Note: Dr. Ron Paul was the June 2001 commencement speaker at the University of Texas-Houston Medical School.
Being invited to address you today is indeed a particular honor for me. In seeking advice about my speech I was told to observe three things:
1.) Be brief; no one remembers graduation speeches and too often they are boring. Being brief is not the easiest request for a politician to fulfill. But I did decide not to read the 80-page speech I'd written.
2.) Be positive; don't dwell on the problems medicine faces; this is to be an upbeat event. Now that's a little more difficult for one who titles his weekly legislative report: "Texas Straight Talk."
3.) Be non-controversial; well, that's just asking too much of a politician.
My task today is to remark on the relationship of medicine to society from my perspective as a physician and legislator. To me this is a very interesting task, but difficult to accomplish in a short period.
Before I begin, let me reassure you that I will try hard not to offend anyone, but that's probably not completely possible. If I do offend, I apologize. But you need not worry too much about a disagreement you might have with what I say, because I'm an advocate of a political philosophy that believes social and economic problems should not be solved by passing more laws and using force, but instead, solutions should come through freedom and persuasion.
The same events that early on motivated me to go to medical school later motivated me to participate in politics. Clear memories of the horrors of World War II and the Korean War and the reports of loss of life of family, friends, and neighbors had an impact on me. I knew very early on I never wanted to carry a gun in a war and, with the draft in place, I realized the odds were overwhelming that I would be called up to serve. I definitely knew at an early age that I preferred a medical bag to a gun, healing to maiming, life to death.
I'm sure all of your reasons to become physicians vary, but most young people deciding on the medical profession share the noble goals of promoting health, healing, and life.
There are two short stories I want to tell, one medical, the other political and economic.
First, when George Washington got a serious illness, the best physicians in the country were called in. Three of the best consulted and agreed that bloodletting was the treatment of choice, and the leeches were put in place. Washington's weakened condition that was the result of a serious respiratory infection promptly worsened and he soon died. (There was no malpractice lawsuit filed.)
Good intentions and conventional wisdom were not helpful in saving the life of the father of our country. Medical care involves more than good intentions.
Second, in 1620 the Pilgrims, under the guidance of Governor Radford, landed at Plymouth Rock. For the first two years the guiding principle was "from each according to ability, to each according to need – and by force." Starvation ensued and the colony neared extinction. However, in the third year, Radford, in consultation with the adults of the community, agreed on a system of private plots and self-reliance. Results the next summer were astounding. Productivity shot up, and a community spirit of voluntary sharing replaced the harsh laws that guided the first two years.
Freedom solved the problem of starvation.
The second story reminds me of one of my early lectures in medical school. We were told that Kwashiorkor was the most common illness in the world, killing more persons than any other. Immediately, with delusions of grandeur, I dreamed of being the physician to find a cure for this devastating malady. But later in the lecture I learned that Kwashiorkor was a different kind of illness – it is the end result of starvation. Later it dawned on me that the solution to this problem was more political than medical.
Because we in this country have enjoyed the benefits of the freest society ever known, true famine has never existed here. But a headline a few weeks ago read: "Rickets on the rise in the U.S." I wondered at the time, could this be an early sign that something is wrong? Have we undergone a reversal back toward the philosophy that nearly destroyed the Plymouth colony?
Currently the method of distribution of medical care in the United States is coming under attack by politicians, bureaucrats, hospitals, labs, service providers, doctors, and patients. More laws and more money are demanded from all quarters. But could it be possible that distribution of medical care is now being criticized because of a return to a system of government similar to the early rules of the Plymouth colony? Or is it possible that freedom combined with self-reliance no longer works? A basic understanding of economics helps one to understand why distribution of medical care today is becoming more difficult; quality is down while costs are rising; and everyone seems dissatisfied.
We have, unfortunately, at least for medicine, accepted the rules used in the Plymouth colonies for the first two years … "from each according to his ability, to each according to his needs by force." I'm not convinced that more regulations and government laws – which are demanded on a daily basis – will solve this problem any better than Congress' similar attempts to deal with most other problems.
Managed care is not market-driven, it's government-mandated. It has driven charity out of the system. No more church-financed hospitals and free care for the indigent. Everyone is charged the maximum, and no test is left undone for fear attorneys will be ridiculing us in court alleging our negligence. And if it's not the attorneys, it's the HCFA [Health Care Finance Administration] agents threatening us with fines and prison if we misinterpret any of the 132,000 pages of regulations. This system artificially pushes costs up, bringing calls for price controls, which only mean rationing and shortages.
Greater understanding of freedom and economics by the next generation of doctors would go a long way toward heading off the approaching crisis: the day when the taxpayer has been bled dry and no funds are available. Even during the Great Depression, most people received medical care because of the system. Today that system won't function without taxpayers' money and can't function very well even with it.
The medical degree you receive today makes you a medical doctor. A state license will legally permit you to practice. However, it takes a lot more to be a caring physician to your patients. There are several challenges to the practice of medicine that you, the graduating class, will have to face in the 21st Century to achieve this goal.
Big Challenges Ahead
Managed care is the accepted method of delivering medical care today – to the frustration of many. Read up! There are 132,000 pages of Medicare regulations, compared with only 17,000 pages of the tax code. A compliance plan to guard against mistakes in filing government forms is offered by your friendly attorney for a mere $7,000.
Additional employees are needed to file insurance forms and keep up with regulations in operating laboratories. Even more employees will soon be needed to implement the 1,500 pages of regulations protecting patient privacy – regulations that in reality turn control of all our medical records over to the US government and establish a national medical data bank.
Fines of up to $25,000 and 10 years imprisonment are possible for fraud and for mistakes that are hard to distinguish from fraud.
Capitation depersonalizes medicine. FDA regulations, though designed to help, often delay the arrival and raise the cost of new drugs. An average new drug now requires 15 years of testing and $500 million in costs. Many question whether or not this process is cost-effective. A more liberalized approach to allowing patients and doctors to use experimental medicines could speed up the process and lower costs.
Medical privacy rules are expected to cost $22 billion over 4 years to implement – costs that must be passed on to the taxpayer or to the patient.
HCFA has actually requested authority to carry guns on their audits.
Another challenge to personalized care is the continued influence of technology and super specialization. It's easy for the patient to be lost in the process and become only an object in a scientific whirlwind. This challenge is not new, but it will continue to affect the practice of medicine to an even greater extent.
Legal challenges through lawyer-driven lawsuits are of epidemic proportion and will continue to plague our profession, thus driving up costs while prompting unnecessary testing. Threats of an actual lawsuit do affect the way we all practice. The National Practitioners Data Bank has been set up to keep all the records of doctors' misconduct, which is also subject to the errors of politicians, bureaucrats and spiteful lawyers. Rectifying errors and avoiding misinterpretations in this process are difficult, if not impossible tasks. Centralized government bureaucracy won't solve the problems of ethics and measuring ability in medicine.
The Drug War
The drug war will continue to affect the way we practice medicine. Law enforcement pesters us to be their assistants in turning over to them patients who break the drug laws. This encourages patients to hide rather than reveal vital information to their physicians. Drug laws have also caused many physicians to inadequately treat the pain of the dying patient out of fear of the law. Nursing care has been affected as well.
Some day, hopefully, all drug addiction will be treated more like we treat alcoholism; as a disease or social aberration rather than as a crime. The drug war has done more harm to our society than the drugs themselves. The medical community should help to reeducate the public on this serious problem.
Life and Death
The greatest challenge young doctors face today in their journey to becoming caring physicians is dealing with the new attitude of our profession toward life and our closer alliance with death. Thirty years ago, taking early life was not a routine medical procedure; today it is. Many believe this has coarsened society's attitude toward life.
The changes regarding abortion have occurred in my generation and not without a lot of heated disagreements. The debate will continue until your generation answers a perplexing question. Let me state it: If a woman in an automobile on her way to have an abortion is hit by another vehicle which causes the death of her fetus, does she have the moral right to sue and win a million dollar judgment in a "wrongful death" suit? This is not meant to be a legal question but one pertaining only to our understanding of life and morality. An acceptable answer to this question on both sides of the abortion argument must be found if we ever expect the sharp debate on this crucial issue to mellow.
In the last 30 years, the medical profession has allowed itself to get closer to the implementation of the death penalty than previously. In the 1880s, technology was available to implement the death penalty by injection and was seriously considered. Organized medicine at that time, however, strongly objected to even the principle – believing needles and syringes would portray medicine as a participant – and it wanted no part of it.
With the advent of electricity, the electric chair was chosen over lethal injections. Since the resumption of the death penalty in 1977, lethal injection has been commonly used to carry out the death penalty, with the advice and even the presence of physicians. The strong objections expressed by the medical community a century ago are no longer heard.
Euthanasia
Your generation will deal with euthanasia as we have dealt with abortion. I predict a major and heated debate will occur in the next 30 years. Already one state has legalized "doctor-assisted suicides." I'm not talking about reasoned restraints of heroic measures for the terminally ill at the patient's request. Euthanasia laws as they have progressed in some European nations permit active euthanasia.
We already have the Dr. Kevorkians and angels of death leading the charge in a dangerous and illegal fashion in this country. It's interesting that the promoters of euthanasia always want the doctors involved. This is for a precise purpose, and that is to gain moral sanction not otherwise available. You never hear about having attorney or judge-assisted suicides, but they can figure out the details as well as the medical profession.
This trend is fraught with great danger. Once physicians embark on making decisions over death, rather than always opting for life, they invite too many mistakes. Subjugation to social pressure and family squabbles can affect decisions. The government now assumes nearly a complete role in regulating and paying for health care; economic factors will surely play a role in this decision-making as time goes on. Already we have seen managed care and government regulations dictate rules that are not always fair as to who gets the organ transplant or some other expensive treatment.
Regardless of the law in dealing with these issues, I see no reason why the medical profession has to grant moral approval to the process. Let someone else deal with it and carry out the deed. It's surely not an issue of know-how, and we need not give it credibility by pretending it's part of our responsibility to heal. Society needs and demands our endorsement to make it a medical procedure, which it is not. Our endorsement only prevents others from considering the morality of the issue.
Already a well-known former governor is strongly advocating active euthanasia, saying "the elderly have an obligation to die" and should not hang on to life that offers little.
The US Congress, although technically it has no jurisdiction to do so, has tried to undermine the Oregon law (the first state to pass a law that permits physician-assisted suicide) with proposed legislation that would severely micromanage the care of dying patients. This attempt to do what some see as "the right thing to do" will only cause more problems by intimidating physicians in their efforts to relieve the pain of dying patients. New restraints by government on prescribing for the dying will prove to be an unnecessary aggravation. This is not the answer to a society moving toward euthanasia.
This subject will be with us for a long while. Your generation of physicians will have no choice but to deal with it one way or another. You can't escape it – even total non-participation in the debate is taking a position.
Obviously, problems do exist in medicine, but the profession you have chosen is the best of all. It is a noble calling to enter medicine. You have learned the science, you will get your license, and the only task left before you is to become a caring physician. I am sure that nearly every one of you thought of service to your fellow man when deciding on a medical career. And that's a noble ambition that should never be forgotten.
The true physician draws on this and must be reminded of it throughout his or her life. This is what makes us approach our patients with kindness, gentleness, caring, and concern. Being a good listener is essential. Someday, a sincere thank you or a small gift will remind you of this, and at times it will even surpass in value the fee that you have received for your services.
Good intentions can kill any patient, just as they did George Washington. Good science, without compassion and understanding,will not allow you to practice great medicine. Compassion and care and good science will make you become the physician you dreamed of being. This will require tolerance for alternative medical options – since some may actually work – and a recognition that faith and prayer have a healing quality. Intolerance of this view will not enhance a physician's ability to heal.
Carry These Thoughts With You
A few simple but important reminders are in order. Always remain inquisitive, studying and keeping up with new medical knowledge. This is your easiest task. You have proven your ability just by being here today.
But also be inquisitive in other areas. Economics, politics, and the arts (that you so far have had little time for) are vital subjects that can provide satisfaction and challenge us.
Remain productive. Medicine has discouraged many in the past years and too many are retiring in their prime – that's disappointing. It's expected that one-third of all the nurses are likely to quit practicing in the next year due to problems in medicine.
But regardless of the system, a physician should always be willing to practice the art of medicine for as long as possible in some capacity. We have all heard about the "greatest generation." You are joining the "greatest profession." There can be no better job than being a physician in that it's always possible and easier for you and others to follow the adage "it is better to light a candle than curse the darkness." Every patient facing illness, death, or stress deserves your lighting a candle.
I'm convinced that the freer the society is the better this job can be done, and that can only be achieved through education and political action. Freedom is never automatic. Without due vigilance, the only thing that is automatic is that the good intentions of the politicians, like the good intentions of George Washington's doctors, will not suffice – they will only make our problems worse.
In politics, always opt for freedom. Today, this country is starved for a greater faith in freedom and less dependency on government and management of our lives and our medical system.
Dr. Ron Paul is a Republican member of Congress from Texas.
