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Book Review
Title Terminal Consent
Author Michael Freeny
Publisher Orlando: William Austin Press, 1998.
ISBN 0-9663686-6-5
Pages 371
Price na
Reviewer Dr George Halasz
Honorary Senior Lecturer
Department of Psychological Medicine
Monash Medical Centre, Victoria, Australia
& Consultant child and adolescent Psychiatrist.

Michael Freeny's docudrama novel gives Australian readers a compelling context in which to understand US President Bill Clinton's forceful State of Union Address, in January 1998. The President advocated for a new "Consumer Bill of Rights" for the 160 million Americans enrolled in a managed health care plans, declaring:

"Every American deserves quality care. You have a right to know all your medical options, and not just the cheapest. Medical decisions ought to be made by medical doctors, not insurance company accountants."

Michael Freeny, a Florida writer and psychotherapist, provides a riveting insider's view of America's largest service industry - market driven health care. His is a chilling account of cybercare gone mad. Freeny notes at the beginning of his book that the technology described in the novel is currently available. Thus this book could also serve both doctors and the general public as a primer in the intricacies of the deceptive practices of managed care. Indeed, a note at the end of his book notes that 'Healthcare professionals may be eligible to earn continuing education credit for reading this book.'

The plot is simple. A corrupt for-profit health insurance company weaves a tangled web of intrigue, corruption and murder. The riveting story documents the cost of human suffering paid by families to provide the health insurance industry with huge company profits and CEO salaries; the erosion of patient rights; the sinister corporate deals made on the megabucks diseases of cancer, heart disease and strokes; and how the allotment of contracted care becomes part of profiteering schemes.

An awful reality is exposed: the insurance company's confidential database is perversely used to blackmail its naively trusting members. At the heart of the story is a Big Brother Health Company, with a super computer programmed to deny access or eligibility to patient care by methodically avoiding claims.

How did all this happen? The game plan was simple: the insurance lobbyists' launched a brilliant campaign that systematically labeled doctors as 'greedy' providers, ripping off patients and the government. Sounds familiar? They keep the spotlight on those few bad apples, in order to keep the public attention off their sinister corporate schemes. Next, they offered the government a way to control those 'greedy' health professionals.

The computer-assisted corporation becomes the new robber barons.

Reading Freeny's book I recalled John Grisham's film the RainMaker. That film depicted the breeding ground of negligence, the new health culture in the US. Freeny's parable captures the birth of that culture: a farmer was worried about the eggs in the chicken house being snatched by some weasels, so he throws in a couple of wolves, to stand guard. Now the wolves are looking pretty fat.

As the book exposes the stealth and subversion of the health insurance company Great Health Benefit (GHB) and the programmers of its supercomputer MOM (Multiaxial Outcome Management), a secret, sinister reality emerges, too close to home for comfort. Protected under proprietary laws, thus safe from any accountability to, or scrutiny by, law, the computer's formula for cybercare is actually determined by profit. To serve that end, MOM engages in what amounts to pseudo-consultations: case after case, a semblance of delivering health care which on closer inspection in fact turns out to be gross mismanagement and negligence!

Here the familiar US for-profit style of managed care horror stories come to life: ordinary people run the gauntlet of MOM's programmers: the desperate mother refused treatment for her child; the elderly husband caring for his dying wife is refused analgesics because pain relief extends the duration of life and thus the cost of care; the post operative patient dying of computer assisted neglect The stories build a disturbing picture of denial of basic patient rights.

Standing up for patient's rights has become a matter of urgency in the US and increasingly so in Australia. As the protective walls of medical confidentiality and patients rights to privacy become eroded, the floodgates for abuse open: health systems, instead of serving their subscribers have become a radar screen to vet 'costly patients' as 'bad risks'. In the US this has led to the encouragement of the 'die cheap' philosophy.

According to Freeny, health insurance companies, the new robber barons, now expose their members to other abuses: the confidential information entrusted to their huge databases is now shared, under health information trustees that include hospitals, clinics, support medical personnel, laboratories, case managers, utilization reviewers, insurance managed care entities, employers, third party health administrators, health care researchers, and on so on for 14 more categories.

In summary, according to Freeny the only way to guarantee privacy of medical records is to pay cash, under an alias.

We may well ask where this cut and dried cybercare clinical decision making could lead? If the duty of care, the rights of patients, medical confidentiality and the criteria of medical necessity are all rewritten to assure maximum company profits, are we heading for the Brave New World of government sanctioned medical abuse? Is protest really an exercise in futility? I do not think so.

There are medical traditions worth preserving.

While many US health companies on the Wall Street stock exchange are rolling in profits, they are also the focus of mounting lawsuits and federal and state investigations. While paying their executives and shareholders handsome profits, there is a growing backlash against their unscrupulous business practices.

The Australian community would be making a serious mistake to ignore the painful lessons being learnt by the American medical profession and patients alike. Let us not be tempted to repeat their mistakes!

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Terminal Consent






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