Category Archives: Pharmaceuticals

Big Pharma: Gouges, Casualties, and the Congressional Remedy!

The Congress can overturn the abuses of Big Pharma and its “pay or die,” subsidized business model for its drugs.

Big Pharma’s trail of greed, power, and cruelty gets worse every year. Its products and practices take hundreds of thousands of lives in the U.S. from over-prescriptions, lethal combinations of prescriptions, ineffective or contaminated drugs, and dangerous side-effects.

The biggest drug dealers in the U.S. operate legally. Their names are emblazoned in ads and promotions everywhere. Who hasn’t heard of Eli Lilly, Merck, Pfizer, and Novartis? Big Pharma revenues and profits have skyrocketed. In 2017, the U.S. consumers spent $333.4 billion on prescription drugs.

There are no price controls on drugs in the U.S. as there are in most countries in the world. Senator Bernie Sanders just took a bus tour to a Canadian pharmacy where insulin cost patients one tenth of what it costs them in the U.S. Yet, remarkably, drug companies, charted and operating in the U.S., charge Americans the highest prices in the world. This is despite the freebies our business-indentured government lavishes on Big Pharma. The FDA weakly regulates drugs, which are supposed to be both safe and effective, before they can be sold. Who funds this FDA effort? The drug industry itself— required by a law it has learned to love.

The Big Pharma lobby doesn’t always get what it craves. In the nineteen seventies, Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group, produced two paperbacks for a wide television audience (e.g. he appeared on the Phil Donahue Show). They were titled, Pills That Don’t Work and Over-the-Counter Pills that Don’t Work. Because of Dr. Wolfe’s tireless efforts, hundreds of different pills were removed from the market, saving consumers billions of dollars and sparing them the side-effects.

Big Pharma’s greatest strength is its hold over Congress. That is where it gets its huge bundle of subsidies and monopolistic privileges. During the first term of George W. Bush, the drug companies got the Republicans and some spineless Democrats to forbid Medicare from negotiating volume discounts with the drug companies, as the Pentagon and VA have done for years. Big Pharma had over 1,200 lobbyists swarming over Capitol Hill to get these handcuffs on Uncle Sam. Lobbyists combined with campaign cash donated by Pharma industry players sealed the deal.

Your Congressional representatives gave the drug giants much in return: Lucrative tax credits to pay Big Pharma to do what they should do anyway—engage in research and development. Drug companies are profitable recipients of taxpayer-funded government research on developing new drugs – and then given monopolies that enable them to impose sky-high prices, even when the purchaser is the very government that funded the invention of the new drugs in the first place.

The drug industry has also made sure there are no price controls on their drugs—whether gifted to them by NIH or developed by drug companies internally. The absence of price controls accounts for new “blockbuster drugs” going for $100,000, or higher, per patient per year. Many drug prices generally increase faster than inflation.

Greed is infinite for Big Pharma. In addition to tax credits, free drug R&D (compliments of the federal government), and no price restraints, the drug companies have moved much production to China and India. No antibiotics are manufactured in the U.S.—a clear national security risk to which the Pentagon and Trump should pay heed. Two new books, China Rx and Bottle of Poison, document the safety risks of poorly inspected labs in those countries exuding pills into your bodies without your minds being told of “country of origin” on the label.

The great hands-on humanitarian organization Doctors Without Borders, operating in 70 countries often under dangerous armed conflicts, lists “Six Things Big Pharma Doesn’t Want You to Know,” in its recent alert letter.

They are:

  1. Costs of developing new medicines are exaggerated tenfold or more.
  2. You’re paying twice for your medicines—first as taxpayers and second as consumers or through your government programs.
  3. Drug companies are not that good at innovation. About two thirds of new drugs (called “me-too drugs”) are no better, and may be riskier, than the ones already in pharmacies. But they are advertised as special.
  4. Monopoly patents are extended by clever lawyers to block more affordable generic versions. This maneuver is called “ever greening.”
  5. Pharma bullies low and middle income countries like South Africa, Thailand, Brazil, Colombia, and Malaysia that try to curb its rapaciousness. These drug companies use trade rules and the U.S. government towards their brutal goals.
    In the nineteen nineties, a small group of consumer advocates led by Jamie Love, Bill Haddad, and Robert Weissman persuaded Cipla, an Indian drug firm, and Ministries of Public Health to lower the price of AIDS medicines from $10,000 per patient per year price down to $300 (now under $100). The U.S. drug companies were quite willing to let millions die because they couldn’t pay.
  6. Big Pharma always says they have to have large profits to pay for R&D and innovation. Really? Why then do they spend far more on stock buybacks (one of the metrics for executive compensation), on marketing and advertising than on R&D? Dr. Wolfe exposed this malarkey years ago.

Yet exposure has not stopped the worsening behavior of Big Pharma. Good books by Katharine Greider (The Big Fix) and Dr. Marcia Angell (The Truth About the Drug Companies) are devastating critiques of Big Pharma’s practices. Despite this, the books reach small audiences and are brushed off by the drug giants. Big Pharma is able to ignore these books because it controls most of Congress—candidates rely heavily on the industry for campaign budgets.

But the American people outnumber the drug companies and only the people can actually vote come election time.  Focused voters mean more to politicians than campaign money. The August recess for Congress means your lawmakers are back home having personal meetings. Visit them and make known your demands against the “pay or die” industry. Tell them your own stories.

Or better yet, make them come to your town meetings. Remember: “It’s your Congress, people!”

One galvanizing move by an enlightened billionaire could establish a 20 person advocacy group on drug pricing, focusing on Congress and mobilizing citizens back home. Its effect would be decisive for taming the drug industry’s gouging. Any takers: if so contact Public Citizen at gro.neziticnull@sseccasdem.

  • Image at top from tarbell.org.
  • The Doctor-Patient Relationship Can be Found in the Graveyard of Informed Consent

    My master that was thrall to Love
    Is become thrall to Death.

    — “A Ballad of Death,” by Algernon Charles Swinburne, Poems and Ballads, First Series, 1866

    The 21st century is only in its infancy, and the United States has revealed itself to be a truly remarkable country. We have imaginary jobs, an imaginary middle class, imaginary checks and balances, and an imaginary society. We even have imaginary bioethics. At the root of this new and exciting phenomenon is the dismantling of informed consent and the disintegration of the doctor-patient relationship that has followed in its wake.

    The privatization of health care has contributed to the weakening of the physician-patient bond, as health care has largely been taken over by the gangster capitalists of the pharmaceutical industry, the health insurance companies, device manufacturers, and hospital administrators. In a KevinMD article titled “The Self-Inflicted Death of the Physician,” an anonymous doctor writes, “For certainly we, as a profession, have handed over our authority to others, not all at once, but slowly, inexorably, over decades. We are just a shadow of our former selves.” Mirroring these sentiments, Linda Girgis, MD, writes in Physician’s Weekly, “The doctor is no longer center stage, unless you are watching a puppet show.”

    In what will inevitably foment more unscrupulous behavior, MD/MBA programs are teaching doctors to think like businessmen, an irreconcilable contradiction. Hospital administrators are pressuring doctors to see increasing numbers of patients each day, while the health insurance companies continue to play a major role in stripping doctors of their autonomy by regularly countermanding doctor’s orders. This corporate coup d’état, rooted in avarice, callousness, and sociopathy has caused many clinicians to become unmoored from their traditional moral compass.

    Physicians are now compelled to use electronic medical records (EMRs), which force them to waste countless hours doing mind-numbing data entry. If an attending physician decides to employ a medical scribe, nurse, or medical student to assume responsibility for this onerous task, it means that a third party will be in the examination room during patients’ office visits, which if done without the patient’s permission, constitutes an egregious violation of informed consent. It is also common for businesses to change the health insurance plans of their employees each year, which invariably results in many patients having to leave doctors that they have established long-standing relationships with, and who may be critically important to their physical and emotional well-being.

    In addition to seeking assistance with EMRs, many physicians opt to bring interlopers into patients’ office visits, either because they prioritize teaching trainees to establishing a sound physician-patient rapport, or because they have figured out that it is much harder to be sued if there is a chaperone present in the examination room. Unsurprisingly, the medical institutions that spend the most money on glossy advertisements boasting of their boundless magnanimity and benevolence are frequently the institutions that are the most eager to bully patients into accepting a culture anchored in authoritarianism and absolute contempt for the rights of the patient.

    In a KevinMD article titled “Electronic Health Records Cannot Replace a Doctor Who Knows You,” the authors write: “Ensuring the best medical care is not primarily a technical challenge. It is a human challenge, which requires patients and doctors to be able to form deep and long-standing relationships.” And yet American teaching hospitals are churning out delusional and hubristic creatures who have not been inculcated with a respect for patient privacy and informed consent, and who are incognizant of the fact that once these principles have been jettisoned the majority of their patients will neither trust, nor respect, nor confide in them. The deterioration of this vitally important relationship has resulted in a situation where it is increasingly common for patients to fail to disclose pertinent medical information. The deplorable state of the humanities and the rise of subspecialization have undoubtedly  contributed to this scourge of blindness in American health care.

    Commenting on the dangers posed by medical scribes, Ami Schattner, MD, of the Hadassah Medical Center in Jerusalem, said in an interview with The Medical Bag:

    I have serious concerns about the impact of scribes on the tender dynamic and intimacy of the physician-patient encounter. Perhaps the word ‘sanctity’ is not too strong when talking about the physician-patient relationship.

    In an article titled “Shining a Light on Shadowing,” by Elizabeth A. Kitsis, MD, the author warns of the ethical ramifications of imposing pre-med students on patients during their doctor visits:

    Physician shadowing by college students…may involve subtle coercion of the patient. To maintain his or her rapport with the physician, a patient may feel compelled to allow students into the examination room if his or her physician makes the request. However, the patient may resent the intrusion, and feel uncomfortable during the interaction.

    Indeed, Kitsis’ words are also applicable with regard to nurses, medical students, residents, and fellows observing office visits. In an article in Medscape titled “What is Medical Ethics, and Why is it Important?” the authors write: “Ethical decisions cannot be avoided. Whenever doctors make a clinical decision, they are almost always making an ethical decision, consciously or not.” It is not even unusual for attending physicians to inform patients of ominous test results with their entourage in tow. While this may be very exciting for medical students it can be perceived as callous, degrading, and inhuman from the standpoint of the patient.

    In “Stop the Anti-Doctor Media Bias,” by Rebekah Bernard, MD, the author writes that “Most physicians are dedicated individuals who hold patient care as sacrosanct.” I saw more doctors from 2016 to 2018 than a person would typically work with if they lived to a hundred, and have yet to see a single doctor’s office present me with a choice regarding the presence of observers during my office visits. In what could form the basis of a Kafka story, I had to voice my objections to the same institution and the same departments over and over again ad infinitum. Is this indicative of holding patient care as sacrosanct?

    Jeremy Brown, MD, has proposed that doctors be equipped with body cameras, and Myles Riner, MD, supports the recording of physician-patient encounters, arguing in “Should Physicians Record and Share Conversations with Patients?” that “One thing is certain, this approach is certainly indicative of patient-centered care, and I think many patients would greatly appreciate the effort.” Not to be outdone, The New York Times has waxed glowingly on the subject of group doctor visits. Virtual office visits and doctor visits at work also pose a serious threat to confidentiality. So little value is placed on patient privacy that hospitals have even allowed television crews into emergency rooms, resulting in one New York widow turning on the television one evening, only to watch her husband die before her very eyes. Even if medical students attend a few decent lectures on bioethics, this is frequently negated by what they see their attending doing on a daily basis.

    When the time comes for doctors to be patients, they often take for granted having the finest insurance plans which permit them to see any doctor without restrictions. This is in contrast with the majority of patients, who are increasingly restricted to narrow networks.

    In a KevinMD article titled “Please, be kind to your doctor. We need it.,” Sara R Ahronheim, MD, writes: “But when I go home, I am alone; no one knows your stories, no one sees the tears you cried when I told you the awful things I had to tell you.” No one, that is, except the nurse, medical student, and resident who also happened to be hanging out in the room at the time.

    What will become of the younger generation, being mentored as they so often are, in an environment where degradation is professionalism, indifference is empathy, and the most sordid behavior is hailed as “patient-centered care.” Indeed, this practice embodies everything base, ignoble, and treacherous in contemporary American health care. So relentlessly are patients besieged by these indignities, that there are times when I cannot help but wonder if these are really accidents and misunderstandings or the result of knavery and villainy. Teaching hospitals have a sacred duty to inculcate their trainees with a comprehensive understanding of, and respect for, medical ethics. All too often they are derelict in this duty. That so many attendings and their charges are indifferent to the physical, psychological, and emotional vulnerability of their patients underscores the fact that doctors and patients often speak in completely different languages.

    This imposition of interlopers during physician office visits — a depraved reality show euphemistically called “team-based care” — constitutes a violation of every foundational tenet of medical ethics: informed consent, confidentiality, patient privacy, patient dignity, patient trust, and the oath to do no harm. Moreover, once trainees have learned to disregard informed consent with regard to nonconsensual physician shadowing, it is highly probable that they will do so again when the opportunity presents itself.

    For instance, it is common for medical students and residents to be instructed to do practice pelvic exams on anesthetized patients, and the practice is legal in 45 states. A 2007 study done in Canada — a country with a comprehensive single-payer system — revealed that over 70 percent of medical students had done practice pelvic exams on anesthetized patients, and women have reported pain and bruising from these unauthorized exams.

    Teaching hospitals frequently regard their patients, especially those who lack the best commercial plans, as their property. In an online forum on The Student Doctor Network where the ethics of having trainees perform practice pelvic exams on anesthetized patients is debated, AmoryBlaine writes:

    It’s surprising how worked up some people get over the issue. You will be naked on a brightly lit table for all to see. A medical student will put a tube into your bladder. We’re about to flay your belly open and remove your uterus and ovaries. But to do a pelvic exam! What a violation! If you get into this habit of being deathly afraid of the patient’s feelings about an internal exam you will never learn how.

    Glorytaker writes:

    When I was doing OB/GYN as a med student, the attending would have me do a pelvic right after the patient was under and before we started surgery. Of course, we were doing GYN-related surgery and he wanted me to note the difference before and after a cystocele or rectocele repair. We didn’t exactly get permission but it was for teaching purposes.

    Any rational layperson would be able to tell you that this is unethical, and yet many medical students and residents would disagree. What does that say about our education system? Perhaps it is this sort of degenerate thinking that led The Stanford Encyclopedia of Philosophy to nonchalantly point out that “The turn of the 21st century has seen doubts surfacing about informed consent.” The fighter pilot that bombs wedding parties in Afghanistan and the impressionable trainee who is taught that it is acceptable to do practice pelvic exams on anesthetized patients have much in common. For they have both been inculcated with a profound sense of blind obedience.

    It is common for doctors to do nonconsensual episiotomies and pelvic exams on women in labor, and women are frequently coerced into having pelvic exams in exchange for birth control prescriptions. This is an example of how, with a medical degree and some mental gymnastics, blackmail and rape can be transformed into cod liver oil and brussel sprouts. Writing about the lack of informed consent with regard to Pap smears and testing for cervical cancer, Joel Sherman, MD, has pointed out that cervical cancer is very rare in the United States. In Finland women are given the option of being tested for cervical cancer once every five years. And in an article that appeared in The Milbank Quarterly titled “Cervical Cancer Screening in the United States and the Netherlands: A Tale of Two Countries,” the authors write, “Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries’ mortality trends were quite similar.” Perhaps this egregious lack of ethics in obstetrics and gynecology should come as no surprise, considering the fact that James Marion Sims, who invented the speculum and who is widely regarded as the founder of modern gynecology, performed experiments on black slave girls.

    Will a 25-year-old woman continue to trust her oncologist should she go into permanent early menopause following chemotherapy, and her oncologist failed to disclose this as a common side effect associated with her chemotherapy regimen? What is the likelihood that a cancer patient will continue to trust their doctors should they experience long-term chemotherapy-induced cognitive dysfunction, they are unable to continue with their career, and this too was not disclosed? Indeed, failure to disclose common long-term chemotherapy side effects is standard practice in many American cancer centers. It is also common for school districts to force high school students to undergo genital exams as a requirement to play sports, despite the fact that the scientific rationale behind the practice remains murky at best. And there are medical institutions, such as Memorial Sloan Kettering Cancer Center in New York City, that do not allow patients to change from one doctor to another within any given department, which can leave a patient torn between seeking care at an inferior facility or being the slave of an overbearing scoundrel.

    Informed consent is absent in routine mammography screening, as no evidence exists that mammograms provide any benefit, whereas evidence exists that they have caused considerable harm. Obstetrics and gynecology aside, in no other specialty is there greater contempt for informed consent than in psychiatry, where dangerous side effects from psychiatric drugs are regularly withheld from patients and these drugs are even being prescribed for children. Psychiatrist Lawrence Kelmenson writes in “The Three Types of Psychiatric Drugs – A Doctor’s Guide for Consumers:”

    Psychiatrists are seen as hard-working, caring, understanding healers, but they’re really snake-oil salesmen, drug-dealers, and master-sedaters. What they do should be illegal. Someday everyone will realize that not only do psychiatrists not heal anything, they’re a major contributor to the recent rise in suicides and overdoses.

    Dr. Peter Breggin has echoed these sentiments, and actually specializes in getting people off these drugs.

    It is common for patients who are perceived as “anti-authoritarians” to be diagnosed as “mentally ill,” and a number of school shooters were found to be taking powerful psychiatric drugs at the time they unleashed a fusillade of bullets on their classmates and teachers. Informed consent is frequently absent in the treatment of prostate cancer, and tens of thousands of American men have their prostates removed unnecessarily each year, only to fully understand the dire consequences after the damage is irreversible. (Consider the words of Atul Gawande, MD, in “Overkill:” “The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less.”) These are all examples of how informed consent is routinely disregarded in an unconscionable manner. The Tuskegee Alabama syphilis experiments, as well as medical experiments conducted on the downtrodden of IndiaAmerican prisoners, and on prisoners in Guantanamo are emblematic of the barbarities that can be unleashed when the celestial temple of informed consent lies in ruins.

    After undergoing a surgical procedure in the summer of 2016, I was given a prescription for oxycodone, a semisynthetic opioid. Never was the highly addictive nature of this drug disclosed to me. Thankfully, Dr. Google informed me that oxycodone posed a “high risk for addiction and dependence.” Perhaps this might explain why, according to the CDC, “On average, 130 Americans die every day from an opioid overdose.” Many medical blogs delight in reminding us of the fact that the doctor-patient relationship is foundational to sound health care, and yet narcissism, moral bankruptcy, and careerism are endemic to our health care system. The erosion of trust that has followed this satanic cult of medical coercion has led to a situation where it has become harder for physicians to get patients to follow through with their treatment protocols.

    The hazing and bullying commonly experienced by many trainees can cause medical students and residents to become jaded, and to lose their sense of empathy. Residents are often so exploited that many suffer from depression and are chronically sleep-deprived, and the brutal military-style training they are forced to endure can lead to many trainees forgetting that “gall bladder in Room 213” is a human being with a name. It is incontrovertible that corporations have undermined the doctor-patient relationship and inflicted catastrophic damage to our health care system. And while doctors must support the fight for single-payer, they must also acknowledge the fact that the cavalier attitude towards informed consent on the part of many American physicians has played a critical role in the dissolution of the public’s trust. Inexperienced patients naively assume that every doctor will have their best interests at heart. All too often, this is sadly not the case. Moreover, once this trust has been violated, it can result in grievous and long-lasting emotional harm. A clinician that is indifferent to the doctor-patient relationship, and who is only interested in scans, pathology reports, and blood tests has been infected with the virus of technocracy and fallen into a morass of charlatanism.

    In the Charmides Plato wrote that “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” Medical students and residents may learn how to diagnose and treat different diseases, yet are seldom inculcated with an understanding of medical ethics and why it is so indispensable. In “Bringing Hospitality Back to the Hospital: Lessons From a Bartender,” by Cory Michael, MD, the author writes: “People remember how you make them feel. They don’t care how much you know unless they know how much you care.” Medical terrorism and corporatization are the Goneril and Regan of medical sacrilege. Perpetually locked in a deadly embrace, they fuel one another’s nefarious designs. The tragedy is that so many medical students and residents are being seduced, not by the voice of truth, but by the voice of damnation. Let us recall the chilling words of Iago: “When devils will the blackest sins put on / They do suggest at first with heavenly shows / As I do now.” (Othello II.iii.)

    Informed consent is a river that separates the consecrated light of morality from the profane and blasphemous abyss of amorality. Once this Rubicon has been crossed, there is no turning back. Those who have strayed from their sacred oath will find absolution not in the ways of the wicked, but in a return to the path of compassion, integrity, and righteousness. Indeed, dignity for the patient and dignity for the physician are mutually interdependent.

    The doctor-patient relationship now lies buried in the unhallowed primeval ground; a cemetery where broken tombstones litter the earth with thorns and broken bottles, the land is barren and no flowers grow, and a once-proud beating heart beats no more. Only with a return to this inviolable bedrock of medical ethics can we embrace its resurrection.

    The Doctor-Patient Relationship Can be Found in the Graveyard of Informed Consent

    My master that was thrall to Love
    Is become thrall to Death.

    — “A Ballad of Death,” by Algernon Charles Swinburne, Poems and Ballads, First Series, 1866

    The 21st century is only in its infancy, and the United States has revealed itself to be a truly remarkable country. We have imaginary jobs, an imaginary middle class, imaginary checks and balances, and an imaginary society. We even have imaginary bioethics. At the root of this new and exciting phenomenon is the dismantling of informed consent and the disintegration of the doctor-patient relationship that has followed in its wake.

    The privatization of health care has contributed to the weakening of the physician-patient bond, as health care has largely been taken over by the gangster capitalists of the pharmaceutical industry, the health insurance companies, device manufacturers, and hospital administrators. In a KevinMD article titled “The Self-Inflicted Death of the Physician,” an anonymous doctor writes, “For certainly we, as a profession, have handed over our authority to others, not all at once, but slowly, inexorably, over decades. We are just a shadow of our former selves.” Mirroring these sentiments, Linda Girgis, MD, writes in Physician’s Weekly, “The doctor is no longer center stage, unless you are watching a puppet show.”

    In what will inevitably foment more unscrupulous behavior, MD/MBA programs are teaching doctors to think like businessmen, an irreconcilable contradiction. Hospital administrators are pressuring doctors to see increasing numbers of patients each day, while the health insurance companies continue to play a major role in stripping doctors of their autonomy by regularly countermanding doctor’s orders. This corporate coup d’état, rooted in avarice, callousness, and sociopathy has caused many clinicians to become unmoored from their traditional moral compass.

    Physicians are now compelled to use electronic medical records (EMRs), which force them to waste countless hours doing mind-numbing data entry. If an attending physician decides to employ a medical scribe, nurse, or medical student to assume responsibility for this onerous task, it means that a third party will be in the examination room during patients’ office visits, which if done without the patient’s permission, constitutes an egregious violation of informed consent. It is also common for businesses to change the health insurance plans of their employees each year, which invariably results in many patients having to leave doctors that they have established long-standing relationships with, and who may be critically important to their physical and emotional well-being.

    In addition to seeking assistance with EMRs, many physicians opt to bring interlopers into patients’ office visits, either because they prioritize teaching trainees to establishing a sound physician-patient rapport, or because they have figured out that it is much harder to be sued if there is a chaperone present in the examination room. Unsurprisingly, the medical institutions that spend the most money on glossy advertisements boasting of their boundless magnanimity and benevolence are frequently the institutions that are the most eager to bully patients into accepting a culture anchored in authoritarianism and absolute contempt for the rights of the patient.

    In a KevinMD article titled “Electronic Health Records Cannot Replace a Doctor Who Knows You,” the authors write: “Ensuring the best medical care is not primarily a technical challenge. It is a human challenge, which requires patients and doctors to be able to form deep and long-standing relationships.” And yet American teaching hospitals are churning out delusional and hubristic creatures who have not been inculcated with a respect for patient privacy and informed consent, and who are incognizant of the fact that once these principles have been jettisoned the majority of their patients will neither trust, nor respect, nor confide in them. The deterioration of this vitally important relationship has resulted in a situation where it is increasingly common for patients to fail to disclose pertinent medical information. The deplorable state of the humanities and the rise of subspecialization have undoubtedly  contributed to this scourge of blindness in American health care.

    Commenting on the dangers posed by medical scribes, Ami Schattner, MD, of the Hadassah Medical Center in Jerusalem, said in an interview with The Medical Bag:

    I have serious concerns about the impact of scribes on the tender dynamic and intimacy of the physician-patient encounter. Perhaps the word ‘sanctity’ is not too strong when talking about the physician-patient relationship.

    In an article titled “Shining a Light on Shadowing,” by Elizabeth A. Kitsis, MD, the author warns of the ethical ramifications of imposing pre-med students on patients during their doctor visits:

    Physician shadowing by college students…may involve subtle coercion of the patient. To maintain his or her rapport with the physician, a patient may feel compelled to allow students into the examination room if his or her physician makes the request. However, the patient may resent the intrusion, and feel uncomfortable during the interaction.

    Indeed, Kitsis’ words are also applicable with regard to nurses, medical students, residents, and fellows observing office visits. In an article in Medscape titled “What is Medical Ethics, and Why is it Important?” the authors write: “Ethical decisions cannot be avoided. Whenever doctors make a clinical decision, they are almost always making an ethical decision, consciously or not.” It is not even unusual for attending physicians to inform patients of ominous test results with their entourage in tow. While this may be very exciting for medical students it can be perceived as callous, degrading, and inhuman from the standpoint of the patient.

    In “Stop the Anti-Doctor Media Bias,” by Rebekah Bernard, MD, the author writes that “Most physicians are dedicated individuals who hold patient care as sacrosanct.” I saw more doctors from 2016 to 2018 than a person would typically work with if they lived to a hundred, and have yet to see a single doctor’s office present me with a choice regarding the presence of observers during my office visits. In what could form the basis of a Kafka story, I had to voice my objections to the same institution and the same departments over and over again ad infinitum. Is this indicative of holding patient care as sacrosanct?

    Jeremy Brown, MD, has proposed that doctors be equipped with body cameras, and Myles Riner, MD, supports the recording of physician-patient encounters, arguing in “Should Physicians Record and Share Conversations with Patients?” that “One thing is certain, this approach is certainly indicative of patient-centered care, and I think many patients would greatly appreciate the effort.” Not to be outdone, The New York Times has waxed glowingly on the subject of group doctor visits. Virtual office visits and doctor visits at work also pose a serious threat to confidentiality. So little value is placed on patient privacy that hospitals have even allowed television crews into emergency rooms, resulting in one New York widow turning on the television one evening, only to watch her husband die before her very eyes. Even if medical students attend a few decent lectures on bioethics, this is frequently negated by what they see their attending doing on a daily basis.

    When the time comes for doctors to be patients, they often take for granted having the finest insurance plans which permit them to see any doctor without restrictions. This is in contrast with the majority of patients, who are increasingly restricted to narrow networks.

    In a KevinMD article titled “Please, be kind to your doctor. We need it.,” Sara R Ahronheim, MD, writes: “But when I go home, I am alone; no one knows your stories, no one sees the tears you cried when I told you the awful things I had to tell you.” No one, that is, except the nurse, medical student, and resident who also happened to be hanging out in the room at the time.

    What will become of the younger generation, being mentored as they so often are, in an environment where degradation is professionalism, indifference is empathy, and the most sordid behavior is hailed as “patient-centered care.” Indeed, this practice embodies everything base, ignoble, and treacherous in contemporary American health care. So relentlessly are patients besieged by these indignities, that there are times when I cannot help but wonder if these are really accidents and misunderstandings or the result of knavery and villainy. Teaching hospitals have a sacred duty to inculcate their trainees with a comprehensive understanding of, and respect for, medical ethics. All too often they are derelict in this duty. That so many attendings and their charges are indifferent to the physical, psychological, and emotional vulnerability of their patients underscores the fact that doctors and patients often speak in completely different languages.

    This imposition of interlopers during physician office visits — a depraved reality show euphemistically called “team-based care” — constitutes a violation of every foundational tenet of medical ethics: informed consent, confidentiality, patient privacy, patient dignity, patient trust, and the oath to do no harm. Moreover, once trainees have learned to disregard informed consent with regard to nonconsensual physician shadowing, it is highly probable that they will do so again when the opportunity presents itself.

    For instance, it is common for medical students and residents to be instructed to do practice pelvic exams on anesthetized patients, and the practice is legal in 45 states. A 2007 study done in Canada — a country with a comprehensive single-payer system — revealed that over 70 percent of medical students had done practice pelvic exams on anesthetized patients, and women have reported pain and bruising from these unauthorized exams.

    Teaching hospitals frequently regard their patients, especially those who lack the best commercial plans, as their property. In an online forum on The Student Doctor Network where the ethics of having trainees perform practice pelvic exams on anesthetized patients is debated, AmoryBlaine writes:

    It’s surprising how worked up some people get over the issue. You will be naked on a brightly lit table for all to see. A medical student will put a tube into your bladder. We’re about to flay your belly open and remove your uterus and ovaries. But to do a pelvic exam! What a violation! If you get into this habit of being deathly afraid of the patient’s feelings about an internal exam you will never learn how.

    Glorytaker writes:

    When I was doing OB/GYN as a med student, the attending would have me do a pelvic right after the patient was under and before we started surgery. Of course, we were doing GYN-related surgery and he wanted me to note the difference before and after a cystocele or rectocele repair. We didn’t exactly get permission but it was for teaching purposes.

    Any rational layperson would be able to tell you that this is unethical, and yet many medical students and residents would disagree. What does that say about our education system? Perhaps it is this sort of degenerate thinking that led The Stanford Encyclopedia of Philosophy to nonchalantly point out that “The turn of the 21st century has seen doubts surfacing about informed consent.” The fighter pilot that bombs wedding parties in Afghanistan and the impressionable trainee who is taught that it is acceptable to do practice pelvic exams on anesthetized patients have much in common. For they have both been inculcated with a profound sense of blind obedience.

    It is common for doctors to do nonconsensual episiotomies and pelvic exams on women in labor, and women are frequently coerced into having pelvic exams in exchange for birth control prescriptions. This is an example of how, with a medical degree and some mental gymnastics, blackmail and rape can be transformed into cod liver oil and brussel sprouts. Writing about the lack of informed consent with regard to Pap smears and testing for cervical cancer, Joel Sherman, MD, has pointed out that cervical cancer is very rare in the United States. In Finland women are given the option of being tested for cervical cancer once every five years. And in an article that appeared in The Milbank Quarterly titled “Cervical Cancer Screening in the United States and the Netherlands: A Tale of Two Countries,” the authors write, “Even though three to four times more Pap smears per woman were conducted in the United States than in the Netherlands over a period of three decades, the two countries’ mortality trends were quite similar.” Perhaps this egregious lack of ethics in obstetrics and gynecology should come as no surprise, considering the fact that James Marion Sims, who invented the speculum and who is widely regarded as the founder of modern gynecology, performed experiments on black slave girls.

    Will a 25-year-old woman continue to trust her oncologist should she go into permanent early menopause following chemotherapy, and her oncologist failed to disclose this as a common side effect associated with her chemotherapy regimen? What is the likelihood that a cancer patient will continue to trust their doctors should they experience long-term chemotherapy-induced cognitive dysfunction, they are unable to continue with their career, and this too was not disclosed? Indeed, failure to disclose common long-term chemotherapy side effects is standard practice in many American cancer centers. It is also common for school districts to force high school students to undergo genital exams as a requirement to play sports, despite the fact that the scientific rationale behind the practice remains murky at best. And there are medical institutions, such as Memorial Sloan Kettering Cancer Center in New York City, that do not allow patients to change from one doctor to another within any given department, which can leave a patient torn between seeking care at an inferior facility or being the slave of an overbearing scoundrel.

    Informed consent is absent in routine mammography screening, as no evidence exists that mammograms provide any benefit, whereas evidence exists that they have caused considerable harm. Obstetrics and gynecology aside, in no other specialty is there greater contempt for informed consent than in psychiatry, where dangerous side effects from psychiatric drugs are regularly withheld from patients and these drugs are even being prescribed for children. Psychiatrist Lawrence Kelmenson writes in “The Three Types of Psychiatric Drugs – A Doctor’s Guide for Consumers:”

    Psychiatrists are seen as hard-working, caring, understanding healers, but they’re really snake-oil salesmen, drug-dealers, and master-sedaters. What they do should be illegal. Someday everyone will realize that not only do psychiatrists not heal anything, they’re a major contributor to the recent rise in suicides and overdoses.

    Dr. Peter Breggin has echoed these sentiments, and actually specializes in getting people off these drugs.

    It is common for patients who are perceived as “anti-authoritarians” to be diagnosed as “mentally ill,” and a number of school shooters were found to be taking powerful psychiatric drugs at the time they unleashed a fusillade of bullets on their classmates and teachers. Informed consent is frequently absent in the treatment of prostate cancer, and tens of thousands of American men have their prostates removed unnecessarily each year, only to fully understand the dire consequences after the damage is irreversible. (Consider the words of Atul Gawande, MD, in “Overkill:” “The forces that have led to a global epidemic of overtesting, overdiagnosis, and overtreatment are easy to grasp. Doctors get paid for doing more, not less.”) These are all examples of how informed consent is routinely disregarded in an unconscionable manner. The Tuskegee Alabama syphilis experiments, as well as medical experiments conducted on the downtrodden of IndiaAmerican prisoners, and on prisoners in Guantanamo are emblematic of the barbarities that can be unleashed when the celestial temple of informed consent lies in ruins.

    After undergoing a surgical procedure in the summer of 2016, I was given a prescription for oxycodone, a semisynthetic opioid. Never was the highly addictive nature of this drug disclosed to me. Thankfully, Dr. Google informed me that oxycodone posed a “high risk for addiction and dependence.” Perhaps this might explain why, according to the CDC, “On average, 130 Americans die every day from an opioid overdose.” Many medical blogs delight in reminding us of the fact that the doctor-patient relationship is foundational to sound health care, and yet narcissism, moral bankruptcy, and careerism are endemic to our health care system. The erosion of trust that has followed this satanic cult of medical coercion has led to a situation where it has become harder for physicians to get patients to follow through with their treatment protocols.

    The hazing and bullying commonly experienced by many trainees can cause medical students and residents to become jaded, and to lose their sense of empathy. Residents are often so exploited that many suffer from depression and are chronically sleep-deprived, and the brutal military-style training they are forced to endure can lead to many trainees forgetting that “gall bladder in Room 213” is a human being with a name. It is incontrovertible that corporations have undermined the doctor-patient relationship and inflicted catastrophic damage to our health care system. And while doctors must support the fight for single-payer, they must also acknowledge the fact that the cavalier attitude towards informed consent on the part of many American physicians has played a critical role in the dissolution of the public’s trust. Inexperienced patients naively assume that every doctor will have their best interests at heart. All too often, this is sadly not the case. Moreover, once this trust has been violated, it can result in grievous and long-lasting emotional harm. A clinician that is indifferent to the doctor-patient relationship, and who is only interested in scans, pathology reports, and blood tests has been infected with the virus of technocracy and fallen into a morass of charlatanism.

    In the Charmides Plato wrote that “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” Medical students and residents may learn how to diagnose and treat different diseases, yet are seldom inculcated with an understanding of medical ethics and why it is so indispensable. In “Bringing Hospitality Back to the Hospital: Lessons From a Bartender,” by Cory Michael, MD, the author writes: “People remember how you make them feel. They don’t care how much you know unless they know how much you care.” Medical terrorism and corporatization are the Goneril and Regan of medical sacrilege. Perpetually locked in a deadly embrace, they fuel one another’s nefarious designs. The tragedy is that so many medical students and residents are being seduced, not by the voice of truth, but by the voice of damnation. Let us recall the chilling words of Iago: “When devils will the blackest sins put on / They do suggest at first with heavenly shows / As I do now.” (Othello II.iii.)

    Informed consent is a river that separates the consecrated light of morality from the profane and blasphemous abyss of amorality. Once this Rubicon has been crossed, there is no turning back. Those who have strayed from their sacred oath will find absolution not in the ways of the wicked, but in a return to the path of compassion, integrity, and righteousness. Indeed, dignity for the patient and dignity for the physician are mutually interdependent.

    The doctor-patient relationship now lies buried in the unhallowed primeval ground; a cemetery where broken tombstones litter the earth with thorns and broken bottles, the land is barren and no flowers grow, and a once-proud beating heart beats no more. Only with a return to this inviolable bedrock of medical ethics can we embrace its resurrection.

    The Contented Classes: When Will They Rebel?

    For all the rhetoric and all the charities regarding America’s children, the U.S. stands at the very bottom of western nations and some other countries as well, in terms of youth well-being. The U.S.’s exceptionalism is clearest in its cruelty to children. The U.S. has the highest infant mortality rate of comparable OECD countries. Not only that, but 2.5 million American children are homeless and 16.2 million children “lack the means to get enough nutritious food on a regular basis.”

    The shamelessness continues as the youngsters increase in age. The Trump regime is cutting the SNAP food program for poor kids. In 2018, fewer children were enrolled in Medicaid and CHIP than in 2017. To see just how bad Trump’s war on poor American children is getting, go to the web sites of the Children’s Defense Fund and the Children’s Advocacy Center.

    Trump brags about a robust economy—still, however, rooted in exploitation of the poor and reckless Wall Street speculation with people’s savings.

    Trump’s pompous promises during his presidential campaign have proved to be a cowardly distraction. He claimed he would take on the drug companies and their price gouging. The hyper-profiteering pharmaceutical goliaths are quietly laughing at him. Worse, Trump continues their tax credits  and allows them to use new drugs developed with taxpayer money through the National Institute of Health free of charge—no royalties. Even though he talks tough, Trump lets these companies sell imported medicines manufactured in China and India with inadequate FDA inspections of foreign plants.

    Torrents of Trump tweets somehow overlooked H.P. Acthar Gel, a drug produced by Mallinckrodt to treat a rare infant seizure disorder, which increased in price from $40 per vial to $39,000 per vial! Other drug prices are booming cruelly upward, while Trump blusters, but fails to deliver on his campaign promises.

    For years our country’s political and corporate rulers have saddled college students with breathtaking debt and interest rates. Student debt is now at $1.5 trillion. Both corporations and the federal government are profiting off of America’s young. In no other western country is this allowed, with most nations offering tuition-free higher education.

    On May 2, 2019, The New York Times featured an article titled, “Tuition or Dinner? Nearly Half of College Students Surveyed in a New Report Are Going Hungry.”

    When you read the stories of impoverished students, squeezed in all directions, you’d think they came out of third-world favelas. At the City University of New York (CUNY), forty eight percent of students had been food insecure in the past 30 days.

    Kassandra Montes, a senior at Lehman College, lives in a Harlem homeless shelter. Montes  “works two part-time jobs and budgets only $15 per week for food… [She] usually skips breakfast in order to make sure that her 4-year-old son is eating regularly.” Montes said: “I feel like I’m slowly sinking as I’m trying to grow.”

    When you don’t have a living wage, have to pay high tuition, are mired in debt, and live in rent-gouging cities, where do you go? Increasingly, you go to the community college or college food pantry. In a nation whose president and Congress in one year give tens of billions of dollars to the Pentagon more than the generals asked for, it is unconscionable that students must rely on leftover food from dining halls and catered events, SNAP benefits, and whatever food pantries can assemble.

    The CUNY pantries are such a fixture in these desperate times that they are now a stop on freshman orientation tours.

    As long as we’re speaking of shame, what about those millions of middle and upper middle class informed, concerned bystanders. They’re all over America trading “tsk tsks” over coffee or other social encounters. They express dismay, disgust, and denunciations at each outrage from giant corporations’ abuses, to the White House and the Congress’ failings. They are particularly numerous in University towns. They know but they do not do. They are unorganized, know it, keep grumbling, and still fail to start the mobilization in Congressional Districts of likeminded citizens to hold their Senators and Representatives accountable.

    For Congress, the smallest yet most powerful branch of government, whose members names we know, can turn poverty and other injustices around and help provide a better life for so many Americans. These informed, concerned people easily number over 1 percent of the population. They can galvanize a supporting majority of voters on key, long-overdue redirections for justice. Redirections that were mostly established in Western Europe decades ago (For more details, see my paperback, Breaking Through Power: It’s Easier than We Think).

    These informed, concerned people—who don’t have to worry about a living wage, not having health insurance, being gouged by payday loans, and having no savings—were called “the contented classes” in The Culture of Contentment, a book by the late progressive Harvard economist John Kenneth Gailbraith. His main point—until the contented classes wake up and organize for change, history has shown, our country will continue to slide in the wrong direction. He said all this before climate disruption, massive money-corrupting politics, and the corporate crime wave had reached anywhere near their present destructive levels.

    The question to be asked: Who among the contented classes will unfurl the flag of rebellion against the plutocrats and the autocrats? It can be launched almost anywhere they please. A revolution can start the moment they decide to prioritize the most marginalized people in this country over their comfort.

    Mystery Killer Spans the Globe

    Public health experts have been warning for decades that overuse of antibiotics reduces the effectiveness of drugs that cure bacterial infections. At least 2,000,000 Americans get antibiotic-resistant infections per year.

    Notably, gluttonous overuse of antimicrobial drugs to combat bacteria and fungi via hospitals, clinics, and farms is backfiring and producing superbugs or “Nightmare Bacteria,” which is especially lethal for people with compromised immune systems and autoimmune disorders that use steroids to suppress bodily defenses.

    Federal Centers for Disease Control and Prevention (“CDC”) recently labeled a fungus called Candida auris or C auris an “Urgent Threat.” This Nightmare Bacteria is a brutal killer that’s unstoppable and flat-out travels fast.

    The CDC claims antibiotic resistance is “one of the biggest public health challenges of our time.”

    According to the World Health Organization: “The world is facing an antibiotic apocalypse.”

    The UK’s chief medical officer believes antimicrobial resistance: “May spell the end of modern medicine,” as routine surgeries turn into medical emergencies.

    In short, new antibiotic resistance mechanisms are emerging and spreading worldwide, quickly. Knowledgeable sources worry that society at large is headed for a “Post-Antibiotic Era,” in which common infections and minor injuries can kill once again.1

    According to a recent British governmental study, without new medicines and without curbing unnecessary use of antimicrobial drugs, infections followed by ensuing deaths will likely eclipse cancer deaths over succeeding decades. The harsh fact is nearly one-half of patients that contract C auris die within 90 days.2

    Nowadays, the dangers of “Nightmare Bacteria” are growing out of control. The latest concern is that C auris will begin spreading to healthier populations, even though healthy people are normally not at risk. Within only five years, C auris has established itself as one of the world’s most intractable health threats. It is drug-resistant, tenacious and nearly impossible to exterminate and travels the globe looking for innocent victims, killing people mostly in hospital settings.

    C auris has already established a beachhead in Venezuela, Spain, the UK, India, Pakistan, South Africa, New York, New Jersey, and Illinois. Nobody knows where else it may be cloaking.

    A British hospital aerosolized hydrogen peroxide in a C auris-infected room for one week solid. Subsequently, only one organism grew back in a Petri dish in the room. It was C auris. The hospital serves wealthy patients from Europe and the Middle East, and it has not made a public announcement of the outbreak.

    An outbreak of C auris at a Spanish hospital resulted in 41% deaths of infected patients. The hospital has not made a public announcement of the outbreak.

    In the U.S., the Brooklyn branch of Mount Sinai Hospital had a case of C auris with an older man hospitalized for abdominal surgery.

    According to a New York Times article:

    The man at Mount Sinai died after 90 days in the hospital, but C auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it… C auris is so tenacious, in part, because it is impervious to major antifungal medications, making it a new example of one of the world’s most intractable health threats: the rise of drug-resistant infections.3

    Indeed, Mount Sinai’s public exposure is an exception, as hospitals and governmental agencies keep C auris’s whereabouts secret. Public transparency is shunned. Hospitals and local governments are reluctant to disclose outbreaks because of concern about tarnishing reputations and spreading of rumors. Even the Center for Disease Control is not allowed, in a pact with states, to publicly announce outbreaks.

    There are multiple causes behind antibiotic-resistant infection outbreaks. As for one, using antifungals on crops to prevent rotting, in turn, contributes to drug-resistant fungi infecting people. Also, infamously, antibiotics are widely used (in fact, overused-by-a-country-mile) for disease prevention of farm animals.

    Indeed, researchers estimate that up to 70 percent of all antibiotics sold in the U.S. are given to healthy food animals to artificially expedite their growth and compensate for the effects of unsanitary farm conditions. This routine use of antibiotics in animals presents a serious and growing threat to human health because it creates new strains of dangerous antibiotic-resistant bacteria.4

    Furthermore, and of serious deliberate interest, Denmark is testament to what occurs by restricting non-therapeutic use of antibiotics in cattle, broiler chickens, and swine. Following Denmark’s restrictions, the use of antibiotics for swine dropped 50% from 1992-2008. Results: (1) swine production increased by nearly 50% and (2) antibiotic resistance in humans decreased.

    By way of contrast, in the United States up to 70% of antibiotics go to farm animals that are not sick.

    One pressing issue is no new classes of antibiotics have been invented for decades. In fact, all the antibiotics brought to the market in the past 30 years have been variations on existing drugs discovered by 1984, meaning they are just follow-up compounds, without a novel mechanism of action, meaning no major breakthroughs.

    Problematically, only a few large drug companies are involved in antibiotic research and development because the cost of developing the drugs is high and profit margins are slim. In that regard, according to the Center for Infectious Disease Research and Policy: The antibiotic pipeline is near collapse, and the country needs to act now to preserve the infrastructure to support antibiotic research and development.

    Pew Charitable Trust/Antibiotic Resistance Project is trying to muster public support for the Preservation of Antibiotics for Medical Treatment Act (PAMTA, H.R. 1587/S. 619), which withdraws from animal production use of seven classes of antibiotics vitally important to human health, unless animals are diseased or drug companies can prove that their use does not harm human health.

    Other groups in support of legislation include the American Medical Association, American Academy of Pediatricians, Infectious Diseases Society of America and World Health Organization.

    In a letter to congressional leaders February 5, 2019 The Pew Charitable Trusts, Infectious Diseases Society of America, and Trust for America’s Health, together with U.S. antibiotic developers large and small, called on Congress to move swiftly to enact a package of economic incentives to reinvigorate the stagnant pipeline of antibiotics.

    A number of sponsors for congressional action are urging concerned citizens to call their representatives and senators and push for action on this life-or-death issue.

    1. WHO Fact Sheet on Antibiotic Resistance, November 2017.
    2. Pew Campaign on Human Health and Industrial Farming.
    3. New York Times, “Deadly Germs, Lost Cures: A Mysterious Infection, Spanning the Globe in a Climate of Secrecy”, April 7, 2019.
    4. How Much Do Antibiotics Used on the Farm Contribute to the Spread of Resistant Bacteria?” Scientific American magazine.

    Corporate and “Progressive” Democrats Threaten Medicare Itself

    The Democratic Party won a majority in the House of Representatives in the November 2018 elections by making health care one of its top “messages.” Yet events from Bernie Sanders’ bill of 2017 to legislation that “progressive” Representative Pramila Jayapal introduced on February 27, 2019 show that the Party is on its way to destroy Medicare.

    For decades activists identified the prize as “single payer health care.” The program would issue a Medicare card to everyone, like the one senior citizens get now. The card would be good at any doctor’s office, clinic, hospital, laboratory, and prescription pharmacy. These largely private businesses would be reimbursed from a public single-payer fund. The fund would receive broadly collected tax revenues; the patient would pay little or nothing at the reception desk, and no monthly premium. This is guaranteed, comprehensive health care.

    In other words, single payer is Medicare for all, carried to completion by eliminating Part B premiums and by more comprehensive coverage including prescribed drugs.

    Health care activists always agonized over the colorless name “single payer.” A few years ago many of them began to speak of Improved Medicare for All. Actually, it had been in the title of the benchmark bill, H.R. 676, when congressperson John Conyers introduced it in 2003. A few years later he shortened the title to The Expanded and Improved Medicare for All Act. The text remained stable, and although the bill went nowhere in Congressional committees, H.R. 676 became the centerpiece of organizing. It is readable, only thirty pages of double-spaced large type. Hundreds of trade union locals and councils endorsed this model legislation in a steady stream year after year.

    The health care industry has enjoyed a long-term phase of expansion, like railroads in the latter half of the nineteenth century. Back then, the new way of moving heavy goods and people was amazing and useful; today, new biological and biochemical understanding makes possible longer life, survival from a heart attack, restored clarity of vision, and so on. In both situations, capital has had strong pricing power and taken fat profits. And just as anger at railroads swelled into a populist revolt against The Octopus (Frank Norris’ novel about the Southern Pacific railroad corporation), people today are angry at insurance corporations, pharmaceutical monopolies, and hospitals, whether or not they call themselves “non-profit.”1

    Opinion polls measure growing support for single payer health care for all. Employers continue to raise the employee cost of coverage, or simply not provide a health benefit. Health insurance purchased individually on the so-called exchanges of the Affordable Care Act (“Obamacare”) turns out to be full of exceptions like a slice of Swiss cheese.

    Sanders Promotes Health Care for All Then Undercuts Conyers

    Popular support erupted into a political force when Bernie Sanders launched his presidential campaign at the end of April 2015. Record-breaking crowds filled his rallies around the country. The top three issues in a Sanders speech rotated – sometimes including inequality of wealth and income, sometimes climate change – but he always revved up on health care for all. It had been the cause of a few thousand health care activists. Now Improved Medicare for All became a challenge to the neoliberal establishment. For the first time in forty years, people were on the verge of a mass campaign for a major gain in their quality of life and their security.

    It did not happen. Sanders did not win the Democratic presidential  nomination. He returned to the Senate, making an implicit or private deal with the party: he would speak as a independent progressive, but he will act on all serious matters as an unannounced Democrat.

    Doing something about health care for people largely fell out of public view. Health care activists carried on. Policy aficionados spun proposals. Sanders had used the issue in his campaign, but sustained mass organizing for it did not happen.

    Then in September 2017, senator Sanders introduced his “Medicare for All Act.” S. 1804 is three times as long as H.R. 676, and the reader must unravel cross-references within the text. Sanders made no mention of Conyers’ H.R. 676 at his press conference. Since then, no one has asked him the obvious question: Why didn’t Sanders simply introduce the text of H.R. 676 in the Senate?

    The “Buy-In” Trap

    Sanders’ bill would actually undermine Medicare. It would set up a “Transitional Medicare Buy-in Option and Transitional Public Option.” Sanders portrayed it as a four-year period (longer if necessary) to bring people of age 55 or over into Medicare, then down to age 45, then down to age 35, then everyone. This scheme is the very opposite of guaranteed single-payer health care for all.

    How is Medicare financed today? Most of the money comes from payroll and income tax revenues, not enrollees’ Part B premiums, by a ratio of 3½ to one.2 We all pay into Medicare. At the moment when someone needs care, she gets it, period – without financial worry. That is the single-payer principle, and Medicare implements it, although not entirely, since enrollees must keep up-to-date on their Part B monthly premiums, and there are some co-payments for services.

    Expanded and Improved Medicare for All would eliminate premiums and co-pays. That is what H.R. 676 declared, but in Sanders’ S. 1804 people younger than 65 could “join” Medicare by paying fat monthly premiums (a “buy-in”). People who want to sign up this way would use the notorious Obamacare exchanges.

    Trade union campaigners for genuine Medicare for all, H.R. 676, wrote in a December 11, 2018 letter:

    Unlike HR 676, S 1804 inserts supposedly incremental steps of public options and Medicare buy-ins for four years prior to arriving at a real single payer plan. Because S 1804 expands care while maintaining the private insurance companies, costs will skyrocket before the savings of single payer kick in. The incremental steps will become a roadblock rather than a path to single payer. Perhaps the worst part of this inclusion of the public option and the Medicare buy-in is the reinforcement of the false notion that there should or must be transitional steps to single payer. Neither the public option nor the Medicare by-in are based on sound policy. To place them in the bill for even a short period of time endangers the single payer goal.

    All Unions Committee for Single Payer Health Care, HR 676, Kay Tillow, coordinator

    It is a neat trick: under the guise of expanding Medicare, you make it more dependent on premiums. You change it from a public good, like the neighborhood fire station, into a commodity insurance product that individuals buy. You make health care dependent on the patient’s finances.

    This perversion of Medicare is not only a fraud upon people of age 55, 45, or 35. It is a threat to Medicare itself. Whenever Medicare seems headed for a financial crunch, real or conjured, the pressure in Congress will be to shift more and more toward a premium- and co-pay-financed program rather than one supported by general and progressive tax revenues – and to take chunks of medicine out of Medicare.

    An independent in name but a Democrat, in fact, senator Sanders at his press conference happily introduced several corporate Democrat co-sponsors of his bill. Behind closed doors he had let them write sections of S. 1804! The public option section was written by senator Kirsten Gillibrand of New York. “One part of the bill that I worked with my colleagues to put in was the ability for every American to buy into a nonprofit public option as part of a four-year transition…,” she said during the news conference introducing the bill.

    A public option is a competition with insurance corporations rigged in their favor. They know how to repel potential enrollees who are likely to need expensive care. A government health plan cannot and, of course, should not play that game. It can either raise premiums, or it can turn the program into something like its poor cousin Medicaid. Either way, it cannot become improved Medicare for all.

    Democratic Party: “Death to H.R. 676!”

    Two important bills stood in contradiction to each other: one for Expanded and Improved Medicare for All (H.R. 676), the other a threat to Medicare itself (S. 1804). Conyers’ bill has been the acknowledged model legislation since 2003; Sanders introduced his in 2017.

    But words do not move on their own. The corporate Democratic Party soon put H.R. 676 on the chopping block. Representative John Conyers was pushed out of Congress in a #MeToo incident, resigning from a hospital bed, denying the charges but not up to the rigor of a fair hearing if he could get one.

    Somehow, sponsorship of H.R. 676 went to new congressperson Pramila Jayapal. 3 She immediately announced that she was in consultations to rewrite it. In the meantime, she surrendered the number 676 that had been reserved for Conyers’ bill since 2003. It was issued to military legislation on January 17, 2019.

    After the Democrats won control of the House of Representatives in the November 2018 elections, it became more urgent for them to gut single payer health care for all. Otherwise, they might have to deliver. Representative Nancy Pelosi, during a post-election whirlwind of bargaining to make sure she became Speaker of the House, agreed to help advance the same scheme that senators Sanders and Gillibrand had put into S. 1804: a buy-in to a premium-based option for people age 50 to 64. Jayapal, who also praised Pelosi during her run for Speaker, spoke out of both sides of her mouth. “I would prefer to have a reduction of the age of Medicare so that more people could qualify but not a buy-in, because that continues the problems that we have right now.” She said lowering the eligibility age “would be an appropriate way to go where we’re taking a step forward towards a system that will ultimately cover everybody.”

    The Buy-in Trick Again

    Representative Jayapal introduced H.R. 1384, her replacement for the Conyers’ model, on February 27, 2019. The 119-page bill is a masterful card trick. On one hand, it maintains the ban on premiums and co-payments, and it specifies a broad list of covered medical services, including some never proposed before in such legislation.

    On the other hand, Jayapal copied Sanders’ big step backward – an optional “buy-in” transition period with premiums, only shortened from his four years to two. (After the first year, minors up to age 18 and people 55 and older would move automatically into the new system.) H.R. 1384 states:

    The Administrator shall determine the premium amount for enrolling in the Medicare Transition buy-in, which may vary according to family or individual coverage, age, and tobacco status,… (H.R. 1384, Title X, Subtitle A, Sec. 1002 (e)(A))

    Since Conyers introduced H.R. 676 in 2003, his bill never had a premium-based buy-in. Why does Rep. Jayapal think a buy-in period is necessary?

    With a buy-in transition, the first experience people would have with the new system would be yet another commodity insurance plan with monthly premiums. This is a recipe for political failure. During those two years the tentative new system would soon be under attack as financially unworkable and just not popular enough.

    People could buy in if they wished as individuals through the notorious Affordable Care Act exchanges (“Obamacare”). Because of the extensive benefits, the plan would be one of the most costly choices. Unaffordable for most as an individual premium plan, trying to compete in an unreformed health care system with its bloated costs, the buy-in would attract few enrollees. Enemies of genuine universal health care will pounce on the result, demanding that genuine Medicare for All be postponed and turned into a supplement of one kind or another to corporate health insurance.

    Only H.R. 676 delivers guaranteed healthcare for all, the equal care for all of which our advanced society is capable. Bernie Sanders and Pramila Jayapal, just like openly corporate yet arguably less devious Democrats, cower before insurance capital, pharmaceutical capital, hospital capital, etc. These parasites demand that healthcare be a set of commodities that some can afford and others cannot. The people or the dollar – that is the inescapable choice.

    1. A nominally “non-profit” hospital today is not the church-run charity that it might have been a hundred years ago. Non-profit simply means that the corporation is tax-exempt. It does not pay dividends to stockholders, but it still makes a profit. Banks share in the loot, and layers of executives are paid millions of dollars. Affiliated for-profit clinics and labs may suck profits out under cover. Examine the Sutter Health and Kaiser hospital chains in California, for example.
    2. Medicare trust fund trustees’ report, 2018, pp. 45 and 78.
    3. Jayapal went to elite Georgetown University, got an MBA after that, worked on Wall Street on leveraged buyouts, switched to executive positions in several nonprofits, sat a mere two years in the Washington state senate, and won election to the House in 2016.

    Medical Ethics Can Only Be Restored With a Single-Payer System

    It is the year 2019, and American health care is in a state of profound crisis. While oligarchic parasites from the pharmaceutical industry and health insurance companies make enormous profits, bankruptcy and the fear of being denied care hang over the American people like a sword of Damocles. This diabolical order, predicated on greed and placing profit-making over human life, has stripped doctors of their autonomy and given birth to an inhuman and deeply unjust multi-tier system.

    Unless we are able to disenthrall ourselves from the tyranny of privatized health care, Americans will continue to die as a result of avaricious insurance companies denying coverage for needed drugs and procedures, and from treatment which is delayed due to requests for “prior authorizations.” Moreover, medical students and residents are being taught that good health care is a privilege and not a right, and that the oath to do no harm applies, but only to a privileged few. In a world turned upside down, doctors in training are being inculcated with the pernicious notion that the job of a doctor is not to listen to the patient, perform a comprehensive physical, respect the patient’s privacy, get an accurate history, diagnose, treat, and follow up; but rather to help their employer maximize the greatest possible profit. Indeed, the number of patients doctors are expected to see each day has become increasingly unwieldy, and this has gravely undermined their ability to practice good medicine.

    Are we to continue to buy and sell health care as if it were a consumer good? The wealthiest can buy a Ferrari, the upper middle class a Lexus, the working class a Toyota, and the poor a used car. The very destitute cannot afford a car at all and have to take the bus. Clearly, it is barbaric to run a health care system in such a manner, and yet this is precisely what we are doing.

    From their very first day of residency, doctors in training are being indoctrinated with the following code of dishonor: “This patient has a right to privacy, while this patient doesn’t. This patient has a right to informed consent, while this patient doesn’t. This patient has a right to linger following their surgery, while this patient has to leave immediately following their procedure. This patient has a right to their own room with a view, while this patient will be crammed into a room with a stranger.” The idea that medical ethics can coexist with such an ideology is inane and deeply delusional.

    Many institutions have established multi-tier systems which are so egregious that it has resulted in the implementation of a Jim Crow health care system. Indeed, these institutions often place the “humans” and the “subhumans” in physically separate facilities. In this internationalization of the third world model, patients with inferior insurance are regularly arm-twisted into being clinical guinea pigs and used as laboratory animals with which to teach impressionable residents and fellows. This railroading of the “losers” into resident clinics magnifies the innate power imbalance inherent in the doctor-patient relationship a hundredfold, and constitutes a violation of patient privacy, informed consent, confidentiality, and patient dignity all of which fall under the umbrella of the physician’s oath to do no harm.

    In an article in Annals of Emergency Medicine titled “Observers in The Medical Setting”, by Joel M. Geiderman, MD, the author posits that:

    Privacy is treasured by citizens in free societies around the world, and any infringement on it is considered by many to be an affront to personhood. In the United States, the right to privacy runs deep in the American soul.

    Residents that have no qualms about observing office visits without the patient’s consent are likely to go on to violate the privacy of their patients as attendings, and may very well spend their careers mindlessly violating and debasing their fellow human beings, only to periodically vent their frustrations on the Internet over all the “self-entitled” patients that don’t appreciate their diligence and divine wisdom. And while there are undoubtedly some residents that may have misgivings over participating in a clinic which coerces patients with unglamorous insurance plans into being medical models, as we have largely become a nation of careerists, the apelike majority will blindly follow orders.

    Geiderman writes:

    In addition to informational privacy, or protection of their personal health information, patients are also entitled to physical privacy, that is, a zone of personal space where access is under the patient’s autonomous control. Closely linked is the right to one’s modesty, a human value that is expressed in the Bible in Genesis, as Adam and Eve wished to shield their nakedness even from their Creator.

    Should a physician order countless tests and prescriptions which are subsequently vetoed by the insurance companies, assuming they are not vehemently opposed to single-payer, they are unequivocally not to blame for this. However, once a doctor has knowingly participated in a clinic which is predicated on coercing patients with inferior insurance into being clinical guinea pigs for residents and fellows to practice on, they have stepped into a void beyond which lies a wasteland devoid of honor, dignity, integrity and morality. Any participation in such an egregious multi-tier system on the part of a physician threatens the survival of the doctor-patient relationship and constitutes unbridled and unmitigated heresy.

    This descent into barbarism is glaringly on display in many dermatology departments, which are able to choose from the crème de la crème of our nation’s medical graduates, dermatology being one of the most competitive and sought-after specialties. These departments often assign patients with inferior insurance to a resident, who in turn has to be supervised. And so through artifice and trickery, the patient is duped and arm-twisted into being a medical model without their consent. The attending arrives and spews platitudes such as “The more eyes the better,” “There’s nothing we’ve never seen before,” and “We’re all professionals here” as if this can mitigate the fact that they are teaching their residents that the have-nots deserve neither privacy nor respectful care. That neither the attending nor the resident would even think of seeking care in such a clinic underscores the fact that in the innermost recesses of their addled brains they are cognizant of the fact that what they do is unethical. To gain admission into MS-13 one would likely have to commit murder. When doing a dermatology residency at an elite Manhattan medical institution, violating the privacy of hundreds of patients is the price of admission into this rather alarming society.

    In conjunction with this uncivilized behavior, doctors in training are duly inculcated with the idea that informed consent is a privilege and not a right. Many of these creatures will go on to do practice pelvic exams on anesthetized patients, or even perform forced cavity searches at the request of law enforcement. Indeed, doctors that have no respect for informed consent are a danger to themselves, and a danger to those who place their trust in their care.

    Reactionary physicians at elite institutions take for granted having the finest insurance, and delude themselves into thinking that patients go to resident clinics of their own volition, and not because their insurance dictates that they go there. Few realize that if a Medicaid patient sees a doctor out of network they can actually lose their insurance. Restoring physician choice to the American patient is absolutely vital if we are to restore any semblance of democracy to our health care system. For as long as a vast swath of American society is forced to work with doctors that they do not wish to work with, all talk of “patient-centered care” is farcical and absurd.

    If a woman with good insurance needs a prescription for birth control, she can leave a doctor who insists on doing a pelvic exam prior to ordering the prescription, whereas a patient with inferior insurance can be bullied into submitting to the unnecessary exam due to the lack of gynecologists that take their insurance. While the pharmaceutical companies, health insurance companies, and hospitals grow fat with the lucre sucked from the blood of their patients, not a day goes by when the underinsured do not experience such indignities. And while the government continues to abrogate its social responsibility to implement a single-payer system, many patients that do have good insurance are a cancer diagnosis or car accident away from losing their job and their superior insurance along with it.

    In non-union jobs employers often change insurance plans every year, perpetually searching for the plan which is most affordable. This in turn forces patients to constantly change doctors, and if a patient has a complex medical condition, the consequences of perpetually denying such an individual continuity of care can have disastrous consequences. Indeed, even if a patient is healthy, this can result in reduced health care outcomes over the long-term. And just as the multi-tier education system has come to be accepted without question by millions of our countrymen, the multi-tier health care system has likewise left its mark on the consciousness of millions of Americans, and is increasingly accepted as “normal” by the insouciant and the knavish alike.

    Patients that freelance can also see their insurance change while their income fluctuates, and this can likewise force a patient to change doctors. Like a marriage, the doctor-patient relationship is predicated on a sacred trust, and being forced to constantly change doctors disrupts, destabilizes, and destroys these relationships.

    The takeover of the medical decision-making process by insurance companies – essentially criminal gangs – has stripped doctors of their autonomy and is a driving force behind physician burnout. For after every treatment plan agreed upon between a doctor and a patient, doctors’ orders are increasingly countermanded by the patient’s insurance company. Not a day goes by without a doctor prescribing a drug which a patient’s insurance refuses to cover. The doctor then calls in a second drug – a variation on the first – and the insurance company may refuse coverage for this as well. Then a third drug is called in – perhaps not even of the same class – and this too may be rejected. Meanwhile, the patient has been examined by their doctor, not by an MD working for the insurance company. Should a physician order a PET or CT scan to determine whether a patient has metastatic cancer following a needle biopsy that has revealed a mass to be malignant, it is not uncommon for the patient’s insurance to declare this request as requiring “prior authorization.” This pervasive undermining of a doctor’s authority is without precedent in American health care, and these delays have caused people to die.

    In addition to living paycheck to paycheck, millions of Americans are under the illusion that their health insurance plan is much better than it is, incognizant of the fact that they are a health problem away from financial ruin. The insouciant among us who ask where the money is going to come from should consider why they failed to ask this question prior to the invasions of Iraq and Afghanistan. The money will come from demilitarizing our society and transferring to a peacetime economy. Are the underinsured not victims of terrorism?

    As their entire raison d’être is anchored in maximizing the greatest possible profit, hospitals ruthlessly exploit their residents, many of whom work eighty hours a week or more. In an article on KevinMD titled “The secret horrors of sleep-deprived doctors,” by Pamela Wible, MD, a doctor speaks of their training:

    I did my internship in internal medicine and residency in neurology before laws existed to regulate resident hours. My first two years were extremely brutal, working 110 to 120 hours/week, and up to 40 hours straight. I got to witness colleagues collapse unconscious in the hallway during rounds, and I recall once falling asleep in the bed of an elderly comatose woman while trying to start an IV on her in the wee hours of the morning.

    It is not uncommon for young doctors to accidentally kill patients as a result of being so exploited and sleep deprived, and this has undoubtedly played a role in making hospital errors the third leading cause of death in this country. Wible quotes another physician:

    I have made numerous medication errors from being over tired [sic]. I also more recently misread an EKG because I was so tired I literally couldn’t see straight. She actually had a subarachnoid hemorrhage, and by misreading the EKG, I spent too much time on her heart and didn’t whisk her back to CT when she came in code blue. She died.

    This is the inevitable result of exploiting residents as if they were fast food workers. Moreover, as has transpired with education, health care is simply becoming unaffordable. In an article for KevinMD titled “The demonization of socialized medicine,” by Matthew Hahn, MD, the author writes, “It’s almost become a ritual now where a patient (who usually has health insurance) is diagnosed with cancer, and then we attend their community fundraiser to help them with the costs of their care.”

    Many doctors are compelled to spend countless hours each month filling out electronic medical records which have been foisted on them by the insurance companies. To assist with this onerous task, doctors increasingly employ a nurse or medical scribe to type the required information into the computer during a patient’s office visit. This destroys any semblance of confidentiality and undermines the physician-patient bond. It can also result in the doctor failing to obtain a comprehensive history.

    Some physicians feel that the way to regain autonomy is to not take insurance at all, but by doing this they are denying care to patients with low income; i.e., the majority of the country. In theory, doctors take an oath to do no harm. In reality, they are in thrall to rapacious corporate power and are more likely to spend a lot of time violating patients’ privacy, doing mind-numbing data entry, and failing to disclose the risks of extremely dangerous drugs such as opioids and psychiatric medications.

    Liberal saints Obama and Hillary had an opportunity to make a push for single-payer, but instead chose to spend trillions of dollars murdering large numbers of people in Ukraine, Iraq, Afghanistan, Yemen, Libya, Honduras and Syria while maintaining nearly a thousand bases all around the world. How many more patients will be forced into bankruptcy? How many more souls will be debased and defiled? How many more human lives will be lost?

    Liar, Liar

    The dictatorship’s mistake was to torture but not kill.
    — Jair Bolsonaro, Radio interview, 2016

    I won’t get voted out of office.
    — Bill Gates, Bill Moyer Interviews Bill Gates

    I hate the indifferent. I believe that living means taking sides. Those who really live cannot help being a citizen and a partisan. Indifference and apathy are parasitism, perversion, not life.
    — Antonio Gramsci, Prison Notebooks, International Publishers Co; Reprint, 1989 edition (November 24, 1971)

    The sadist needs the person over whom he rules, he needs him very badly, since his own feeling of strength is rooted in the fact that he is the master over someone.
    — Erich Fromm, Escape from Freedom, Holt Paperbacks; Owl Book ed edition, September 15, 1994

    Years ago Robert Bly talked about Ronald Reagan’s capacity for lying. He said Reagan grew up lying about his father, an alcoholic, and his dysfunctional childhood which he routinely described as happy. How the enormity of that lie, and all the attendant pressures of such intimate dishonesty made lying about the Iran/Contra deal much easier. And I recently heard Gabor Mate say the same sort of thing about Donald Trump. How Trump grew up with an abusive authoritarian father, one who humiliated and belittled the boy Trump, and the world of that boy was one of cruelty and abuse. And if that is the only world you know growing up, that is the world you will see everywhere around you later. And the only way to navigate a world of abasement and lying was to be better at it than those who had abused you. The grandiose aggressiveness and paranoia of Trump is the product, in part, and probably in large part, of a family that operated on strict hierarchies of power, a punitive and sadistic family dynamic. Trump’s brother, of course, drank himself to death.

    Countless Presidents came out of dysfunctional families, ones often with authoritarian and alcoholic fathers. Gerald Ford, or Bill Clinton with his stepfather. The list is quite long. British Prime Ministers are also disproportionately the product of similar childhoods. But the point is really about a system that rewards men and women who have developed pathological coping mechanisms that include an ability to lie, an inability to feel empathy or remorse, and who are adept at cheating and taking credit for the accomplishments of others. The deformed character that comes out of such dynamics is, it seems, perfectly suited for the public spectacle of political life. Perfectly suited for a career as a carny barker, too.

    All hierarchical systems are to some degree systems that encourage winning and punish losing.

    Before the last Presidential election I wrote this about the two leading candidates…

    For that is it, a rich white anti intellectual with openly self embraced bad taste, Trump valorizes half the white men in America for their seeming failures. He is saying, ok, you are not rich like me, but the rest, yeah we are one. But Trump has no role without his co-star, Hillary Clinton. Hillary is the cliche woman who is overbearing, petty, resentful and spiteful, but also functions as a female destroyer. And that role is complex, here. Hillary is not the purifying force of Kali, she is not the forest fire that brings regeneration. No she is simply the electric chair with a short, a sadistic contraption of flawed construction that terrorizes and disseminates suffering and cruelty. And while I have thought it impossible that Hillary doesn’t win this dog and pony show, it is now becoming apparent that Trump is the candidate of masculine revenge. Every misogynist looks to Mr Orange Hair to get even. And that misogyny is interlaced with race and colonial memory. And this is where the importance of Heidegger and Schmitt looms. And it is where the rising tide of left liberal antisemitism appears alongside peak Islamaphobia. It is all of a piece, in a sense.

    — “Cunning of Unreason“, May 8, 2016 John-Steppling.com

    Hillary, too, came from a dysfunctional family environment.

    The message here is, I think, most of America is made up of dysfunctional families. Perhaps all families under capitalism are dysfunctional. Most learn to lie about their families. Only today, one form of lying to confess about it and advertise one’s own self improvement program as a response. The therapeutic often, it seems in my experience anyway, to simply be another form of lying. Or self delusion. Americans love to “work on themselves”. It’s a bit like working on your car, or those DIY projects to convert the garage into a ‘rec room’. Of course, fewer and fewer people own their own homes anymore. Maybe they need a show for those living out of their cars. DIY for building portable sidewalk showers without risking police persecution.

    Dysfunction is the cost of Capitalism. ‘Wrong life cannot be lived rightly’, as Adorno put it. So one part of the fall-out from this prolonged exposure to the irrationality of life in neoliberal America has been to normalize lying. When Alexandria Ocasio Cortez praises Nancy Pelosi…I have found many people, maybe the majority, expressing something along the lines of, well ‘she has to say that sort of thing’. Or she is only kissing the ring so she can later create possibilities for real change. The fact she was lying is excused. It is excused because America itself lies. And deep down those saying this stuff know full well Ocasio Cortez will become Nancy Pelosi, not fight against her.

    In Brazil, the new fascist in power praised his father for the beatings his dad gave him. Young Jair Boslonaro said it helped make him a man. Jair is now out to destroy the rain forest of the Amazon basin. Which might well kill off the planet. We can all partly thank dad for that.

    Capitalism is an emotional plague on the planet. Wilhelm Reich said that. Bertell Ollman wrote of Reich’s ideas…

    If the desire to accumulate property lies at the origins of sexual repression, its chief function today is to produce submissive beings of both sexes. In our treatment of character structure, the diminution of critical faculties, general passivity, resignation, and other negative effects of repression were identified. The work of sexual suppression is carried on primarily by the family. In his Marxist period Reich believed the suppression that was most decisive in determining character occurred between the ages of four to six in the ways parents respond to sexual play and questions. So important is the role of the family in these early years that Reich refers to it as the “factory of submissive beings.” To him, it is no coincidence that “the lack of victorious spirit, the outlawry of protest, the absence of personal opinions characterizes the relations of faithful children to their parents just as they do the relations of devoted bureaucrats to the state authorities and that of non-class conscious workers to the owner of the factory.
    — Bertell Ollman, Social and Sexual Revolution: Essays on Marx and Reich, 1979

    For the first time (last census) more Americans are living alone than in families. The loss of jobs, the onerous economic burden of child rearing, and gender inequality were all tied into an impossible model for any but the most affluent classes.

    Millions of men who have been denied their family wages find refuge for male domination in right-wing anti-woman politics and fundamentalist and Catholic religions with their emphasis on denying women’s independence through anti-abortion and anti-birth control movements, opposing equal wages for women and denying support for raped and battered women. Other men seek to take back their male power through guns. (None of the explosion of mass killings have been committed by women.) Millions more seek power in heterosexual pornography in which women are portrayed as inviting sexual degradation.
    — Harriet Fraad, “Living Alone:  The Rise of Capitalism and the Decline of Families“, Truthout, October 3, 2012)

    Families propagate violence. Sons of violent parents are 1,000 times more likely to batter their adult partners, and daughters of violent parents are 600 times more likely to batter their partners. Children who are bullied at home are more likely to bully and to be bullied at school. Child abuse is rampant in the capitalist family system. We cannot know how rampant, because it goes on behind closed doors, most is never reported, and adults tend to normalise what they experienced as children. When neglected, they conclude that they did not deserve better. When physically terrorised, they will rationalise: “Sure, I was hit. But I deserved it.” According to the Adverse Childhood Experiences study, more than one in four American adults lived with alcohol or drug addiction in their childhood homes, 28 percent were physically abused as children and 21 percent suffered sexual abuse. ( ) Capitalism promotes sympathy for child victims and prosecutes adult perpetrators. But today’s perpetrators are yesterday’s victims. While only a small minority of child victims become adult perpetrators, studies of those who do perpetrate reveal that almost all were traumatised as children. Capitalism cannot acknowledge that most perpetrators are former victims, because it cannot admit that families transmit trauma from one generation to the next.
    — Susan Rosenthal, Capitalism, alienation and the family, Socialist Review, 2015

    Rosenthal notes something else, and that is that Capitalism in the transition from agricultural production to industrial removed labor from the family. It created this amorphous social sphere of leisure time or free time. But as Adorno noted sixty years ago, there is nothing free about it and leisure had already begun to resemble alienated work.

    Rosenthal also adds….

    Impossible gender expectations create crushing disappointment. The woman is raised to see the man as a champion and a prince who will make her dreams come true. When she discovers that he cannot do this, she expresses her disapproval or withdraws in despair. The man gets the message that he is not measuring up. How could he? The man is raised to expect a warm attentive partner who is always ready for sex. What he gets is an overworked, exhausted and frequently irritated partner. Both of them blame themselves, and both of them blame each other.

    The American political drama, or electoral theatre, is reinforced so aggressively because it is the most basic and effective distraction people have for their social malaise and misery. Voting is a reflection of binary models. It is really just exchange value. And voting makes everyone equal. And Americans have even taken to wearing little stickers that proclaim they voted. So electoral theatre as a shaming device. But voting becomes even more than just a threadbare symbol of equality, it takes on almost occult significance for many. It is one of the few rituals in bourgeois society that seems to encompass something almost magical. Voting is an affirmation of one’s existence, of one’s autonomy and even freedom. I can vote for whoever I choose. Well, off a menu of two.

    But I have seen leftist writers proclaim lesser evilism is not to be debated. This is, apparently, because Trump is some sort of special category of evil. This is a hugely regressive and politically immature position. Firstly, voting is not going to solve shit. Full stop. No, the entire apparatus of elections and voting machines and voter suppression or corrupt counts is part of this grand theatre. And this emphasis also promotes a popular idea with the ruling class, that of individualism.

    I wrote this several years back…

    Voting is the constant reinforcement of the idea of equality. Everyone has a vote, therefore everyone is equal. This is of course not true, however. But the expanding of campaign season ( a bit like the expanding of Christmas shopping season) is serving to keep this illusion foremost in the minds of citizens. The act of voting is then a sort of magic elixir for conveying a sense of equality, and it is coupled with the idea of ‘responsibility.

    Dentistry as Art, John-Steppling.com, September 2015.

    It is no doubt true that America is a full blown open fascist society today. But it was already. It’s hard to decide what was the starting point, but it certainly could be Bill Clinton’s second term. Or after 9/11. By Obama it was most certainly fascistic in operation. Gabor Mate noted that the ruling class was not fooled by Obama and all that hope and change stuff. Wall Street backed and funded his candidacy. They knew he was one of them. He rewarded them the second he was elected. No, only the mass public believes ANYTHING of what the political class tells them.

    The Democratic Party has taken positions actually to the right of Trump on many issues (here is an issue Democrats fell in line with…) And does anyone believe real action would take place if Dems controlled the government? I mean they have, and not that long ago, and what happened? But none of these things are as significant as the wholesale swath of destruction that US and NATO military action has caused in Africa and west Asia. And nobody asks this during election season. Unless I missed something, no candidate or news talking head brought up why NATO even exists anymore. Nobody asked why the US needed to upgrade its nuclear arsenal, or why it occupies a third of Syria. Or why there are military bases in almost every country in Africa. Why there are 900 worldwide.

    But more hidden, in a sense, and therefore more insidious is the role of giant foundations and non-military uses of coercion and control. Jacob Levich writes:

    For the ruling classes do not rule by guns and laws alone. Rather, they need to be able to do so without the constant resort to force. So, [Joan Roelofs] argues, they manufacture the consent of the ruled through the activities of a broad range of institutions, activities and persons (not necessarily themselves members of the ruling class) who disseminate the ideology of the ruling class as if it were merely common sense. While dissent from ruling class ideas is labeled ‘extremism’ and is isolated, individual dissenters may be welcomed and transformed. Indeed, ruling class hegemony is more durable if it is not rigid and narrow, but is able dynamically to incorporate emergent trends.
    — Jacob Levich, “The Real Goal of the Gates Foundation“, Aspects of India’s Economy, May 2014

    The role of foundations is, to most Americans, opaque and almost inexplicable. Nobody in political/Electoral theatre mentions this ‘third sector’. Neither business nor government, these foundations operate with budgets in the multi billions of dollars. This is the stuff discussed at Bilderberg Meetings, and other summits of the world’s richest people.

    The fall of the Soviet Union ushered in the present phase of public health philanthropy, characterized by the Western demand for “global health governance” – purportedly as a response to the spread of communicable diseases accelerated by globalization. Health has been redefined as a security concern; the developing world is portrayed as a teeming petri dish of SARS, AIDS, and tropical infections, spreading “disease and death” across the globe and requiring Western powers to establish centralized health systems designed to “overcome the constraints of state sovereignty.” Imperial interventions in the health field are justified in the same terms as recent “humanitarian” military interventions: “[N]ational interests now mandate that countries engage internationally as a responsibility to protect against imported health threats or to help stabilize conflicts abroad so that they do not disrupt global security or commerce.
    — Jacob Levich, “The Real Goal of the Gates Foundation“, Aspects of India’s Economy, May 2014

    I mention this only as a sort of corrective to these naive notions about voting. Voting is not the issue. Not in an absolutely controlled system of perception management. Back in 2014 Gates warned about overpopulation in places “we don’t want it” (sic) and he mentioned Pakistan and Yemen. Huh. Yemen, you say? Yeah, well, I guess that’s not an issue anymore. The U.S. Imperialist agenda is about control. It is adaptive and flexible.

    Malthus’s heirs continue to wish us to believe that people are responsible for their own misery; that there is simply not enough to go around; and to ameliorate that state of wretchedness we must not attempt to alter the ownership of social wealth and redistribute the social product, but instead focus on reducing the number of people.

    — Manali Chakrabarti, “Are There Just Too Many of Us?”, Aspects of India’s Economy, No. 55, March, 2014

    I digress a moment to add on here that the overpopulation mythology has taken on a green cover of late. Suddenly the same old Malthusian eugenics is sprinkled with Gaia jargon and sensitivity to global ecologies. But the thrust and engine driving the idea remains the same.

    Most non-profits do the dirty work of what a society is looking more and more to not provide for – mental health care for a bigger and bigger share of the USA population; disability services for a larger and larger swath of Americans mentally, psychologically, intellectually, socially, physically, and spiritually broken or disabled; financial, employment, education, housing assistance for an ever-growing population of humans who are not able to work and live and transport and find health care for themselves in this New Gilded Age.

    The non-profits I have worked for are top-heavy, have very little money put aside or earmarked or grant-provided for the workers; many of the non-profits hire development associates, upper management shills, PR folk, marketing and events coordinators; many are in shining and remodeled digs while casting shadows on the street people they supposedly care about.
    — Paul Haeder, “The Punditry of Shithole Thinking“, Dissident Voice, January 15th, 2018

    In the 1950s came the development of the first psychiatric drug, the antipsychotic drug Chlorpromazine. This marked the beginning of what has come to be a mammoth and powerful industry in chemical warehousing of an unwanted population.

    This industry was founded on a single ideology—the “mental illness” theory, or “medical model” (which I’ll refer to simply as the medical model)—an ideology that gave this industry
    tremendous power and influence. The medical model essentially states that distressing states of mind can, for the most part, be categorized into discrete “mental illnesses,” and that although these mental illnesses continue to the present day to be rampant and even growing within our society, we must rest assured that the great medical advances of this industry have already developed powerful drugs that can generally contain them, and that it is just a matter of time before our medical technology will eliminate these illnesses altogether.

    — Paris Williams, “Madness and the Family: Exploring the Links between Family Dynamics and Psychosis”

    As Williams has pointed out, the very term mental illness is something of a self fulfilling prophecy. The profits from all psychotropic drugs is almost incalculable — Xanax (alprazolam), Zoloft (sertraline), Celexa (citalopram), Prozac (fluoxetine), Ativan (lorazepam), Desyrel (trazodone HCL), Lexapro (escitalopram). Exact numbers are hard to know but the best guess by the government itself is that over 35 million people took psychotropics between 2013 and 2014.

    A common side effect of psychotropic medication is difficulty feeling certain emotions once the drug accumulates in a person’s system. For example, many people complain of losing the feelings they used to have, report a reduction in their ability to laugh or cry, or experience a decrease in libido. Side effects of SSRIs that might affect one’s sexuality and love relationships, such as diminished sexual interest, are discussed in a chapter from Evolutionary Cognitive Neuroscience.

    GoodTherapy.org

    Psychiatrists claim their drugs save lives, but according to their own studies, psychotropic drugs can double the risk of suicide. And long-term use has been proven to create a lifetime of physical and mental damage, a fact ignored by psychiatrists. Common and well-documented side effects of psychiatric drugs include mania, psychosis, hallucinations, depersonalization, suicidal ideation, heart attack, stroke and sudden death. Not only that, but The US Food and Drug Administration admits that probably one to ten percent of all the adverse drug effects are actually reported by patients or physicians.

    — The Citizen’s Commission on Human Rights

    It is no different in the U.K. The Council for Evidence Based Psychiatry states…

    The latest prescription figures from the Health and Social Care Information Centre show that the UK is in the midst of a psychiatric drug epidemic. Over 57m prescriptions for antidepressants were issued in England in 2014, enough for one for every man, woman and child. This represents a 7.5% increase since 2013, and over 500% since 1992.

    Now there is a kind of psychological blindness affecting Americans, today. A perhaps banal example, but still useful, is the popularity of American football. Since the incontrovertible proof that collisions on the field cause brain damage, acute irreversible damage, the sports popularity has actually increased. Never mind the jingoism attached to this sports-tainment empire, the fact that players are literally risking their lives and mental health to play is one thing, and there is an economic coercion involved, but how is it people want to watch this? Hollywood even made a film about the man who researched the phenomenon of Chronic Traumatic Encephalopathy (CTE). A very popular film starring Will Smith. But more and more people tune in each week. Nobody talks about it. Sitting on the couch, a slice in one hand, Bud light in the other, the question is, I’m guessing, never broached…’Hey bro, so, these guys, you think they’re aware their brains are turning to mush?’ But then the league is 70% black, so, for many it’s a kind of unconscious de-facto solution. Racism in America is indelible and deep. Even animal shelters acknowledge black dogs are harder to place than white. (This is a fact, not the Onion).

    This blindness is the product of decades, now, of electronic media indoctrination. People even admit this, accept that it’s true. But they still remain habituated to their various screens. They still wear buttons saying ‘I voted’. They still become shrill and near hysterical at the idea YOU voted for a third party candidate, or worse, didn’t vote at all. How does that work? The presidency of Obama is revealing, both as it happened, and now as an object of near history. If you tell people Obama was the president who signed off on (and presumably helped design) the joint US/Saudi assault on Yemen, you will get denial or blank stares. If you say, well, ICE deported people under Obama, and at a record clip. You get denial. Or that Obama was notorious for persecuting whistle blowers and for narrowing press freedoms as much as possible. Denial. Blankness. Obama was the fulcrum for a very late onset of amnesia. Collectively speaking. He has taken the role of mental black hole. History began and stopped with Obama. (I actually think Michelle might run for President in 2020).

    Americans collectively cannot grasp their own family relations. They are not sure, most of them I would wager, on even how to define *family*. But, the idea is past its sell by date I suspect. People are living alone, they have no choice. Often alone and on the street. A recent typhus outbreak on the mean streets of skid row Los Angeles suggests the U.S. is inching or hurtling toward 3rd world status.

    This social morality, anchored in all individuals and reproducing itself permanently, has in this manner a reciprocal effect on the economic base in a conservative direction. The exploited person affirms the economic order which guarantees his exploitation; the sexually repressed person affirms even the sexual order which restricts his gratification and makes him ill, and he wards off any system that might correspond to his need. In this manner morality carries out its socio-economic assignment.
    — Wilhelm Reich, Mass Psychology of Fascism, Farrar, Straus and Giroux; 3 edition (November 1, 1980)

    The drastic increase in economic inequality has also generated the need for official explanations and justifications. I am reminded of Otto Fenichel, that most neglected of early psychoanalysts who complained in his 1938 book The Drive to Amass Wealth (and quoted by the worthy Russell Jacoby, whose own work Social Amnesia should be required reading today) of what he saw as Ferenczi’s psychologism:

    The instincts represent the general tendency, while matters of money and the desire to become wealthy represent a specific form which the general tendency can assume only in the presence of certain definite social conditions.  The existence of the erogenous pleasure in collection causes Ferenczi to overlook the fact that when the capitalist strives to increase his capital he does this on very rational grounds: he is forced to it by competitors who produce on a larger scale …. A social system of this kind makes use of and strengthens erogenous drives that serve the necessity for accumulating. Of this there can be no doubt. There is considerable doubt, however, as to whether the existing economic conditions of production were created by the biological instinct.

    At the end Fenichel suggested sometime in the future such conditions would no longer exist. And perhaps somewhere in the distant past they also did not. Capitalism is not inevitable nor is it some kind of natural law. It’s a fact that Google and Facebook censor socialist sites. Why would they do that if they were not afraid? The authority structure, the proprietor class, they want you asleep. That’s the idea.

    We are at the tail end of a kind of Ayn Randian period of simplistic one dimensional and crude capitalist cheerleading — and it began in its current form under Reagan. He of the happy childhood. The president who no doubt suffered from Alzheimers even BEFORE he became the commander in chief. And this has led to the marketing industry to double down on certain tropes of American happiness. We are still within a Norman Rockwell cocoon in terms of propaganda. Each holiday season Hollywood churns out one after another fairy tale of the American family — Thanksgiving fables or Christmas. Oh heck, families can be complex, but gull darn it, we always overcome and celebrate together. But a fairy tale is all it is. And a pernicious one. Most families I know struggle through the Holidays, buffeted by guilt and resentment. And depression. It is the cruelest season.

    Anti-depressants, and all those millions and millions of prescriptions written in the U.S. and U.K. may (!) alleviate symptoms in some or even many patients, but even at their most effective (and I reserve acceptance they actually do any real good for anyone) they do nothing to change the conditions that created this depression. When mass shooters appear, especially white ones, they are *mentally ill*. If non-white they are likely terrorists. The system is not indicted either way. Only the victims of that system. The U.S. is a remarkably unwell place and it has created a political system that rewards the most pathological people in this unwell place. Donald Trump is the perfect man to be President of this asylum. He is ignorant, and proud of it, a narcissist and pathological liar. A racist and misogynist. He often seems he to be made up of the worst qualities of his predecessors. Bush, Clinton and Obama were all in various ways pathological. But who is President really is not the point. The point is class hierarchies. Until Americans learn to talk politics in terms of class, nothing will change.

    The U.S. is reaching an economic/social singularity; there are no jobs, there is no health care, and no education. There is a throughly debased culture and much of the country is in the hands of Evangelical Christians. And Evangelicals, especially Dominionists like Pence and Pompeo and Kudlow and DeVos would have, in an earlier time, been shipped off by their family to some discreet asylum or hospital. We are sort of living a Marat/Sade nightmare. The American fairy tale isn’t working anymore. People may cling to its remnants but at their most lucid I suspect most people know it’s all bullshit. The cultural landscape is so depressing most can only intermittently engage with it. The ruling elite are further distanced from the rest of the populace. The educated liberal bourgeoisie is in crises. All the myriad identity-based systems of belief are less and less convincing. The violence of the military complex finds expression domestically in a militarized sadistic and racist police apparatus. A nation where mass shootings are now routine is a kind of movable hell. Mass incarceration is growing still. It is my experience that people can no longer easily read facial expressions or hear the pitch or intonation of speech — they mimic autistic symptoms in fact. And sociopathy is everywhere. From the wholesale killing of wildlife, to bald faced lies about food ingredients, contaminants in factory farmed meats. But drinking water might be the worst. Across the rust belt and through the southwest, mostly from abandoned mining sites. In Arizona, New Mexico, Oklahoma and on across to Georgia. Detergents, solvents, pesticides, and things such as vinyl chloride and PCEs, paint sludge and boron. A recent report detailed by the Center for Public Integrity noted….

    Across the country, in Albany, Georgia, three separate areas of groundwater are polluted with cyanide and chloroform from various industries. One of the contaminated areas came from a landfill on the Marine Corps’ Logistics Base. The U.S. Navy has taken responsibility for the base and is providing residents in the majority African-American town with an alternative water supply due to the health risks associated with the pollution. Politicians and researchers say industrial sites are more likely to be located near low-income and minority communities.’More heavily polluting industries were located near communities of color or minority communities or poor communities because they didn’t have the political clout to fight back.

    The EPA estimates, now, that since 1987, various industries have dumped about 600 million pounds of toxic substances, including ammonia and nitrates into the Ohio river. Six hundred MILLION pounds of poisonous crap into the once pristine Ohio River. Cue Doc Watson singing On the Banks of the Ohio.

    No, don’t.

    In 2015, the top 1% of Americans made almost thirty times as much income as the bottom 99 percent — an increase from 2013, when they earned twenty five times as much. This from the Economic Policy Institute in DC. There is a racial divide, too. The billionaires who make up the Forbes 400 list of richest Americans now have as much wealth as ALL African-American households, plus one-third of America’s Latino population, combined. In other words, just 400 extremely wealthy individuals have as much wealth as 16 million African-American households and 5 million Latino households. (from Forbes own statistics)

    That is America today. And everyone knows it. But they can’t say it. They can’t look at it soberly and honestly. It is too much to bear.

    And America is exporting its misery at an accelerated clip. The far right fascist sensibility is growing across Europe. There are few NATO countries without a powerful fascist party participating in government, and in several places — Hungary, Italy, Poland, they ARE the government. And now Brazil. One might think the recent summer of apocalyptic fires in the U.S. would be a wake up call, but it’s not. The horror cannot be faced by most. Lying, family or household dysfunction, and chemical numbing are the ground floor reality today. When the ruling class own everything, people must find ways to cope. Once you have mastered lying to yourself, lying to others is easy.

    I almost do not exist now and I know it; God knows what lives in me in place of me.
    — Fyodor Dostoevsky, The Idiot, 1868–1869; separate edition 1874

    Of Course, Medicare For All would increase Federal Spending…

    Of course, a National Improved Medicare for All (NIMA) system would increase federal spending, but not by as much as they claim. NIMA would create a national health insurance, like most other wealthy countries have, funded only through taxes. This would replace our current complicated, privatized healthcare system, funded through a mix of premiums, out-of-pocket costs and taxes, which is the most expensive in the world. Countries that treat health care as a public good invest in a universal system because they know it improves the health of their people and is the most efficient.

    The United States currently spends twice as much as the average wealthy nation, over $10,000 per person each year. Unlike other wealthy nations, though, the US leaves tens of millions of people without coverage and tens of millions more with coverage but still unable to afford care. The US consistently ranks low in comparison to other countries on health outcomes. Life expectancy is declining in the US, now for two years in a row, the first time this has happened in over 50 years. Death rates for infants and mothers in the US are many times higher than in other wealthy countries.

    A single payer healthcare system like NIMA would decrease administrative costs and the prices of goods, such as pharmaceuticals, and services dramatically. Rather than having hundreds of different healthcare plans, each with different rules, there is one comprehensive plan with one set of rules. It would relieve families, employers, health professionals and hospitals of the burden of navigating the current complex system. Everyone is in the system for life. If a person needs health care, they see a health professional of their choice, the health professional cares for the patient and submits a bill to the system, or they are paid a salary, and that’s it. Simple. Just as it is in most other industrialized countries.

    The Mercatus Center study is flawed in serious ways. First, it analyzes the Senate bill, which was first introduced last September and has significant weaknesses. It would be better to examine the House bill, HR 676, which has been introduced every session since 2003 and is based on the Physicians’ Working Group Proposal by Physicians for a National Health Program, the leading experts on single payer health policy in the US (here is the updated proposal). Second, it grossly underestimates the savings of a single payer system and makes unrealistic assumptions about utilization of services.

    There have been many studies over the past few decades on how much money a single payer system would save in the United States. In 1991, the General Accounting Office found “If the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs [10 percent of health spending] would be more than enough to offset the expense of universal coverage.” Since that time, administrative costs have ballooned to one-third of our healthcare spending and the prices of pharmaceuticals have soared, so the savings would be greater.

    In 1991 and 1993, multiple analyses by the Congressional Budget Office found that covering everyone under a single payer system might increase spending at the beginning, but it would be offset quickly by the savings. Since then, studies by non-governmental institutions, including one by Ken Thorpe who, since his alliance with Hillary Clinton, now claims the opposite, have all shown that compared to other reforms, NIMA is superior in savings and in the number of people and benefits that are covered.

    It is important to distinguish between total healthcare spending and federal spending, the part the US government spends. Buried within the Mercatus Center study is a fact that the corporate media has missed. Although they estimate that federal spending would increase, because all health spending would become federal, they calculate that overall health spending would decrease by more than $2 trillion over ten years.

    Single payer systems save money. The only system we can’t afford to maintain is the current one. Private health insurers are insatiable. The government subsidizes them by hundreds of billions of dollars a year, and still they raise premiums and out-of-pocket costs and ask for more. Pharmaceutical companies are increasing their prices by as much as they can get away with. A single payer system is the best way to put private insurers where they belong, on the margins of our healthcare system, and to control the pharmaceutical industry.

    So, when you hear someone saying that NIMA would increase federal spending, tell them, of course, it does, that’s the point. Instead of paying premiums, deductibles and co-pays to a private insurer, we all contribute into a federal system that is there when we need it. But if they try to scare you with large numbers, tell them that single payer systems prove time and again they are the least expensive. If we want to talk about scary numbers, let’s look at how much the US spends on the military and have a conversation about priorities – ending lives or saving them.

    •   First published in Health Over Profit

    When Health Care is a Privilege and Physician Shadowing is a Right

    As it is presently constructed, the American health care system is predicated on the pernicious idea that good health care is a privilege. Meanwhile, medical students, residents, and other interlopers regard observing patients’ doctor’s visits to be their right, regardless of whether or not the patient’s consent has been obtained. This dichotomy embodies the egregious inequality inherent in the two-tier system, and is indicative of a complete inversion of the way any humane health care system must be ideologically oriented.

    The subject of physician shadowing is inextricably linked with unfettered capitalism and the neoliberal project, where the privileged few have a vast array of options in regards to where and with whom they can seek care, while the under-insured masses can spend countless hours – sometimes in vain – searching for the appropriate specialist that takes their insurance. If an under-insured patient is able to find a specialist that takes their insurance, they often fall prey to the scourge of nonconsensual physician shadowing, as they can be coerced into becoming a medical model and teaching tool without their consent.

    Physician shadowing must never be done without the patient’s consent, as this constitutes an egregious violation of medical ethics, patient privacy, and the patient’s moral right to meet with a physician in private should they choose to do so. Moreover, once a patient feels that their trust in the system has been violated, it will be extremely difficult, if not impossible, to ever fully restore it.

    While a great deal of lip service is paid to “privacy,” “consent,” and “the doctor–patient relationship” in American teaching hospitals, all of these things are summarily jettisoned once medical students and residents get inculcated with the idea that it is acceptable to shadow a physician regardless of whether or not the patient’s consent has been obtained. In actuality, physician shadowing is a privilege that can be granted by one person, and one person only: the patient.

    Under the neoliberal project, many physicians have been pulled inexorably into a vortex of amorality. This is because they are trained in an environment whereby the scourge of free market ideology has distorted their thinking and debased any sense of morality. Indeed, many young physicians are inculcated with the shameful idea that unless a patient has an excellent commercial plan privacy, consent, and confidentiality should have no bearing on the care they will receive.

    Medical schools compel undergraduate pre-med majors to shadow a physician for a significant number of hours. This practice should be banned, as these students are not officially medical students. Consequently, they are totally unvetted. Allowing high school students to shadow a physician, or observe medical personnel at work in an emergency room or operating room, is an outrage. Having a secretary serve as a “chaperone” – deemed desirable by some physicians, as this can protect them from lawsuits – is likewise unethical and thoroughly repugnant.

    The dismantling of the humanities has played a significant role in fomenting dehumanization and moral bankruptcy in health care, because without the humanities, many health care professionals have lost their ability to be compassionate and empathetic. Indeed, without a humanities education, what separates a urologist from a plumber, or an auto mechanic from a gastroenterologist?

    In an online discussion on forums.studentdoctor.net titled “Isn’t Shadowing Intrusive?” doctors and medical students nonchalantly discuss physician shadowing. One philistine writes, “If you agree to the student being in the room, how is your privacy being violated? Everyone should stop being so hysterical – if the patients don’t like something, they can speak up.”

    While another defends the right of undergraduates to shadow: “Medical training has to start somewhere. There is not (or shouldn’t be) a glaring divide between premedical and medical education. Better to make sure our students are better prepared for medical school and know what they are getting themselves into. And if anything, many patients are happy to have someone else to talk to. It never was a problem when I shadowed.”

    Actually, many patients are interested in talking with a physician in private – and without interlopers barbarically violating their privacy. In all the many times I have experienced this at Weill Cornell and Sloan Kettering, never was my consent first obtained. In fact, at Memorial I had to complain dozens of times before my request to meet with my various doctors in private was finally granted. There are certain departments at Cornell where you can issue complaints ad nauseam, yet they will still not allow a patient with inferior insurance to meet with an attending physician in private.

    Another morally bankrupt knave writes: “I’ve seen at least 100 patients in shadowing experiences. Not one asked me to leave. If you’re at a teaching hospital, and the patient has been there before, they know the deal.”

    “The deal” is that there is a crisis in American health care, where all too often patient privacy is nonexistent. Also, the notion that patients can easily object is deeply fallacious. Would this hold true with the under-insured, who are acutely aware of how limited their options are? Even a patient with the finest insurance may have a hard time objecting to unwanted observers at Sloan Kettering, as Memorial has a policy of denying patients the right to change from one oncologist to another within whatever department they are ensconced in. Moreover, as these comments demonstrate, the cavalier dismissal on the part of many medical students, residents, and attending physicians that nonconsensual physician shadowing could leave patients with real emotional scars, is indicative of an extraordinary degree of insouciance regarding the delicate nature of the doctor-patient relationship, as well as a deep-seated callousness and moral bankruptcy that has metastasized throughout our entire health care system like a cancer.

    Once the callow are inculcated with the idea that nonconsensual physician shadowing is an acceptable and everyday part of learning how to be a doctor, what follows? Catheterizing anesthetized patients without their knowledge? Having medical students do practice pelvic and rectal exams on anesthetized patients? Willful nondisclosure of long-term chemotherapy side effects, such as cognitive difficulties and early menopause? Over-prescribing opioids? Psychiatrists overprescribing psychotropic drugs? Indeed, these are things that have already come to pass.

    It is unequivocally true that the principal devils in the American health care crisis are the private insurance companies, the pharmaceutical industry, and the hospital administrators. Yet throughout my many long and arduous years as a patient, I have witnessed medical students, residents, and fellows instructed by attending physicians to do things that are undeniably unethical. All too often their medical training is corrupted by the two-tier system and the moral bankruptcy that this spawns.

    What kind of doctors will medical students and residents become, when every day they are immersed in an environment where do no harm applies to a privileged few? Where the haves are endowed with an endless array of good options, and the have nots are commodified and railroaded into resident clinics which prey on the under-insured, and which coerce patients into surrendering all vestiges of privacy? Privacy, confidentiality, and consent are foundational to any humane health care system, and once they become a privilege for the few, the very basis of medical ethics is torn asunder.

    Capitalism has distorted and inverted our sense of morality – so that rights such as good health care, a good education, equality under the law, safe drinking water, affordable housing, etc. – have become privileges, whereas privileges, paradoxically, have become rights.

    Once at Cornell Dermatology, I was subjected to an examination with a resident present and a nurse going in and out of the room, despite my requests to meet with a dermatologist in private. As I am at risk for melanoma and was overdue for a checkup, I deemed the visit to be medically necessary. Moreover, had I elected to go somewhere else (a specious argument frequently posited by anti-privacy ideologues), the other dermatology departments in Manhattan that take my insurance are run in a similar fashion. This is not a coincidence, as those who manage resident clinics are acutely aware of the fact that many of the under-insured who walk through their doors have few if any options.

    I often think about this resident, and whether she was cognizant of the fact that she played a role in egregiously violating my privacy, as well as the oath that she took to do no harm. Did she fail to see the double standard – that she was participating in an assault on a patient’s privacy that she would vehemently object to – indeed be mortified by, herself? She has since completed her residency at Cornell, and is now ensconced at the dermatology department at The University of Pennsylvania. While these things may look nice on one’s resume, I can’t help but wonder how many hours she had to spend shadowing, and how much of this shadowing was done without the patients’ consent. I can only hope that now that she is an attending physician, she can use her influence to give patients a choice in regards to whether observers are present during their doctor’s visits, and that this will be done regardless of what type of insurance these patients may have. It is regrettable that for many ambitious young doctors privacy and consent matter little in the face of blind obedience, authoritarianism, and careerism.

    Doctors know much more today than they’ve ever known before. Yet ironically, they are trusted and respected less than was the case in the 50’s and 60’s. Losing their autonomy to the private insurance companies, as well as being forced to see an increasing number of patients each day, have undoubtedly played a role in the diminishing of the doctor’s prestige. However, a growing number of patients are acutely aware of how morally compromised many doctors have become, as unfettered capitalism and the profit motive have come to permeate and defile the very soul of our society. Indeed, many physicians that ardently defend nonconsensual physician shadowing, are the first to use their superior health insurance plans to avoid this very thing when it is time to see a doctor themselves.

    It is deeply disturbing watching medical students and residents being instructed to obey unethical orders from an attending physician. Only with a single-payer system will we disenthrall ourselves from the barbarism of the two-tier system – a system which destroys the souls of doctors and patients alike.