Where Social Justice Fits In Medical Decision-Making

Where Social Justice Fits In Medical Decision-Making

Posted on Saturday, November 15th, 2014 at 8:32 pm by lifemediamatters

Courtesy WikiMedia Commons

Courtesy WikiMedia Commons

This initial posting will set the stage for many essays that will be featured in this space. We all know that our current reimbursement system curtails choices for citizens, either by narrowing networks, imposing stricter guidelines for coverage or setting deductibles so high that access to care is unrealistic due to the upfront out of pocket costs required before coverage starts. There is a reason for this, and it is called social justice.

Social justice implies fairness and mutual obligation in society: that we are responsible for one another, and that we should ensure that all have equal opportunities to succeed. Being reasonably healthy is a basic necessity to succeed at providing for oneself or one’s family.

Social justice is one of the four tenets of bioethics, along with autonomy, beneficence and non-maleficence. Bioethics concerns questions about basic human values and society’s responsibility for the life and health of its members. Bioethics involves issues relating to the beginning and end of human life, from in-vitro fertilization and abortion to euthanasia and palliative care. Essentially, social justice is about fairness in a world of limited resources.

The U.S. spends 50 percent more per capita on medical care than any other country in the world, some 17.9 percent of GDP in 2010. At the same time, the U.S. achieves poorer health than many Organisation for Economic Cooperation and Development (OECD) countries. These member countries include some of the most advanced countries and various emerging ones.  From an economic perspective, curative medicine seems to produce decreasing returns in health improvement while expenditures increase.

The following is a breakdown of each dollar spent on healthcare in the U.S.:


Only 3 cents is devoted to public health activities, resulting in the neglect of many social and environmental determinants of health.

Social determinants of health are factors in the social environment that contribute to or detract from our health. These factors include socioeconomic status, nutrition, education, transportation, housing, access to services, discrimination and social or environmental stressors. More specifically, social determinants of health refer to the set of factors that contribute to the social patterning of health, disease and illness. According to the World Health Organization, “the social conditions in which people live powerfully influence chances to be healthy. Indeed factors such as poverty, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities between and within countries.” In fact, medical care alone only impacts health by 10 percent.

As a result, the discussion around social justice is becoming more relevant in medical decision-making because the cost of care is squeezing out the ability to pay for the other influencers of health. Physicians are being asked to consider not only the right treatment but also the fair allocation of scarce resources in a society of burgeoning needs.

The essays you read here will raise questions about social justice and leave you with more questions than answers. When you finish reading, you will understand why scholars and ethicists have spent decades arguing various positions. Even though bioethical discourse can become very emotionally charged, serious dialogue must be supported by strong and well-researched arguments. Pure emotion does not make for a defensible position.

This is certainly true in end of life decisions, and is as true at the beginning of life and mid-life as well.

Martin A.B. et al. (2012) Growth In US Health Spending Remained Slow in 2010; Health Share of Gross Domestic Product Was Unchanged from 2009,” Health Affairs, retrieved from http://content.healthaffairs.org/content/31/1/208.short

Saward, E. & Sorensen A. (1980)The current emphasis on preventive medicine: Issues in health services (pp17-29). New York: John Wiley & Sons

World Health Organization.

The World Health Report: 2004: Changing History. ISBN 92 4 156265 X (NLM Classification: WA 540.1) ISSN 1020-3311

Making Better End Of Life Decisions Starts With Conversations

Posted on Saturday, June 22nd, 2013 at 12:00 pm by Life Matters Media

Two Harvard physicians are informing Americans about what awaits them at the end of life if they opt for aggressive, life-prolonging treatments. Drs. Angelo Volandes and Aretha Delight Davis are producing and distributing short videosshowing how some patients suffer from these common treatments in an effort to better inform patients about end of life care.

Image: Advance Care Planning Decisions

During their appearance on “The Diane Rehm Show,” a production of Washington D.C.’s NPR affiliate, the physicians decried the fact that though most Americans say they want to die at home, 75 percent spend their last moments in hospitals or nursing homes. Hospitalization usually means more painful, costly and futile attempts to prolong life; this type of care accounts for 30 percent of all Medicare spending.

“What we often find is that doctors use complex language to start the conversation, and we live in a visually literate society,” Volandes said. “If a picture speaks a thousand words, videos speak hundreds of thousands of words.” Too often, they noted, physicians are the ones initiating these conversations.

These videos also aim to dispel fears of awkwardness surrounding end of life conversations among families, so they will in turn become more common. “The conversation is one of the most difficult, yet one of the most important discussions you will have in your lifetime,” Davis said. Families should ask questions about concerns and fears, as well as about intervention and treatment preferences.

Their efforts have not gone unnoticed, and they pride themselves on being “the most subversive doctors in the medical field.” However, according to Davis, the U.S. is currently facing a “war on death.” She said:”If you have not translated your values, your wishes, the core of who you are into some sort of medical plan, unfortunately what I will do is often times provide marginal benefit, cause great suffering to you and your family, and frankly, only postpone your death.”

Advance Care Planning Decisions, the nonprofit organization founded by Volandes and Davis, features more than a dozen videos ranging in topic from the benefits of hospice care, CPR procedure and how feeding tubes work. Certain videos are even available in Mandarin, Tagalog and Japanese.

In 2010, Medicare paid about $55 billion on doctor and hospital bills during the last two months of patients’ lives– more than the budget for the Department of Homeland Security, according to research from the Dartmouth Institute for Health Policy. Some 20 to 30 percent of those medical expenses may have had no meaningful impact on patients’ health.

Life Matters Media Participates In “Great Challenges”: Caregiver Crises

Posted on Monday, April 22nd, 2013 at 3:17 pm by Life Matters Media

Life Matters Media is proud to participate in the TEDMED “Great Challenges” program, sponsored by the Robert Wood Johnson Foundation. The caregiver crisis has been designated as one of the twenty “Great Challenges” in health and medicine. The program’s mission is not to solve the caregiver crisis, but to provide unbiased, inclusive viewpoints of the challenges from a multidisciplinary perspective.

At the conclusion of TEDMED 2013, Life Matters Media was pleased to take part in “Great Challenges Day,” held at George Washington University, in which participants explored how storytelling and narrative framework can be used to gain a deeper understanding of the caregiver crisis. Storytelling is at the core of what our organization aims to do as we prepare to launch our full digital platform in the coming weeks, and the “Great Challenges” program shares our belief that greater understanding in health care and decision making stem from sharing true narratives- not data.

Below is the “Discovery Doodle” by graphic recorder Robbie Short, depicting some of the challenges offered by program participants in coming to grips with the caregiver crisis.

"Discovery Doodle"

“Discovery Doodle”

An estimated 44 million people provide care for the elderly, disabled, sick and injured. Caregivers have few tools and few support systems as they carry out their tasks, and they receive minimal, if any, training for these responsibilities.

Here are some of the contributing factors that make the caregiver crisis such a pervasive health and social problem, as offered by “Great Challenges” team members:

-Lack of recognition by payers, providers, employers and regulatory agencies on the value and financial impact family caregivers bring the health care system. (Cheri Lattimer, Consulting Management Innovators)

-Emotional isolation and lack of support (paid and unpaid) to help a family caregiver balance his or her life. (Suzanne Geffen Mintz, National Family Caregivers Association)

-The graying of the U.S. – 10,000 Americans turn 65 every day (Alan Blaustein, CarePlanners)

The Future Of Caregiving Could Be A Talking Dog

Posted on Sunday, April 21st, 2013 at 12:39 pm by Life Matters Media

Pet avatars offered as a solution to caregiver crisis at TEDMED 

The thought of virtual pets evoke 1990s toy memories for millennials, but a new incarnation of such may help stave off dementia in their grandparents- and provide them  enriching social connections.

GeriJoy companions, virtual “talking dogs,” are now providing pet therapy, personal companionship and computer services to the elderly, and peace of mind to their long-distance loved ones.

“We’ve transformed what it is like to be a caregiver,” said GeriJoy CEO Victor Wang, as he presented his tablet-based software at the TEDMED 2013 conference in Washington, D.C.

Wang says he was inspired to create the real-time avatars as a result of his family’s experience emigrating from Taiwan- and his grandmother’s subsequent deep depression as she remained behind, alone in their home country. His parents could not afford to employ the services of a caregiver, so they lived in fear that his grandmother would harm herself, while they were rendered helpless.

“We can help increase seniors’ self-worth and improve their mental health,” Wang says, noting that more than 800,000 Americans suffering from Alzheimer’s disease live alone, and that more than half of those lack a caregiver. These numbers are expected to exponentially increase in the next two decades, and the current four-to-one ratio of able-bodied caregivers per senior is expected to drop to one-to-one.

“There are not enough real people in the U.S.,” says Wang, and he sees his GeriJoy companions as a solution to not only providing seniors with emotional interaction, but capable of updating scattered family members with the condition and overall well-being of their loved one.

Each avatar is monitored 24 hours a day by GeriJoy staff who are available to engage each virtual pet in dialogue with its senior. Relatives can use the company’s website to upload photos and updates for seniors to view and talk about with their companion. GeriJoy staff log the content of each interaction online, so that family can see how their loved one is faring.

Wang predicts that his software will soon be helpful in detecting senior abuse and accidents, as well as have the capacity to provide daily medication and activity reminders.

Wang says GeriJoy is changing the traditional definition of caregiver. “It’s about the joy, conversations, friendships and health that comes from all of this and the relationships that we build.”

To learn more: www.gerijoy.com

Community Cancer Clinics Turning Thousands Away

Posted on Monday, April 8th, 2013 at 2:30 pm by Life Matters Media

Image: Flickr, TipsTimes via Creative Commons,

TipsTimes via Creative Commons

Many U.S. cancer clinics have started to turn away thousands of patients due to the sequester’s cuts to Medicare.

As The Washington Post’s Sarah Kliff reports, some oncologists say the reduced federal funding makes it impossible for community clinics to administer expensive chemotherapy to seniors and remain financially stable. These patients must now seek treatment elsewhere, even as hospitals accepting Medicare beneficiaries grow more overcrowded.

Jeff Vacirca, chief executive of North Shore Hematology Oncology Associates in New York, told Kliff, “If we treated the patients receiving the most expensive drugs, we’d be out of business in six months to a year.” Vacirca said his clinics have stopped administering drugs on which they lose money. His clinics have also ceased to treat one-third of their 16,000 Medicare patients.

Pancreatic cancer patient Harold Rosen, 81, has been receiving chemotherapy at one of Vacirca’s cancer centers, but sequester cuts will soon change that.

“When I first came here, I was afraid to come because everyone’s dying. But everyone here is so pleasant. They smile, they laugh, they care about you. You would never know it’s a place of cancer,” Rosen said to NBC News. Rosen’s physician told him he must start receiving treatment in a hospital.

Vacirca said he is sad to turn away patients like Rosen, but he insists he must.”I have to be financially responsible to be here,” he said. “I owe it to my patients to not go out of business.”

Although Medicare is only facing a 2 percent reduction in funding- much less than other federal programs- oncologists say cancer patients are losing the most.

Seniors’ medications are mostly covered under the optional Medicare Part D. However, cancer drugs must be administered by physicians, and they are paid for by Medicare Part B. Part B covers doctor visits and is facing the sequester’s cuts.

According to Kliff, “The federal government typically pays community oncologists for the average sales price of a chemotherapy drug, plus 6 percent to cover the cost of storing and administering the medication.” But physicians cannot change drug prices, so the 2 percent cut will have to come out of the 6 percent cover charge- “akin to a double-digit pay cut” for clinics.

recent survey of more than 300 oncology practices by the Community Oncology Alliance determined that 72 percent of them will change how they treat Medicare patients if the cuts continue.

The Alliance has pledged to “fight this unjust and devastating cut to cancer care” with an online petition.

A Milliman report shows that half of all U.S. cancer spending is associated with Medicare beneficiaries. Chemotherapy in hospital settings costs the federal government about $6,500 more than treatment in community clinics does. Some of those costs are then handed to patients, who pay another $650.

Will hospitals be able to absorb these patients? The same study shows almost 70 percent of Medicare patients receiving chemotherapy are treated in community clinics. Clinics in Connecticut, New York and South Carolina have already stopped treating patients.

What is the sequester?

In 2011, Congress passed a law stating that if no legislation was passed to reduce the federal deficit by $4 trillion, some $1 trillion in automatic budget cuts would take effect in 2013.