Vandals at the Gates

Journal/Website: 
Journal of the Medical Association of Georgia
Article Type: 
Editorial
Published Date: 
Wednesday, November 2, 1994

But what events have led us to this deplorable state of affairs with American medicine headed inexorably in the wrong direction—down the path of welfarism, collectivism, and corporatism? To answer this loaded and troublesome question, perhaps one should ponder the words of the politician par excellence, Franklin Delano Roosevelt, who once admitted, “Nothing just happens in politics. If something happens, you can be sure it was planned that way.”  So, in our search for answers, let us glean and ponder the changes ushered in the 1960s by the Great Society of President Lyndon B. Johnson.

A Modern Trojan Horse

During that time, many people thought government could solve all of society’s problems. Physicians were no exception. So yes, many physicians succumbed to the allurement of Medicare and Medicaid in 1965. “After all,” they asked themselves, “why not accept government payment for medical services formerly provided the indigent as charity, pro bono publico?” With the questions finally answered in the affirmative by a pragmatic leadership, physicians listened to the seductive songs of the sirens that weakened their natural defenses to government intrusion. So began the government onslaught that ultimately resulted in the breaching of the walls of the House of Medicine.

Perhaps physicians should have listened to their literary confrere, Dr. Anton Chekhov, who as a devoted Russian physician often worked without payment and once revealed, “I am poor and broke because I thought it desirable for myself and my independence to refuse the remuneration the cholera doctors receive.” Suffice it to say, the cholera doctors he referred to were employed by the government. Likewise, today, many physicians are again listening to the alluring sirens of managed care, scurrying about to sign up with this or that network—thinking [that]...“managed care is here to stay, and in any event, if I don’t, others will.”

Dr. Thomas A. Dorman, a California AAPS member wrote in 1992 in his office practice newsletter, “It seems that we in America are about to embark on an accelerated venture of harnessing the capitalist engine for the destruction of healing...an unholy marriage of corporate capitalism to government bureaucracy.” Only this “partnership with government,” that everyone from President Bill Clinton to Secretary of Labor Robert Reich are vaunting, is more correctly denoted corporate socialism—the same economic arrangement we witnessed in Italy, Germany, and Japan in the pre-World War II era—the economic component of Fascism. Individually-based, patient-oriented, Hippocratic medicine and virtue-based ethics are quietly being pushed aside.

The Beginning of the Great American Decline

Let us now return to the legacy of the Great Society. The government onslaught against American medicine was launched in tandem with the concerted, all-out assault upon the various institutions of American society that (with one notable exception we will mention later) had served America, the land of opportunity, so well.(1) Yes, along with the government inroads made into the edifice of the medical profession, the 1960s also witnessed major changes in the criminal justice system, so that the rights of criminals came to supersede those of the victims. Crime began to pay for itself, and it paid handsomely. And while criminals were pandered by a permissive society which relinquished individual responsibility and moral accountability, gun control became a panacea for growing violence and street crime. The Gun Control Act of 1968, fashioned after Hitler’s gun laws of 1938,(2) was passed to compensate for the changing societal mores and the increasingly weakened criminal justice system.

It was also about this time the ethics of the civil justice system (tort) underwent a serious transmogrification. After centuries of a common law tradition, whereby lawsuits were filed only as a measure of last resort, now lawsuits were felt to be good for society, not only as a method of resolving legal disputes, but also as a powerful weapon to effect a more “equitable” wealth redistribution in society. Malpractice lawsuits became commonplace and reached destructive epidemic proportions. Of course, this redistribution did not affect the large profits made by the attorney-litigators or what the legal scholar Walter Olson has penned, the “sue-for-profit litigation industry.”(3) These swashbuckler litigators saw themselves as crusaders stamping out injustice and correcting the alleged perceived evils of American capitalist society. Moreover, in this egalitarian, adversarial, litigious atmosphere, societal contracts were deemed no longer sacred and could be violated with impunity by activist jurists.

The inception of the welfare state of the Great Society heralded the beginning of the great American cultural decline. It was also the beginning of the end of the Golden Age of Medicine and the beginning of the erosion of the independence of American physicians and the previously sacrosanct patient-doctor relationship. And with these lamentable developments, in due time, patients would lose physicians as their true advocates, and with it, the right to expect the best care that their private physicians could provide.

On the economic front, the sweeping reforms ushered in the final devaluations of the currency so that after a series of monetary reforms, beginning in the 1930s with the policies of the Federal Reserve System, U.S. paper money by 1968 (for U.S.citizens) and by 1971 (for foreigners), was no longer backed by (and thus, irredeemable with) gold or silver.(4) The predictable, unrestrained printing of paper money or fiat currency by the Federal Reserve, without precious metal backing allowed inflation to become a permanent fixture of the American economy.

Meanwhile, Keynesian economics was accepted by President Richard Nixon and the establishment as an explicit substitute for truly free-market capitalism. The implementation of wage and price controls in 1971 was then used to justify the fight against the inflation the government had created in the first place.

For physicians, their share of the health care budget pie, which has remained unchanged at 19%, meant that with inflation, their real earnings, like everybody else’s, were eroding. So, it is not surprising that for some physicians Medicare and Medicaid promised a path to financial prosperity. Physicians made more money than ever before with government intervention, but it was at a heavy price, for it carried the hidden cost of their independence.

No doubt the reader will be surprised to learn that it was also about this time, in the years 1971 to 1974, that the mechanics of managed competition were worked out with the diligent cooperation of the private and public sectors, and thereby, the sponsorship of both Republican President Richard Nixon and Democratic Senator from Massachusetts, Edward Kennedy. The consensual road was paved as to proceed with the delivery of medical care via Health Maintenance Organizations (HMOs), through the prepaid consumption of medical care via government-approved group practices.* Senator Kennedy would lead the charge for government intervention in health care through the 1970s and 1980s, and would support the corporate concept of managed competition, hand in hand with, and through the ill-fated attempt at the government takeover of the American health care industry by President Bill Clinton’s Health Security Act of 1993, to the end of the century.

Progressive government intervention in every aspect of American society heralded the beginning of the decline of the truly individual-based, free enterprise system, and the erosion of America’s sense of self-reliance and rugged individualism.  And in my estimation, it also marked the beginning of the ebb of Western civilization and the American way of life.

The Legacy of the Great Society

Despite spending $4.5 trillion dollars, on the social front the War on Poverty, by all estimations, has been an utter failure. In fact, it has worsened the lot of those it had intended to benefit. The traditional family is rapidly disintegrating as families are headed not by fathers, but by the faceless bureaucrats of the nanny state. Illiteracy is rampant, despite public schools and record per-pupil expenditures. Teenage pregnancy and illegitimacy have doubled, tripled, and are still climbing. White illegitimacy is approaching 20% and Blacks 60% (in some inner-cities, it exceeds 80%). Not surprisingly, among the many societal ills, we have been afflicted with a veritable epidemic of premature, low-birth weight infants (along with relatively high U.S. perinatal morbidity and mortality statistics), and consequently, soaring health care costs necessary to care for these infants.

This unfortunate occurrence has been cited as another pretext for government intrusion, but the truth is that this sad state of affairs has nothing to do with the quality of care provided by American physicians, but much to do with societal decay and the loss of individual responsibility.

Likewise, the legacy of the 1960s created a “generation gap” that alienated children from their parents; students from teachers; and not surprisingly, respect for elders and civility were lost. Absolute and universal truths gave way to moral relativism and situational ethics. Immediate gratification and “follow your bliss” philosophy was substituted for hard work, honest living, and deferred gratification. Rugged individualism gave way to the cult of victimhood. A wall of separation was erected between church and state,** and organized prayer was prohibited in public schools.

Earlier, I mentioned a notable exception to the disastrous policies of the 1960s, and indeed, a singular but empyrean zenith was reached with the end of legal discrimination and the eradication of institutionalized racism. But, alas, even the achievements of the civil rights movement (e.g., the Civil Rights Act of 1965) have been turned upside down with the concept of affirmative action and racial quotas which stigmatizes the members of minority groups who have triumphed from the establishment of true equality of opportunity, and has relegated the intended beneficiaries to a perpetual cycle of dependency from which there has been no escape.

The truth is that, no matter what their intentions might have been, the elitist mindset of government bureaucrats has inculcated upon its intended beneficiaries the erroneous idea that they cannot succeed without government handouts and the paternalism of the welfare state.  This policy, or rather philosophy, sent countless victims down the path of government dependency and onto the demoralizing travails of the liberal plantation, from which (it is worth repeating) there has been no escape.

On the political front, it was the beginning of the politics of envy to justify the taking of the fruits of the labors of hard-working individuals (via taxation or otherwise) to give to others, not so predisposed. It was and continues to be redistribution of wealth via institutionalized, legal plunder on a grand scale. In the meantime, success especially when accompanied by wealth creation (for some who are not as equal as others) became immoral. Yet, through all this time, the government was (and continues to be) getting larger and more intrusive at the expense of productive citizens. With this legacy, it is no wonder that the government bureaucrats are not only consolidating and perpetuating their positions of power and control, but also are dividing and conquering, in Machiavellian fashion, while “inhaling” and imbibing heavily on the divisive and destructive politics of envy.

Marching to the Drumbeat of Medical Socialism

On the medical front, we have established how with the inception of Medicare and Medicaid, the government had made its first major incursion into American medicine, and now a precedent had been effectively set for the step-by-step encroachment into the realm of American medicine. In time, a long train of abuses and usurpations followed, and soon swarms of officers, government officials, and sundry vandals began their relentless conquest of the best health care system in the world. Such abuses and usurpations in the late 1980s led to the establishment of what I refer to in a brief but apropos editorial as the medical gulag (6); ineffective price-controls for hospitals via DRGs and for physicians via RBRVS (a methodology derived from the Marxist labor theory of values); behavioral conditioning via Volume Performance Standards (VPS); Big Brother intimidation tactics via perennial threats of Medicare and Medicaid sanctions, and sundry other abuses obstructing the administration of justice in medical practice.

Physicians, especially those who refuse to march in lockstep with government edicts, are harassed and intimidated with attestation statements appended to the potential, arbitrary charge of waste, fraud and abuse, and other threats. Violation of these edicts could trigger harsh penalties, civil and criminal asset forfeiture proceedings, and land such “disruptive” physicians in jail.

No documentation was ever provided to support the Inspector General’s assertion that fraud and abuse amounted to 10% of health care costs, but we do know that less than 2% of physicians were ever convicted of violating Medicare rules and sanctioned. And of those, all had been enticed by government programs and government money. Moreover, utilization review was found to be notoriously cost-ineffective and counterproductive: For every dollar saved, ten dollars were wasted in reviews and administrative costs.(7)

In time, physicians would also have ex post facto laws foisted upon them as in the case of the Clinical Laboratory Improvement Act (CLIA) and authoritarian and extortionary tactics in the form of Occupational Safety Hazard Administration (OSHA); and all of this, mind you, under the looming threat of the odious and potentially calamitous accusation of waste, fraud and abuse, and civil and criminal asset forfeiture proceedings. To add insult to injury, a charge of this nature would, under the aegis of administrative law, be administered by impersonal bureaucrats who are not restrained by the shackles of constitutional protection.

Consider the predicament: Physicians in the trenches of health care delivery, virtually under siege, bound to obey cryptic laws, deliberately vague and arbitrary, so that Big Brother can call them guilty whenever he likes. And frankly, with HMOs and managed care, ideas conceived at least 30 years ago by government bureaucrats in collusion with willing private entities with a vested financial interest in managed competition, I see no cause for comfort. Practicing physician and their patients should, nevertheless, take solace in Goethe’s words, “whosoever, aspiring, struggles on, for him there is salvation.”

Historic Parallels: Panem Et Circenses and the Politics of Envy

In every major historic era, the diligent student of history will find epochal events and eerily familiar historic parallels. This is not because history is necessarily cyclical as many learned people believe, but because human nature itself has not changed in the last 6000 years of recorded history. Human nature and actions, particularly those of strong personalities, are responsible for many of the crucial human events recorded on history's pages.

Consider the fact that in our own age, divisive political demagogues have honed down the politics of envy to a fine degree so that, for example, during the 1992-1994 debate, we repeatedly heard such terms as “price gouging” and “greedy providers,” referring to the pharmaceutical industry and physicians, respectively—to instigate modern class warfare.  And through 1995 and early 1996, we heard repeatedly the rhetorical mantra: “The Republicans are seeking to cut Medicare by $270 billion dollars to pay for a $245 billion dollar package of tax breaks for the rich.”

This amplification of the divisive politics of envy has been employed to pave the way for the planned, step-by-step transformation of the American health care delivery system, and the subjugation of the medical profession as to make physicians employees of the up-and-coming, powerful private-public partnerships under the rubric of the oxymoron of managed competition and the statism of corporate socialized medicine.

To the student of history, the situation today becomes analogous to that which befell the Roman Republic in the 1st and 2nd Centuries B.C. For as you would remember—after nearly four centuries of glorious constitutional rule, triumphant conquests, and enormous expansion—the Roman Republic reached a pinnacle of prosperity and resplendence. It was then that it fell prey to populist demagogues who claimed to speak for the people and the lower classes, but spoke for their own selfish ends, their own greed, and their own thirst for power.  They promised the populace land, bread, and circuses. They instigated riots and insurrections, and preached class hatred and class warfare in the name of justice and equality.

Law and order and the ancient Roman precept of the rule of law were discarded. For all intents and purposes, the once glorious Republic had degenerated into an unruly mass democracy, with populist politicians currying favor with the incited masses and threatening to establish a tyranny of the majority, a desultory majority which, no longer informed and vigilant, could be manipulated on the promise that they would be given other peoples’ land and wealth. This chaotic situation could not stand, and it too, quickly degenerated into a mobocracy (the rule of the mob). Here we should perhaps pause and note the words of Sir Alex Fraser Tytler (18th Century): “A democracy cannot exist as a permanent form of government.  It only exists until the voters discover they can vote themselves largess from the public treasury.  From that moment on, the majority always votes for the candidates promising the most benefits from the public treasury, with the result that a democracy always collapses over loose fiscal policy, always followed by dictatorship. The average age of the world’s great civilizations have been 200 years.”

In the end, as is well known from history, when law and order disintegrate, the citizenry will inure oppression in exchange for peace and security; and in the end, give up their liberties and freedoms and hand power over to a strong man who promises to re-establish law and order. That is just what happened when Julius Caesar crossed the Rubicon, seized power in a bloody civil war, and formally overthrew the Republic.  Roman citizens gave up their votes and their time-honored constitutional, republican principles happily, quid pro quo, public largesse and other panem et circenses. This included getting on the public dole for bread and other government subsidies, and being given free gladiatorial entertainment in the Roman arenas.

For their part, great men, statesmen, philosophers, and republican leaders like Cato the Younger, Cicero, and later, Seneca the Younger, died honorably for their republican sentiments and their beliefs in the natural rights of man, the rule of law, and the tenets of the Roman constitutional Republic.

Fortunately, as Terence once wrote, “Fortune favors the bold,” and the mighty Roman Empire that followed and that enforced a Pax Romana for nearly two centuries, retained many of the republican institutions (such as the Consulate, the Roman Senate, and some of the rights of citizenship) so that even with the founding of a great empire, Rome, and by in large, the average Roman citizen, continued to prosper.

During this period, genuinely devoted medical ethicists and celebrated Roman physicians, such as Scribonius Largus and Aulus Celsus, flourished. Scribonius, for example, expounding on the precepts of Hippocrates, formulated the basic tenets of medical humanism, humanitarianism, patient responsibility for their own medical care, and prescribed the best possible drugs and medications for his patients. For his part, the Roman medicus, Celsus, took medicine to a pinnacle of glory in the fields of internal medicine, surgery, and professional ethics. And Pedacious Dioscorides, a Graeco-Roman surgeon who followed the Roman legions into far-reaching corners of the empire, expanded the frontiers of medical knowledge and wrote and illustrated his magnum opus on medical pharmacology, De Materia Medica.

All of these physicians believed in a sacrosanct patient-doctor relationship, and were able to place major building blocks of knowledge in the great edifice of medicine, because during this period, the practice of medicine remained independent and unimpeded by government intrusion. The practice of medicine was guided by virtue-based medical ethics and the sanctity of the patient-doctor relationship. Like Hippocrates’ medical ethics, theirs was a voluntary, self-imposed, professional code. Medicine had become an honorable, respected, and learned profession. Wise governments recognized that physicians were valued members of a profession whose purpose and function ultimately benefitted society, and therefore, were best left alone to practice their profession, as long as they practiced according to the ethical standards of the particular school of philosophy to which they adhered and swore to uphold.

Footnotes

* A simple concept of HMOs for pre-payment of medical care had been pioneered by industrialist, Henry J. Kaiser, and physician, Sidney Garfield, M.D., in California in the 1930s.

** The term is derived from a letter written by Thomas Jefferson to the Baptist officials in Danbury, Connecticut (January 1, 1802) in which he did not claim a separation of religion be made from public life, but instead opined his view that the establishment of a state religion was not within the purview of the federal government.(5)

References

1. Faria MA Jr. Vandals at the Gates of Medicine—Historic Perspectives on the Battle over Health Care Reform. Hacienda Publishing, Inc., Macon, Georgia, 1995.

2. Simkin J, Zelman A, and Rice AM. Lethal Laws. Milwaukee,Wisconsin, Jews for the Preservation of Firearms Ownership, 1994.

3. Olson WK. The Litigation Explosion—What Happened when America Unleashed the Lawsuit. Truman Talley Books, Dutton, New York, 1991.

4. McManus JF. Financial Terrorism—Highjacking America under the Threat of Bankruptcy. Western Island, Appleton, Wisconsin, 1993.

5. Barton D. The Myth of Separation. Wallbuilder Press, Aledo, Texas, 1991.

6. Faria MA Jr. The medical gulag. J Med Assoc Ga 1993;82(2):56. See Chapter 22.

7. Annis ER. Code Blue—Health Care in Crisis. Regnery Gateway, Washington, DC, 1993.

Written by Dr. Miguel Faria

This article, which originally appeared in the November 1994 issue of the Journal of the Medical Association of Georgia as Dr. Faria's "Editor's Corner," was subsequently updated and re-published as Chapter 2 in Medical Warrior — Fighting Corporate Socialized Medicine (1997). It has been posted here and is now accessible on this website for the benefit of our readers.

Copyright ©1992-2012 Miguel A. Faria, Jr., MD

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Comments on this post

Disruptive or obstructionist MDs?

A re-read of this article mentioning "disruptive physicians," in passing, reminded me of a more recent brief editorial published in SNI. The editorial was critical of obstructionist "disruptive physicians," and although written in good faith by a conscientious nurse administrator, I thought it was necessary to present the other side of this dilemma. I did not feel the administrator had thought of the fact dissenters had a right to dissent from policies they feel had been railroaded in by administrators acting as agents of powers that be. Below is my response to that article.

Respectfully, this “article” does not have significant details to allow the reader to render an informed judgment about what really went on. It seems, frankly a holier-than-thou outburst for what may be discourtesy or nonconformist behavior! What exactly was the disruption that eventually rendered the judgement of “zero tolerance”? In fact, Nurse St---. is correct that courtesy and civility are on the decline, but the egalitarian zeitgeist of our time empowers everyone to have opinions, as misinformed as they might be, and to remonstrate, as obnoxiously as they want — i.e, as long as the opinions and remonstrations are not political incorrect!

Yes, courtesy and civility paradoxically are on the decline, while political correctness and the curtailment of informed political and social speech advances on the aegis of the intelligentsia.

Nurse St---. writes: “5–10% of the respondents were openly hostile and accusatory to the physicians who were involved in the discussions.” What was said or done? Who were these respondents? Were they participants or not, physicians, patients, or general public? Hecklers or violent individuals should be escorted out of the premises, but dissenting voices should be allowed to speak and express contrary views.

Furthermore Nurse St--- writes, “Many patients with serious medical problems are emotionally vulnerable.” True but were patients involved in the discussion or is she now speaking in general terms? She goes from a seemingly specific incident to broad general accusations involving patient care and safety! When did the discussion move from one to the other? This is absolutely not clear.

Moreover, Nurse St--- uses two disturbing terms that require further explanation. “Disruptive physicians” was a term that came into vogue a couple of decades ago, applied by the leaders of the progressive and elitist AMA (“organized medicine”) and their medical publications to silence, intimidate, and even censure nonconformist physicians, who expressed disapproval of the organizations’ direction or who refused to play the role of sheep in the herd.

Civility and courtesy are one thing, and I am all for them, but censorship for voicing contrary opinions that may divert the discussion in a direction different from that intended, and thus termed a “disruption,” is another. Let me give you an example. I remember participating in a discussion on universal health coverage at the time of the promotion of HillaryCare and the secret health care task force in 1994, but “sources of funding (i.e., more taxation)” was not permitted in the discussion. When I insisted that it be discussed, I was called “disruptive” by one of the promoters of socialized medicine. The participants sided with me. At the conclusion of the conference, it was decided that universal health insurance in the U.S. was too expensive for the alleged benefits and that improving access was more feasible!

The other trendy and politically correct but short-sighted authoritative term is even more disturbing —i.e., “zero tolerance.” This simulacrum of authoritative justice has been responsible for school children being reprimanded and suspended from schools for bringing a water gun to class or drawing a picture of a firearm, or even for expressing politically incorrect opinions or religious faith, while brawlers and bullies were and are permitted to wreak havoc, intimidate classmates and truly disrupt classes with melees and general delinquency. “Zero tolerance” is an authoritarian “one size fits all” rather than measured and thoughtful punishment fitting the transgression.

I hope this reply is taken just as a contrarian view, intending to dissent as well as to inform (while attempting its utmost to remain courteous) rather than deride or disrupt. Free speech and the right to express opposite views is too important to liberty to persiflage or relinquish in silence. No disrespect or lampoonery was intended to offend the author of this editorial!

Miguel A. Faria, M.D.