Philosophy

The “smarter medicine” movement uses the choose wisely campaigns to influence all Western healthcare systems with its ideas.

It is a well-packaged rationing movement that fundamentally questions the effectiveness of medical actions on behalf of a few and irrelevant medical procedures. The secret intention behind this is to reduce medical costs while increasing happiness and well-being in the population through avoidance of harmful medicine.

Choosing Wisely is an utilitarian movement that seeks to justify the distribution of limited resources and to eliminate allegedly unnecessary medical treatment.

It is not clear where all the money saved will go, nor do we know whether the concept of distributive justice destroys the security of supply and by that ultimately increases costs.

It is a gut feeling movement. The medical profession reacts with increasing fatalism, burnout, opposition and depression. One’s own education, one’s own medical knowledge, is completely threatend by the claim of economic distributive justice.

The resulting therapeutic frustration not only destroys the patient’s trust in the doctor. It also leads to medical nihilism and pessimistic medicine. This is the opposite of what may happen in a therapeutic relationship.

The medical helplessness sometimes discharges on the patient. Claims and desires are answered with the question, “Do you want to live with it for another five minutes longer?”, as a housedoctor told a patient recently who was taking Ezetimibe, a cholesterol lowering drug.

The bioethical-utilitarian movement is in the process of replacing the pillars of the medical profession. Instead of the “primum nil nocere” is now the “primum numquam nocere” and thus the abolition of medicine.

Instead of optimistic motivated treatment, the necrophilous beautiful accompaniment into death (pulchra mori) is the new goal of treatment, the premature termination of a socially and economically considered low-valued life.

While elsewhere such actions are unthinkable, in Switzerland they work to subordinate life to the totalitarian claim of economy.

The result is a desolidarization within society. Centripetal forces are served, the individual is more and more thrown back on himself, excluded from his social network, the egoisms of the healthy and the nihilism of the sick become the new norm.

Parlance

Legal requirements appropriateness, effectiveness and economy define the framework conditions for the health service (WZW Rule).

In the context of these terms, medicine has been developed and is evolving, on the one hand as a scientific, on the other as a social system. However, the success of medicine is also based on the ethical principles that have been in force for millennia, from which altogether the normative has developed in medicine. This means, among other things, that the order, at first not to harm “primum nil nocere” should minimize nocebo effects. Conversely, this means that the placebo effects of the medicine are part of the positive affection and mediation of confidence, hope and relief or healing.

The functioning of medicine as a social and scientific system can be irritated by foreign influence, but not controlled (Niclas Luhmann). According to this, medicine can only become more inefficient by influencing foreign systems (VEMS, the association for ethics and medicine Switzerland, has published a position paper on utilitarianism in health care.)

Foreign influence on medicine thus leads to irritation. This is made operational by the use of language, and especially there very clearly visible. Medicine no longer needs to be functional and effective for the individual, but useful at the societal level. The usefulness of medicine is alien to it, since it was not designed to offer society a total benefit. In this context, medicine becomes a department of economics, always based on limited resources.

Medicine is now judged to be useful or not useful by health economics. Useful is what has been useful, not what could be effective and expedient. The location of the health economy is temporally downstream of the medical action and thus completely foreign to medicine, since medicine must act and hope a priori.

The positive attitude of medicine towards the expected effect is a cornerstone of medical activity. Health economics doubts the effectiveness of medicine simply because it does not work at all, wasting money that would have been better spent elsewhere. It thus conveys a negative attitude towards medicine, which in turn undermines trust and opens the door to pessimism in medicine.

With the introduction of the concept of utility in medicine as a social system, the pessimism against the usefulness of medicine unfolds, which is now automatically linked to expediency. That medicine sometimes does not help and sometimes even harms is the inevitable side effect, which faces every effect of medicine.

The SAMW is now taking a further step, in which the goal of medicine should not be to harm. Prof. Kind, President of the Central Ethics Council of the SAMW writes this in a draft for dying in Switzerland. This means: instead of the “primum nihil nocere” Prof. Kind introduces the “primum nunquam nocere”, he wants that the medicine does never – in now case – harm,  which by consequence is the abolition of the medicine itself. Effective medicine will always include the possibility to harm.

With that we have reached the point of irritation. If one understands medicine from the point of view of  health economics,  medicine belongs abolished, since it harms.

Conveying confidence, hope and relief or healing are replaced by the doubt of medicine itself. Choosing Wisely wants in the context of the Smarter Medicine movement nothing else than the waiver of the use of medicine in case of need. It would therefore be wiser to wait and see or avoid the medicine completely. What is not mentioned here: the origin of this message lies in the supposedly high cost of medicine.

Smarter Medicine with the demand for wise selection are terms that are foreign to medicine. There are no logical studies that examine the effect of these terms in medicine. It lacks the ethical basis. If, in fact, a study were conceived which would base an expected and effective therapy on the “choosing wisely” principle, e.g. 50% of subjects would not receive the therapy, any ethics committee would have to reject this study worldwide.

The propagation of the new terms Smarter Medicine and Choosing Wisely by medical societies massively irritates the structure of medicine as a scientific and social system. In addition, there are no legal foundations for this. The WZW rule would have to be completely rewritten.

In summary, the introduction of terms such as smart medicine and choosing wisely in medicine shows the irritating potential for medicine, a new force whose harmful effects will be judged by future generations. However, what makes you aware of this is that it is often medical doctors themselves who want to completely override the medical system.

Ultimately, the medical profession will have to split. In those who adhere to the WZW rules and implement them in everyday life, and in those who are smarter than the others first and make wiser decisions.

Implications

Smarter medicine is an authoritarian movement that understands choosing wisely as a command. The impact of this movement on security of supply has not been explored.

On the patient side (patient centered view), the uselessness of medicine and the dangers, if used nonetheless, are linked as an action path with a wise decision. However, such wise decisions serve only the rationing of medical services. The problem here is the burdening of medical decisions on the patient, who asks a question of medicine: if I am healthy, I am ill. This question is no longer possible, with the state of health associated fears are reflected back to the patient. As a result, one forces the patient to solve his own health problem himself. This is also desirable, because only when the patient does not even go to the doctor, the system can save money. The situation becomes particularly uncomfortable for people who are actually ill or for those who are close to the end of their lives. This is where “choosing wisely” claims arise, which can only be solved with self-euthanasia. The quality of life is also endeavored. The quality of life is worsened by medical measures or the accompaniment of illness and dying without too much medical activism understood as a new romance about illness and death. Scientifically, this discourse is supported by the QALY parameter, according to which, for example, the national research project NRP 67 asks what the people are willing to pay for a year of life in good quality (Telser, Polynomics, Beck, CSS Versicherung).

On the physician side, any cost causation is primarily presented as a waste of economic resources. Thus, the doctor passes hope and positive thinking in favor of primary cost considerations. This perverting of medicine and the WZW criteria is consciously generated by the protagonists of smart medicine, in order to put pressure on the doctors to look primarily at the costs. The scientific content of the “voting wisely” list is completely irrelevant. It is merely an excuse to install the economic discourse as primum movens in the mind of medical doctors in the context of medical discourses, ie brainwashing. With this, the smart medicine movement is clearly leaving the soil of the medical sciences and making itself a henchman in health economics.

In the synthesis, smart medicine causes an abolition of medicine as a problem-solving offer, for which the patients finally pay their premiums. Instead of professional assistance, the patient receives rejection and a guilty conscience for daring to make his “problem”.

The sponsorship of smartermedicine.ch is composed as follows:

Swiss Society of General Internal Medicine (SGAIM), www.sgaim.c
The Swiss Academy of Medical Sciences (SAMS), www.samw.ch
Umbrella Association of Swiss Patients’ Offices (DVSP), www.patientenstelle.ch
Swiss Foundation SPO Patient Protection, www.spo.ch
Swiss Association of Professional Organizations in Health Care (svbg), www.svbg-fsas.ch
physioswiss – Swiss Physiotherapy Association, www.physioswiss.ch
Foundation for Consumer Protection, www.konsumentenschutz.ch
Fédération Romande des Consommateurs (FRC), www.frc.ch
Associazione Consumatrici e Consumatori della Svizzera Italiana (acsi), www.acsi.ch

Legal Aspects

Medical services must comply with the WZW criteria:  Treatment must be “a priori” effective, useful and economical. The expert opinion on efficiency improvements of 20% -30% in the annual costs of the health care system now amounting to 80 billion francs per year comes from a posteriori estimates and have no relation to the medical reality at all.

A doctor is required to act a priori in accordance with the WZW criteria, even though he knows that the treatment does not work the same for everyone at all or at all. Boosting efficiency here would mean rationing services where the likelihood is low enough that the therapy works or the imaging shows an unlikely pathology, according to the motto of choosing wisely and smarter medicine: “where there is probably nothing, there is nothing”.

Such systems of thought are neither based on medical verified evidence nor do they have a legal basis for this: namely, there are also issues of relevance to the law and the destruction of constitutional guarantees concerning the excellence mission of our health services http://docfind.ch/Kieser052015.pdf and The opposite is the danger of an increase in inefficiency.

Statistical Aspects

Choosing Wisely and Smarter Medicine want a rationing of medical services by claiming that less medicine is better for health. The basis for this is the high cost of health care and not scientific evidence.

Naturally, medicine always works a priori, the result can be assessed a posteriori. The a priori estimation thus always corresponds to an estimation regarding the probability that the a priori expectation becomes true a posteriori.

This can be exemplified by a medical test (it could also be a medical treatment). The doctor suspects a diagnosis due to the discomfort, e.g. typical symptoms of coronary heart disease in a 40-year-old woman. The probability of pretest due to age, gender, discomfort and risk factors is 10% for typical cardiac symptoms for constriction of the coronary arteries.

In this context, Choosing Wisely means that no further investigations will be carried out, since in 90% nothing is found anyway and the costs for further clarifications can amount to between 5’000 and 8’000 Swiss Francs.

The refusal of further diagnostics leads to the fact that 10% of the diagnoses are missed. Extrapolated to the diagnoses altogether a horrendous idea.

With missed diagnosis, this patient will suffer a heart attack, sometimes with fatal consequences. An excellent healthcare system can eliminate such dangers and avert such dangers early on. The smarter medicine movement is making fun of it. It waits for the first time, especially when the doctor is still under the pressure of a capitation – so a global budget.

In Switzerland, 5 million citizens are insured in such capitation models (about 60% of the population). So far, nobody has been interested in what the implications of missed diagnoses in these models mean for patient safety, for avoiding unnecessary follow-up costs, and for indirect costs at the societal level.

Swiss Academy of Medical Sciences (SAMW)

Summary

The normative statements of SAMS on terminal care and assisted suicide must be understood as a contribution to the smarter medicine movement. In the foreground, according to Prof. Dr. med. med. Christian Kind, St. Gallen, questions about quality of life, the benefit to the effort – and thus to the cost -, the disempowerment of medicine, which must never hurt, the new standard that shutting down life-sustaining measures is not an active killing, the utter The absence of a proposal for accompanying scientific research in the context of killings and suicides and the emphasis on subjectivity instead of social dying, and thus an individualization of death in over-reliance on the patient alone.

As a result, the threshold for killing (euthanasia) and suicide (assisted suicide) is lowered and linked with new ethical and legal norms that increase the social acceptance of voluntary retirement from life, and thus implicitly, for cost reasons, become the new norm To die.

With this, the SAMW declares its utilitarian view of health care and again declares itself to be the protagonist of a rationing movement in Switzerland. A corresponding disclosure at ZEK and SAMW is now required.

Contribution

Particularly interesting is the active participation of SAMW in the smarter medicine movement. It is therefore necessary to examine the extent to which the SAMW implements new norms for dealing with dying and death in the new medical-ethical guidelines of the SAMW, which advocate the rationing of medical services in life-weary persons or people towards the end of life or in the process of dying. These are mainly Chapter 6.2 (Actions Controversial), Chapter 2 (Ethical Principles), Chapter 5 (Guidelines for Decision-Making) and Chapter 6 (Actions that may or may not be the cause of death accelerate).

Prof. Kind, the president of the self-proclaimed Central Ethics Committee (not to be confused with the National Ethics Commission), first formulates the three principles. 1. Aim of the medical action. 2. Self-determination rights. 3. Protecting the patient from himself (“… be protected from uncritically fulfilling the wishes expressed by them, even though they do not conform to their enlightened, free and well-considered will”).

As feared, the SAMW wants to make better use of the potential for rationing in dealing with the mortality costs via these steroid guidelines. This is achieved through numerous gray-zone proposals, which then leave it to the individual to make “subjective” decisions without further control.

The following specific proposals for standards of the SAMW are to be discussed:

The right of self-determination is placed before the dialogue and thus the personal rights of relatives, and thus the entire social context of a person secondary.
The quality of life is taken as a measure of action, although the temporal limitation and enormous subjectivity of quality of life may be subject to massive fluctuations. The proposal aims at not supporting life with poor quality of life if possible
Suffering and suffering reduction should be in the foreground and can also be abbreviated, e.g. the purpose of the treatment (Chap. 2.5) is to seek the quickest possible death.
In the decision-making processes, the suicides should be increasingly included, without it being clearly defined on which medical basis decisions are made at all.
In the event of disagreements, the cantonal adult protection authority is ultimately to be consulted without discussing the role of these authorities in the event of terminal care.
Intensive care measures may only be started or continued if there is a reasonable prospect of continuing to live with a reasonable quality of life outside of the acute medical environment. Therapies without
Prospects of success can not be claimed by the patient or relatives. However, an adequate quality of life is not defined
In the standardization of assisted suicide by doctors, the SAMW remains daring, it leaves it to the discretion of the doctor, whether a suicide escort is a goal of medicine
The elimination of death by stopping a life-sustaining measure at the express request of the judgmental patient is not an active killing. This standard explains the ZEK by the text-free footnote 25. The footnote 25 refers to the text-free footnote 12. The footnote 12 refers to Chapter 2.1 of the Annex. There, proposed treatment goals are defined, and under 2.1.4 the target is mentioned: “the intended induction of death in the most painless and least burdensome way. The medical action is primarily with this intention “. The SAMS here speaks of euthanasia as a possible treatment goal, but claims earlier that stopping life-sustaining measures would not constitute active killing. The SAMW / ZEK therefore proposes in all seriousness that euthanasia in medical practice is considered a penalty-free act, that it is not an active killing.
Goals of medicine: It must not hurt. This new norm abolishes medicine.
The word benefit as a new norm in the medical context has to be read in the Kotext of the relationship between costs and benefits:
In the context of a limited therapy, individual life-sustaining measures are dispensed with, because the associated impairment of the quality of life the expected benefit of a possible gain in life expectancy from the perspective of the patient
exceeds or wants the therapy waiver for other reasons.
In the case of omission or termination of a potentially life-sustaining treatment, it is generally assumed that this leads to a shortening of the lifespan. Time and again it turns out, however, that after discontinuation of therapy, the opposite may be the case
can, because the discontinued therapy has done more harm than good.

The normative of the subjective can also be read from

that no accompanying research is required
that the discussion about the prognosis is left to the subjective assessment or remains completely unregulated,
(QALY) (see also constitutional problems in Switzerland) Link as well as the problem of QALY as a scientific instrument link as well as the complete rejection of a 1’500 European expert group on the QALY Link)
that the subjectivity of the helper is not adequately addressed,
that the instruments for verifying problematic death wishes are not sufficiently explained and
that the assessment of the chances of survival or medical therapies should be left to the subjectivity of the physicians,
that the fear of total dependence is not addressed and how it should be addressed
the treatment goal «termination of life»,
to the disposition position of the ethics as normative force with the concept of the “gray zones ethics” as well
the gross lapse to the order of the medicine concerning “primum nunquam nocere”.
the concept of judgment is neither legally nor medically defined and remains so dangerously approximate
The topic of demarcation of palliative medicine and exit institutions is not discussed
the duty to supervise is not discussed
the accompanying research is not addressed
the issue of public communication and the question of whether advertising is allowed is not addressed
The financing of the accompanying suicide is not discussed
The clarification regarding the motives in the desire for assisted suicide without illness is not sufficiently defined.

Specific problem zones:

Page 4: Custom information is not defined.

Page 5: Complete education about the medical situation is not defined. In case of an error in the prognosis, the patient may be mortally afraid. It is essential to include the doctor’s philosophy, especially regarding the attitude to hope, optimism and pessimism. Spreading fear and panic with the goal of saving money can drive people to their deaths.

Page 6: Affliction by relatives in the direction of suicide presupposes that the assessor has information about the financial situation. This generally raises the question of what information should be available in advance of a conversation with the suicidal will and the relatives at all.

Page 6: It is highly questionable whether the assessment of quality of life should be considered a criterion for medical treatment. This claim goes in the direction of QALY. Medical treatment does not become inappropriate because of the quality of life. Here, the SAMW aims at rationing cancer treatments, e.g. Cause nausea. Here a paradigm shift is introduced, which is extremely problematic. A reduction in the quality of life can certainly be accepted if the situation regarding improvement of the prognosis allows this optimism. It is especially dangerous if the quality of life is judged on the basis of “objective observation”.

Page 8: It is not just a question of whether the intention of the therapist is clear, but what attitude he takes regarding worthy and unworthy life, quality of life, optimism and pessimism. Here It needs a clear definition because there is a danger that compassion kills.

Page 9: Here too a meaningful treatment and the associated hope can be prevented by “too early”. The question is what defines high probability and what prediction defines.

Page 11: Best possible evidence is not defined. It must be defined which elements make such evidence possible.

Page 13: It is not clear how a hopeless treatment is defined. Here a great deal of subjectivity can aggravate a situation.

Page 17: Again, there is no information about what constitutes careful information.

Page 18: There is no definition of what information is required to detect a problematic dependency ratio.

Page 23: Ending life as a treatment goal is a very dangerous proposal and is probably aimed at rationing (shorthand for the inevitable dying process).

Page 24: The claim of “no harm at all” is nowhere to be found, and here too corresponds to the desire for rationing services that could be detrimental. Almost all the medicine would then be obsolete. It must mean “primum nil nocere” and not “primum nunquam nocere”.

Page 25: With the term “ethical gray area”, the SAMW gives way to ethical-normative guidelines and declares ethics itself a gray area. The term is wrong in and of itself.

Responsible Subcommittee

Prof. Dr. med. med. Christian Kind, St. Gallen, Chairman

Dr. med. Daphné Berner, Corcelles (former Cantonal Physician)

Susanne Brauer, PhD, Zurich, Vice President ZEK (Ethics)

Sonja Flotron, Reconviller (Nursing / Palliative Care)

Dr. phil. Heinz Gutscher, Zurich (Social Psychology)

Prof. Dr. med. iur. Daniel Hürlimann, St. Gallen (right)

Dr. med. Samia Hurst, Geneva (Ethics)

Dr. med. Roland Kunz, Zurich (Geriatrics / Palliative Care)

Dr. sc. med. Settimio Monteverde, MME, MAE, RN Zurich (Nursing / Ethics)

Dr. med. Hans Neuenschwander, Lugano (Oncology / Palliative Care)

Dr. med. Hans Pargger, Basel (Intensive Care)

Dr. med. Florian Riese, Zurich (Psychiatry / Palliative Care)

lic. iur. Michelle Salathé, MAE, Berne, ex officio (law, SAMW)

Dr. med. Walter Reinhart, Chur (internal medicine)

Dr. theol. Markus Zimmermann, Fribourg (Ethics)

Additional Experts

PD Dr. med. med. Klaus Bally, Basel

PD Dr. med. med. Georg Bosshard, Zurich

Prof. Dr. med. Steffen Eychmüller, Bern

Prof. dr. iur. Bernhard Rütsche, Lucerne

Bianca Schaffert, MSN, Schlieren

Dr. med. Marion Schafroth, Liestal

Dr. med. Jan Schildmann, Bochum

Prof. Dr. med. med. Friedrich Stiefel, Lausanne

Dr. med. Henri Wijsbek, Amsterdam