not without cost. In other words, there are only so many beds and doctors, and only so many hours in a day. As well, there have been questions over rationing and denial of services to some people:

Having recently been in and out of NHS establishments, once for emergency surgery and an extended stay, I can tell you now, we British love to complain about everything, especially in our newspapers.

And while we complain about the NHS, Nigel Lawson got it right when he said "The NHS is the closest thing the English have to a religion." We'll complain, we'll write snarky articles, but the attempted changes to the NHS are likely to lose the current government the next election.

Why? Because while there are issues, while there are failings, we believe having empirically experienced it, that the core idea is correct. Care, to everyone, man woman or child, young or old, cradle to grave.

By God, my own Grandmother, a lifelong conservative, would be out on the streets with a molotov before she'd let the NHS be tampered with. In fact she's old enough to remember when the doctor wouldn't even step over your doorstep without payment.

Much as I despise groupthink, Britain's people are inseparable from the NHS, because by and large we wouldn't trade it, especially for something petty like EVE subscription. You'll get no sympathy 'pon this isle.




Edit: Some additional newspaper perspective: http://www.theguardian.com/society/shortcuts/2013/jul/05/sixty-five-reasons-love-nhs

[Vikarion]

Consider Britain's NHS. The National Health Service is an interesting model. Some prefer it, some prefer a simple single-payer system, and some, such as myself, think that Obamacare is probably worth exploring on a practical level. The NHS largely avoids the problem of people dying for lack of treatment, but the large waiting lists for electives seems to imply that this is not without cost. In other words, there are only so many beds and doctors, and only so many hours in a day. As well, there have been questions over rationing and denial of services to some people:

Having recently been in and out of NHS establishments, once for emergency surgery and an extended stay, I can tell you now, we British love to complain about everything, especially in our newspapers.

And while we complain about the NHS, Nigel Lawson got it right when he said "The NHS is the closest thing the English have to a religion." We'll complain, we'll write snarky articles, but the attempted changes to the NHS are likely to lose the current government the next election.

Why? Because while there are issues, while there are failings, we believe having empirically experienced it, that the core idea is correct. Care, to everyone, man woman or child, young or old, cradle to grave.

By God, my own Grandmother, a lifelong conservative, would be out on the streets with a molotov before she'd let the NHS be tampered with. In fact she's old enough to remember when the doctor wouldn't even step over your doorstep without payment.

Much as I despise groupthink, Britain's people are inseparable from the NHS, because by and large we wouldn't trade it, especially for something petty like EVE subscription. You'll get no sympathy 'pon this isle.




Edit: Some additional newspaper perspective: http://www.theguardian.com/society/shortcuts/2013/jul/05/sixty-five-reasons-love-nhs

I'm not sure how to respond to this, since it does not address a single issue I raised. I have not argued anywhere that we should dump Obamacare or that Britain should dump the NHS.

[Anslol]

Inference. You're saying why should I pay for someone else's health? Logic would point to the conclusion of you wanting to get rid of Obamacare.

[Repentence Tyrathlion]

As someone preparing to move to the US, thanks guys.  You're scaring me

So, let's see.  Unsurprisingly, Vikarion is taking the hardline, pure logic approach and doing terribly at presenting it.  Never go into marketing, dude, you'd be horrible at it

Let's extract a few interesting issues here that have been kind of skated over.  The core issue is, at the end of the day, one of resources.  They are not endless, and that's a problem that's becoming more awkward in every area as the world population grows.  Some kind of priority system is thus needed.  Ollie talked about how this already happens - there might be a basic premise of 'help everyone', but investment vs result considerations apply.  Something did spark my interest in his post though - essentially, 'euthanasia is bad'.

Allow me to open a can of worms: why?

Why is it more justifiable to leave someone living in agony and/or up to their eyeballs on medication, than to give them peace?  Why is it ok to turn off a life support machine for someone who will never awaken, but not to allow someone living half a life to depart on their own terms?  Why are we more humane to our pets than to some humans in the same circumstances?  If someone wants to die, and their continued life is only going to be a drain on resources (and in most of the stories one hears, on the emotional fortitude of their loved ones), then why is it morally 'wrong' to allow them to?  Life is not some sacred gift that must be treasured and preserved at all costs.

I'll clarify that last bit before the pitchforks come out - life is important.  It's our most important possession.  Letting go of it should not be done lightly, and there is a vital difference between not wanting to live, and wanting to die - a question that applies to suicide in general, not just euthanasia.  The former is apathy.  The latter is a choice.  It's just not a choice that we're generally allowed to make.

Speaking of choices.

Eugenics is distinctly dubious road, and I'm not going to amble down that particular discussion, but there is a related consideration - genetic screening.  Technology has advanced to the point where we can trace a lot of genetic diseases, quite apart from the more primitive side of family histories and such.  I can remember a number of years back a fairly heated debate over here about whether people should be allowed to screen out unborn children based upon any conditions they might have.

I was, and still am, in favour.  I'm not a sideline watcher here, either - I have a pretty serious genetic disorder myself.  I'm just a carrier, but my mother has the full form, and it's not remotely pretty.  I have voluntarily removed myself from the gene pool on that basis - I intend to never have children, as quite apart from other considerations, I have no interest in allowing that gene to continue.

I can remember being asked how I would react if someone with a genetic disorder had come up to me and said "If they'd done this, I wouldn't be here to speak to you."  My response was essentially "But you are.  Your point?"

I suppose the point underlying both of these topics, and others that I haven't raised, is that there's a strange obsession with 'life at any cost'.  Not everyone necessarily believes that in private, but that is the dominant moral judgement from what I see in the world, and it's really dumb.  Life is not the be-all and end-all.

One final amusing tidbit for the non-americans: Obamacare, that harbinger of the apocalypse if you listen to the Republicans, is actually based upon a system instituted in Massachusetts by their former governor.  That system had a similar little moniker - Romneycare.

US politics is so very silly.

[Lyn Farel]

Pretty much yeah.

[Vikarion]

Inference. You're saying why should I pay for someone else's health? Logic would point to the conclusion of you wanting to get rid of Obamacare.

It's relatively easy to argue why one should pay for other's care, so they will pay for yours, of course. If my own health were a certain thing, I would not give a cent for that of others. However, no one can be certain of any such thing.

The argument is why I, living in a healthy manner, should have to devote resources to those who abuse their health. Or, to put it to another situation of recent note, why should a well-run and healthy corporation have to bail out a corporation that has invested in such things as sub-prime loans?

[Vikarion]

As someone preparing to move to the US, thanks guys.  You're scaring me

So, let's see.  Unsurprisingly, Vikarion is taking the hardline, pure logic approach and doing terribly at presenting it.  Never go into marketing, dude, you'd be horrible at it

Somewhat fun fact: I actually do produce marketing materials and do client related work in my business. And I'm good at it - judging from how our clients react, I think. I just see no reason why I should need to be acting here.

Or, rather, I didn't. I had no idea people felt emotional about healthcare issues. I'm honestly surprised. 

euthanasia stuffs

I completely agree with voluntary euthanasia. I've been put to sleep for surgery before (which I paid for out of pocket, btw), and it was far more enjoyable than many deaths.

I'll clarify that last bit before the pitchforks come out - life is important.  It's our most important possession.  Letting go of it should not be done lightly, and there is a vital difference between not wanting to live, and wanting to die - a question that applies to suicide in general, not just euthanasia.  The former is apathy.  The latter is a choice.  It's just not a choice that we're generally allowed to make.

Heh. My life is important. Other people's lives are incidental. 

More to the point, are you trying to argue for it as a choice for the individual, or a choice for the society to impose on the individual - i.e., you are costing us too much and goodbye?

Eugenics is distinctly dubious road, and I'm not going to amble down that particular discussion, but there is a related consideration - genetic screening.  Technology has advanced to the point where we can trace a lot of genetic diseases, quite apart from the more primitive side of family histories and such.  I can remember a number of years back a fairly heated debate over here about whether people should be allowed to screen out unborn children based upon any conditions they might have.

I was, and still am, in favour...

Agreed. I think women should be able to have an abortion for any reason. An abortion to avoid a child with Down's Syndrome, Cystic Fibrosis, or other problems is not only a great way to avoid a lot of misery, it also avoids imposing more costs than necessary on society.

US politics is so very silly.

No shit. Now we have Republicans screaming "let us have our way or the government defaults!"

[Ollie]

Let's extract a few interesting issues here that have been kind of skated over.  The core issue is, at the end of the day, one of resources.  They are not endless, and that's a problem that's becoming more awkward in every area as the world population grows.  Some kind of priority system is thus needed.  Ollie talked about how this already happens - there might be a basic premise of 'help everyone', but investment vs result considerations apply.  Something did spark my interest in his post though - essentially, 'euthanasia is bad'.

It's not that it's 'bad'. Apologies if that was either the literal or contextual way I phrased it.

It's just that from the perspective of a doctor, whether or not we believe that it's a patient's right to choose to die, we can't actively assist them to do it because of laws that make it illegal (in my part of the world) and the oaths we take as doctors. Principally the one that states 'first, do no harm'.

Giving someone (or teaching them how to/prescribing for) a lethal dose of medications specifically designed to first dull their senses and then stop their breathing is characterised as doing harm, ethically speaking. It's also defined as first-degree murder under our legal system.

Informing the patient of risks and outcomes of all treatment options and then withdrawing all medications and treatments after the patient has advised you to (either verbally or in the form of a pre-signed advanced health directive - which we encourage all patients to do), providing only those measures that ensure comfort and dignity inevitably accelerates the deterioration of a terminally-ill patient while still fulfilling both the Hippocratic oath (don't harm by overtreating) and the letter of the law.

The difference is largely about perspective. I've got no problems with the latter and have advised on many occasions that it may be the best option in certain cases.

[Vikarion]

It's not that it's 'bad'. Apologies if that was either the literal or contextual way I phrased it.

It's just that from the perspective of a doctor, whether or not we believe that it's a patient's right to choose to die, we can't actively assist them to do it because of laws that make it illegal (in my part of the world) and the oaths we take as doctors. Principally the one that states 'first, do no harm'.

Giving someone (or teaching them how to/prescribing for) a lethal dose of medications specifically designed to first dull their senses and then stop their breathing is characterised as doing harm, ethically speaking. It's also defined as first-degree murder under our legal system.

Informing the patient of risks and outcomes of all treatment options and then withdrawing all medications and treatments after the patient has advised you to (either verbally or in the form of a pre-signed advanced health directive - which we encourage all patients to do), providing only those measures that ensure comfort and dignity inevitably accelerates the deterioration of a terminally-ill patient while still fulfilling both the Hippocratic oath (don't harm by overtreating) and the letter of the law.

The difference is largely about perspective. I've got no problems with the latter and have advised on many occasions that it may be the best option in certain cases.

It sounds like you are sacrificing a patient to the unavoidable throes of extreme pain and suffering for the sake of your own peace of mind.

[Ollie]

It's not that it's 'bad'. Apologies if that was either the literal or contextual way I phrased it.

It's just that from the perspective of a doctor, whether or not we believe that it's a patient's right to choose to die, we can't actively assist them to do it because of laws that make it illegal (in my part of the world) and the oaths we take as doctors. Principally the one that states 'first, do no harm'.

Giving someone (or teaching them how to/prescribing for) a lethal dose of medications specifically designed to first dull their senses and then stop their breathing is characterised as doing harm, ethically speaking. It's also defined as first-degree murder under our legal system.

Informing the patient of risks and outcomes of all treatment options and then withdrawing all medications and treatments after the patient has advised you to (either verbally or in the form of a pre-signed advanced health directive - which we encourage all patients to do), providing only those measures that ensure comfort and dignity inevitably accelerates the deterioration of a terminally-ill patient while still fulfilling both the Hippocratic oath (don't harm by overtreating) and the letter of the law.

The difference is largely about perspective. I've got no problems with the latter and have advised on many occasions that it may be the best option in certain cases.

It sounds like you are sacrificing a patient to the unavoidable throes of extreme pain and suffering for the sake of your own peace of mind.

Not at all. Sacrificing a patient to 'unavoidable throes of extreme pain' (quite emotive for you Vik ) for my own peace of mind would go against that principle I was talking about - do no harm. I've sacrificed plenty in my career but never any of my patients.

One of those comfort measures I mentioned includes provision of adequate pain relief and sedation, usually in doses or via routes that aren't used in patients receiving them for other reasons. There are methods beyond pharmaceutical management too, of course. Palliative care specialists are very good at their jobs, by and large. Results aren't 100% 'good deaths' but in the right hands it's close.

It's worth pointing out that results for euthanasia aren't either - the latter isn't quite the rosy picture of 'peacefully going off to sleep' that a lot of advocates like to universally paint it as. Potassium-based infusions, for instance, which are a staple of some regimens are far more likely to cause those 'throes of extreme pain' you described than a sub-lethal subcutaneous infusion of morphine in combination with midazolam given as comfort measures.

[Vikarion]

Not at all. Sacrificing a patient to 'unavoidable throes of extreme pain' (quite emotive for you Vik ) for my own peace of mind would go against that principle I was talking about - do no harm. I've sacrificed plenty in my career but never any of my patients.

Hah! You should speak with my dentist. I never want to get a root-canal without painkiller again. 

...mostly. Part of me wants to see if I could take it a second time.

I wasn't aware that pallative care had advanced so far. As far as I could tell, my grandparents were not particularly comfortable when they died. As for me, I want control over my death. I don't want to pass peacefully into sleep and die, I don't think. I'd prefer to determine when I die, and how.

[Ollie]

Not at all. Sacrificing a patient to 'unavoidable throes of extreme pain' (quite emotive for you Vik ) for my own peace of mind would go against that principle I was talking about - do no harm. I've sacrificed plenty in my career but never any of my patients.

Hah! You should speak with my dentist. I never want to get a root-canal without painkiller again. 


...mostly. Part of me wants to see if I could take it a second time.

Heh I meant to ask you about that earlier ... it's not an uncommon thing that patients complain about: ie, 'That goddamned Dr. X doing his work hurt like hell and the local anaesthetic didn't do a damned thing'. What I've found is that a lot of colleagues get by by reassuring their (justifiably) angry patient that 'Well, you must be resistant to the LA' or 'Oh, you must be one of those people anaesthetics don't work on'.

Which is true in some patients ... if you're talking about a general anaesthetic that's subject to first-pass metabolism and other means of elimination that's patient variable.

But local anaesthetic? That's supposed to be injected in and around the specific nerve you're trying to anaesthetise. Just about the only reasons for that not to work is inadequate dosing, presence of abscess or localised/contained infection and ... poor knowledge of nerve anatomy (ie, person giving it doesn't know where the nerve is). And really? Part of a root canal is ablating the end nerve that's causing the pain so the dentist should know that anatomy like the back of his/her hand.

More than most of the other things you described I felt bad when you revealed that, because drilling a nerve when it's not been adequately anaesthetised is negligently cruel.

Added to address Vik's edit regarding palliation:

Yeah, I think it comes down to the fact that oncology research is probably the most heavily invested in of all medical fields. And palliative medicine is linked with that. Sure it's not getting the attention that potential advances in curative treatments see, but there's a realisation that however good those curative treatments are there's likely to always be a percentage who either fail treatment or weren't curative to begin with.

Again, there may well be differences too in the system where you are and your grandparents were and where I am. For instance, in most hospitals - large and small - that I've worked in there's access to a palliative care specialist for advice with end of life measures and determining how to 'get it right' for the patient. Sometimes there's an on-site presence while at smaller hospitals there's usually either a tele-health presence (again, covered by our tax-payer system) or a local GP who's had additional post-grad training in palliation medicine.

So my opinions on how palliation vs. euthanasia works might all be informed around how it works within my local context and having said that I don't think that a blanket application of everything that works here will work in other places.

[Vikarion]

More than most of the other things you described I felt bad when you revealed that, because drilling a nerve when it's not been adequately anaesthetised is negligently cruel.

Don't feel bad. I am very resistant to painkillers, so there wasn't much that could be done. Also, I kinda enjoyed going up against that sort of pain and beating it. I will admit that it (a molar root) was one of the more painful things I've done, and I think I even had a slight emotional reaction to it, although I'm not sure what. It was extraordinarily odd. As for the drilling, that was pretty bad, but I think my least favorite part was when they filed the nerves out of the three canals. All because a cavity came in from the thin side instead of the top.

Anyway, what do you actually think about voluntary euthanasia, or assisted suicide, Ollie, provided that it isn't a doc providing the drugs?

[Ollie]

Anyway, what do you actually think about voluntary euthanasia, or assisted suicide, Ollie, provided that it isn't a doc providing the drugs?

It's hard to get the type of drugs we're talking about without prescribers being involved at some point, although the internet in recent years has made it easier.

But ignoring that and just addressing the specifics of the question:

I'm not opposed to it under specific conditions and I think I understand what might drive the desire for it. As I said 'do no harm' is an ethical principle, which means it's fluid.

I think my main concern (without the assistance of medical input) would be safety, which largely revolves around the issue of medical education - specifically the information and knowledge required to do it successfully with the lowest risk possible. 'Risk' in this sense being 'doing it without complications and without additional distress'.

The internet's a 'sometimes useful' resource in this sense, particularly in countries where the practise is deemed criminal. But it's a double-edged sword - most people aren't able to differentiate good information from bad information and having 'information' is distinct from having 'knowledge' in this sense. That confusion is where my concern comes from.

I don't know whether it can be done safely without some form of medical input or not, as a result.

What you specifically don't want to see are people in extreme circumstances who see this as their only hope or option and who end up making things worse for themselves or having themselves or their loved ones go through additional undue distress because something goes wrong and things don't turn out quite 'as advertised'.

There are secondary considerations too (less important to the particular question you had): to what degree are mental health issues (depression, mood and affect) impinging on insight, judgement and so on? What's the impact on family and loved ones? These and multiple other issues inevitably come into play in many individual cases, which I believe makes it more difficult for governments to propose legislation on. That and the divide of thought on it amongst most medical professionals.

Of course, if we're speaking more practically, one person can't stop another from either committing suicide or assisting someone in their attempt if the belief that it will resolve their situation is held strongly enough. I can't stop anyone with resources and access to information from doing this any more than I can stop someone putting a noose around their neck or putting a gun to their head and doing the same. There are also very few, if any, counter-arguments that are valid when dealing with someone who is in command of their faculties, knows they're terminal, wants no further treatment and is content with the quantity of life they've gotten. Outside of the few places that have legalised euthanasia, I don't envy anyone caught in that situation - it's miserable and there are no outcomes that don't have a negative attached to them.

[Vic Van Meter]

On the political point, I'd like to make a bit of a segue here to explain the political situation.  There are a lot of people outside of our country whose lives and economies will be directly affected by a U.S. government default, so I'd really love the blame to land right where it ought to.

The Senate seems to be progressing towards a deal, but everything right now is being held up by the Republican caucus in the House of Representatives (our House of Commons).  Since there are more House seats than Senate seats, the House tends to be selected by smaller and thus less conciliatory groups, thus creating non-conciliatory congressmen.  Since senators are elected at least by half of a state, they tend to be more moderate and professional.

What is happening is essentially that the House Republicans are attempting to ape the rest of the government by rejecting any budget proposal that funds the Affordable Care Act.  While they don't have anywhere near the power to repeal it, they've decided to play chicken with the nation's finances to try and force Democrats to remove it.  The Affordable Care Act is, essentially, creating a virtual marketplace for insurance for the otherwise uninsured or under-insured, then requiring health insurance coverage by law.  The virtual marketplace is going to be full of insurance companies' rated plans, but to make sure they are price- and benefit-controlled, the government will be installing their own plan there.  That sets a sort of bar to follow for the other companies to make sure the uninsured aren't being stiffed when they have to buy insurance.

The aim of all of this is to bring health care costs down by essentially eliminating the uninsured simply not paying medical bills that they can't afford, since that was what health care companies were blaming for high prices of medical care (essentially that the insured have to pay the entirety of costs since you can't just let people die in the street because they aren't covered, but someone has to pay for all that).  It's also meant to dictate a certain level of insurance must be met, as failing to reach these standards mean that someone who has insurance provided by a company can then go to the marketplace and deny their employers' insurance companies their money.

Nobody was ever a big fan of the ACA simply because it either was the first step on a slippery slope or didn't go far enough.  Republicans fall into the former category as a whole, since they think government-provided insurance will simply crowd out the market and will eventually lead to a single payer system.  Democrats essentially have accepted that it's the best they're going to get, but plenty would like to see us with a form of the Canadian system or British NHS.  Say what you want about scheduling your checkup, right now Americans are paying something like 40-50 percent more than the next country in line in terms of expenditures per capita, and are consistently ranking between 20th and 40th on health care outcomes, depending on the survey.  I'm not sure whether the question is whether our system works better; it clearly and demonstrably doesn't.

The real debate seems to be what we can afford, since nationalizing the healthcare system in America isn't just hard politically, it would also be ridiculously expensive.  I work as an architect in health care and my mother's side of the family is almost all engaged in some way or another in medicine.  I've worked desk jobs in private practices when they needed a hand and worked weekly at a free clinic here in town.  Nationalizing the service would be expensive and the first few years, when all of the Americans who are ignoring or hiding what might be serious medical problems, might all suddenly hit the doctors at the same time.

In the meantime, the ACA is also Obama's centerpiece of his administration.  It's a massive step into health care for our government and a giant slap in the face to previously bulletproof insurance companies and HMOs who were sitting somewhere just beneath lawyers on the vitriol scale.  The idea of what we can afford or not seems to be the big issue on one side, with social responsibility on the other side.  Some people try the idea that the government just can't run a health care system efficiently, though they'd really have to be trying to even match our system in terms of outright ineffectiveness.

All in all, American health care funding is a giant, disgusting mess and a huge reason I was looking (and am still looking) for a way out of my own country.  Having essentially grown up with the system, I could see how shockingly broken it is when people have to wonder whether or not they should go to a doctor.  Even if they can afford the copays to see a doctor, they probably can't cover their deductibles if there actually IS something wrong.  So why bother?  Last week, we had a guy come in to the free clinic with a melanoma the size of a golf ball on his back.  So to see the House of Reps actually ready to send us into default in order to block a program that makes health care in any way more attainable has made me seriously rage.

However, we have to keep in perspective that it's not every Republican that's pulling this off.  Mitch McConnell is doing his best in the Senate to come up with something, though there's no reason to believe the House would take the bait.  There's a serious fight going on within the Republican caucus in the House itself, so some of them don't think holding the government hostage and threatening to shoot it is acceptable.  I would say most of the Republicans that I personally know are just hoping this is a stunt, because even the ones who hate the ACA don't seem to be on board with this move.

There's actually a precedent for this.  Newt Gingrich did almost precisely the same thing for precisely the same reason (though he cited Medicare as the reason for the shutdown).  Clinton refused to pass a Republican budget and the government went into a shutdown in the mid 90s.  It didn't turn out well for the Republicans, as Clinton then went on to win the following election with his highest approval rating since his first election (it did drop into the 40% range during the crisis though, nobody likes anyone during one of these shutdowns).  Speaker of the House John Boehner (from my state) seems to know that this is really crushing his party's credibility, especially in swing states.  However, he can't really do anything while tea party conservatives in extremely safe Republican seats that don't need to worry about re-election.  They keep rejecting his proposals.

It will hopefully come to pass that the House will have enough votes to pass the Senate compromise, whatever it turns out to be.  I'm not an economist, but plenty of people expect a default from the U.S. would send the world economy into a tailspin again.  It seems like the outcome is going to swing on if something is going to pass the House majority.  Which really isn't fair, because the U.S. having an economic hiccup isn't just "our" problem.  Plenty of people outside of the continent are going to be feeling the effects if the value of the dollar suddenly drops and interest rates knock the legs out of the world economy.  If they're going to have an ideological debate, I'm really hoping the House does it using some real and honest rhetoric, not by being irresponsible with our position in the world.  Like it or not, U.S. politics aren't just U.S. politics anymore.  We've actually got to keep the rest of the world in mind when we talk about our political situation.

Sorry, I've spent days without Internet angrily ranting about this stuff.  It was going to come out somewhere.