Preventive Health care, John Edwards style

On the front page of Sunday's Philadelphia Inquirer is a shocking expose on what I think is a corruption of medical practice -- the fact that the once-risky (and distinctly icky if not unnatural) procedure of delivering babies by cesarian section is "now is used in about a third of U.S. births":

"This is mostly about changes in culture," said Eugene Declercq, an expert in maternal and child health at Boston University's School of Public Health. "In all the gray areas of clinical decision-making, obstetricians have moved to cesareans. Mothers are more accepting, too."

Cesarean critics worry that doctors are frightening mothers into the surgery.

"A woman who is given reason to be scared that something bad might happen to her unborn child will do anything to avoid it," said Jose Gorrin Peralta, a University of Puerto Rico obstetrician. "If the doctor says, 'Your baby could die unless I do a cesarean,' what woman is going to say, 'Don't do it'? I call it obstetrical terrorism."

Far be it from me to call it "obstetrical terrorism," but if we must call it that, shouldn't we also be looking for the root cause? Is it that there's a new generation of doctors who just enjoy cutting women open? Or is something motivating them?

Sure, it's easier to perform a c-section than ever before, but the rates are still four times that of a normal delivery. The Inquirer hints at economic factors:

....the specter of lawsuits heavily influences the use of cesarean.

At Lankenau, for example, the cesarean rate rose from 28 percent in 2001 to 36 percent the very next year. The jump was largely triggered by a lawsuit contending that a child was born with cerebral palsy because a cesarean was not performed. The parents won a $24 million verdict.

"You can imagine there is that fear of what can happen," said Nancy Roberts, the chief of obstetrics.

A Pennsylvania State University College of Medicine study of 31 hospitals found that the more physicians perceived they were at risk of being sued, the more cesareans they did.

I know Lankenau Hospital very well, and the implications of the statistical change shocked me.

I think it is a violation of the Hippocratic Oath for a doctor to take into account potential legal liability in deciding to cut a woman open instead of waiting for nature to run its course.

It's not preventive health care on behalf of the patient; it's preventive legal care on behalf of the doctor and the hospital.

Doctors, of course, counter that it isn't their fault, and a number of commentators have pointed the finger at John Edwards:

Edwards specifically has made much of his fortune suing doctors for not performing C-sections, arguing that they help prevent cerebral palsy in children. In 1970, six percent of all births were C-sections; in 2003, that number had climbed all the way up to 28 percent. However, as John Stossel reports, there had not been a decrease in prevalence of cerebral palsy during that time. Hence, although Edwards' lawsuits have not, apparently, prevented anycases of cerebral palsy, they have, at least in part, yielded a great increase in the occurrence of C-sections. Now doctors do C-sections "just to be safe," meaning safe from lawsuits, though the procedure is not so safe for mothers. While C-sections are not overly dangerous, women are four times more likely to die during a C-section than during vaginal birth; this is not an insignificant risk.
Michael Fumento has more on the c-section scam, especially the role of John Edwards:
Medical malpractice was his specialty, and he reportedly tried more than 60 such cases, winning more than $1 million in over half of those. Most involved Ob/gyns. Indeed, he was so feared, according to the Center for Public Integrity, "that doctors would settle cases for millions of dollars rather than face him at trial."

Edwards' specialty was cerebral palsy, a set of permanent conditions affecting control of movement and posture that usually appear at toddler stage. There is no cure, although stem cell studies in both humans (umbilical cord cells) and rats (neural cells) have produced promising results. More than 10,000 U.S. children are diagnosed with it yearly. Edwards claimed the disease developed because negligent doctors ignored fetal heart monitors indicating the child might not be getting enough air during birth and thus failed to deliver it immediately through cesarean surgery.

Yet Edwards won his cases not because scientific evidence favored him but because of his smooth-talking "trust-me" demeanor -- and heart-wrenching pleas in which he ghoulishly sometimes pretended to be the voice of the unfortunate child crying out for justice.

The rise in c-sections parallels the rise in this legal strategy:
in what's called "defensive medicine," lawsuit fears increased the number of "When in doubt, cut it out" C-sections. Cesareans in the U.S. had begun dropping in the late 1980s, going as low as 22 percent of deliveries. As Edwards and friends spread fear across the Ob/gyn land, rates began to climb again. The rate is now 30.2 percent, a record high for the nation.

There are probably many reasons for the increased popularity of C-sections, before and after the Edwards era. One is that women often choose it over the pain of labor Dr. Bruce Flamm, clinical professor of Ob/gyn at UC Irvine, told me. Still, "The biggest reason is probably the litigation issue" he said.

Photos released by the Edwards campaign often feature him surrounded by his wife and kids. No doubt he loves them very much. It's too bad he thinks so little of the families of others.

One advantage of blogging is that I'm allowed to mention stuff that the Inquirer fails to mention, and I can easily understand why John Edwards' role in the rise of c-sections might be off-limits.

I'm not saying this is the Inquirer's fault, either.

There's just too much money involved, and too much money is why there will never be meaningful tort reform, as trial lawyers like Edwards fill the coffers of the Democratic Party money machine.

But Edwards is a man of the people, right? There's been some discussion recently which was linked by Glenn Reynolds to the effect of how unfair it is that rich guy like Edwards is seen as phony whereas in the old days, the sincerity of patricians like FDR went unquestioned. I agree with Glenn that identity politics is largely to blame -- because it assumes that in order to speak for the poor, you must be poor, in order to speak for a woman you must be a woman, etc.

....FDR was a rich guy who cared about the poor, he says, so why can't John Edwards be?

Well, John Edwards is no FDR. But the answer to Krugman's complaint is found in the post 1960s political zeitgeist. Back before identity politics, and the notion that "the personal is political," the idea of a rich guy representing poor people was entirely plausible. He could be rich, but still have ideas about poverty, and care about them. But now that we have identity politics and the like, that's impossible: If only a woman can represent women, only a black person can represent blacks, etc. -- Barbara Boxer even suggested that Condi Rice couldn't understand mothers because she was childless -- then obviously only a poor person can represent poor people. And since there are no poor people in American political office, poor people perforce go unrepresented. Thus, the "progressive" causes of identity politics and personalization mean that the progressives' key clients can't get "authentic" representation. This is probably bad for the country, but it's certainly a bed that the progressives have made for themselves.

It is a shame, because I'm sure there are progressives like FDR who should be able to legitimately advocate on behalf of the poor.

His father James Roosevelt was heir to a huge coal and railroad fortune, while his mother Sara Delano was heir to an opium fortune amassed by her drug-smuggler father. Such a background might (along with heavy influence of Endicott Peabody) well have contributed to the development in young Franklin a sense of guilty noblesse oblige, and a genuinely earnest desire to help the poor.

No matter what might be said about the sources of FDR's parents' income, no one can say that he made money by taking it from the needy (especially in the form of 40% contingency fees).

I agree that John Edwards is no FDR.

And while I don't agree with the way identity politics has thwarted genuine noblesse oblige, I don't think the man has any more moral authority to speak for the poor than anyone else.

I'm not even sure that Edwards has earned the moral authority to speak for the handicapped babies he's enriched, because he's taken so much of their money doing it.

What about the pregnant women who've been hoodwinked into having themselves cut open unnecessarily by obstetricians fearful of Edwards-style litigation? While it might not be "legal terrorism," it sure isn't FDR-style moral authority.

posted by Eric on 06.12.07 at 02:17 PM


My wife and I are in the healthcare fields (long term care administrator and pharmacist respectively) and are about a month away from the birth of our second child. Our experience with this pregnancy has been an eye opener to say the least.

Wasteful and excessive doesn't even begin to cut it. Perhaps some of it can be chalked up to defensive medicine, but as more and more referrals, specialists, and extra testing are recommended (the latest, which we politely seclined - twice weekly fetal heart monitoring for an otherwise normal healthy pregnany!) we can't help but think there is alot of profit motive at work here.

Likewise it'ws alot more convenient and economical (for the providers) to schedule a procedure - be it a c-section or chemical induction, than allow nature to take it's course.

ThomasD   ·  June 12, 2007 5:32 PM

Wow, I have never been called a terrorist before because I'm an obstetrician. Most prenatal testing is done because many people don't want a child that is not "perfect." (And I have never delivered a child who is perfect.) There have been multiple lawsuits where parents have stated that they would have aborted their child had they only known beforehand that the baby had down's syndrome or whatever. So we do offer lots of antepartum testing. Patients are free to decline it. If they do, I ask them if they would abort their baby if the baby has the condition that we are testing for. Most will say that they wouldn't so I document that, not that I think that it would really help if someone decided to sue because something was missed when a patient declines testing. So I have to have an informed refusal documented. Twice weekly testing that ThomasD describes is offered when a pregnancy is high risk, that may be because of maternal age, HTN, diabetes or some other cause. It's not offered for routine low risk pregnancies and it is rarely reimbursed as OB care is a global fee, meaning I get paid a fixed amount for the entire pregnancy. So why is the section rate so high? Probably because everyone wants that non-existent perfect baby. The only way to monitor a baby in order to make sure that it is doing well is by following its heart rate pattern. Thus there will be many instances where the pattern is ominous but the outcome is fine. Unfortunately I can only determine this retrospectively as my fortune telling ability sucks. So monitoring a baby in labor is like trying to determine if a patient who you can't see and who is in the intensive care unit is doing well only be looking at the cardiac monitor. You don't have a BP, no way to look at the patient to see if he or she looks sick. No way to draw blood to check chemistries or oxygenation....just the damned cardiac monitor.... So we end up playing the odds, if the fetal heart rate looks like crap, the baby will come out now because I have no way of knowing if this will be the one bad baby out of a hundred that will have this strip or whether it will be 99 of the good ones. So the purpose of the c-section is to get a good baby out. If you get a bad baby out then you waited too long.

storkdoc   ·  June 12, 2007 10:20 PM

Yet Edwards won his cases not because scientific evidence favored him but because of his smooth-talking "trust-me" demeanor -- and heart-wrenching pleas in which he ghoulishly sometimes pretended to be the voice of the unfortunate child crying out for justi

Utter nonsense. If the evidence didn't support the verdicts they would have been tossed out by the trial judge, and if not the trial judge, by the appellate court.

Perhaps a good question to ask is, how much do the docs get paid for vaginal delivery as opposed to c-section. It's easy to claim the reason for the advice is liability when it might in reality be (depending on the particular doctor) profit motive.

PI Guy   ·  June 12, 2007 10:58 PM

"Yet Edwards won his cases not because scientific evidence favored him but because of his smooth-talking "trust-me" demeanor -- and heart-wrenching pleas in which he ghoulishly sometimes pretended to be the voice of the unfortunate child crying out for justice"

How does this guy know what the facts of the case were or what made the jury decide the way they did? Perhaps they just agreed with the Plaintiff's expert - who was. . . you guessed it, a doctor!

Anon   ·  June 12, 2007 11:48 PM

Considering the jury system dates to ancient Greece, how would curtailing it be a "classical value"? Or if one doesn't want to go back to antiquity, consider this from Thomas Jefferson: "I consider trial by jury as the only anchor yet imagined by man by which a government can be held to the principles of its constitution."

Are insurance company profits a classical value?

Lost   ·  June 12, 2007 11:53 PM

I went back and reread my post, and I'm unable to find any reference to curtailing the jury system. However, the 40% contingency fee is hardly an honored and ancient tradition. Consider this from Walter Olsen:

The tradition of the English common law, the French and German civil law, and the Roman law all agree that it is unethical for lawyers to accept contingency fees.

My main point is that lawyers like Edwards have pushed doctors into damaging both medical ethics and women.

A cesarean rate of one-third of births is, IMO, unnatural and monstrous.

Eric Scheie   ·  June 13, 2007 8:38 AM

What do you think the "meaningful tort reform" proposed by Olsen and others is but a reduction in the power of the jury?

As for contingency fees, I agree - there ought to be a better way. If you can think of one that allows the average individual to fund a case against an insurance company or a major corporation with thousands of thousands of dollars to spend to defend it, do tell. Mr. Olsen and those at Point of Law would love to eliminate it, as it would give their clients the upper hand. You or I would be buried financially trying to litigate against them out of our pockets.

As for your criticism of Edwards, unless you or the physicians who are making these decisions have reviewed the evidence in his cases, how can you blame him for anything? The cases may have been rightly decided - at least one other physician thought they were.

What rate of C-sections do you believe is acceptable?

Lost   ·  June 13, 2007 11:30 AM

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