Everywhere in politics, but in discussions of healthcare in particular, there is a powerful bipartisan impulse to insist that tradeoffs are illusory—infinite ponies can now be yours! Progressives are too eager to believe that national health care will make it possible to expand coverage while reducing costs—reducing deficits, even!—apparently because all those costs are in pernicious “overhead,” which seems to be joining that political holy trinity “waste, fraud, and abuse.” Conservatives, on the other hand, just seem to be in a weird state of denial about how our existing system actually works when they talk about “rationing.” Here’s Mickey Kaus:
r enough. But I want to make the decision to cut off treatment, not have it made by a cost-watching health board. Choice! The resonance with the abortion debate seems obvious. … Both are life/death decisions. Are they both best handled by individuals and their families in consultation with their doctors? You’d think the case for “choice” at the end of life might be stronger, since the life at stake is likely to be able to participate in making that choice. …
It’s one thing to deny the choice to die, quite another to deny the choice to live. The individual may not have a right to get killed, because the state’s interest in protecting people from coercion and abuse is a good one. But Kaus is concerned about a government that wants you dead — perhaps not by actively offing you, but by maintaining full control over the medical treatments you need in order to fend off death.
In a world where we all wrote personal checks for our health care, I’d be entirely on board with this. If someone with a terminal illness thinks the best possible use of their accumulated wealth is to blow it on a longshot chance of eking out a few more painful days or weeks in an ICU—and the evidence suggests that aggressive end-of-life intervention often doesn’t even get you that—then that’s their choice. I hope that’s not my own reaction when the time comes. A lot of what passes for indomitable where-there’s-life-there’s-hope optimism in American culture is a not-terribly-convincing attempt to camouflage our failure to come to terms with our own mortality. I hope I’ve made my peace well enough not to insist on every desperate gesture of denial science has to offer. Even if it’s a question of genuinely adding a few extra weeks or months to a long life well-lived, I hope I have enough other worthy uses for whatever money I’ve saved that I don’t empty the accounts buying every last available minute. But hey, death is scary. Maybe I’ll feel differently when the time comes; I certainly won’t second-guess anyone who wants to make a different choice.
Except, that’s not actually how our existing healthcare system works. In the real world, the decision to do throw the kitchen sink at every ailment is either funded by the government, or by private insurance. A fair amount of the time, it will be made not by the actual patient, but by family members for whom “do whatever it takes” is a low-cost salve for the guilt of never actually visiting grandma at the home. The insurers are substantially constrained in the range of treatments they need to cover, which gives doctors little enough incentive to control costs or limit tests or treatments themselves. (My impression is that this is partly a function of an increase in the increasingly cozy relationships between referring doctors and testing facilities.) These “choices” are not free. They are not a noble reflection of the infinite preciousness of life. These socialized costs—and they’re effectively “socialized” whether it’s the government or private insurers picking up the tab—raise premium costs, make it more expensive to employ people, push some people out of coverage entirely, and otherwise divert scarce resources from things that might actually help somebody. The notion that this perverse result is somehow required by “medical ethics” is simply grotesque.
This is pretty clearly unsustainable. The more medical technology advances, the greater the number of expensive longshots, the more hours and minutes we can lease back from oblivion at ever greater cost. Over the long term, we can decide that any probability of any added increment of lifespan for people in medical care trumps evey other possible private and public good, or we can ration. That rationing can be by individuals weighing the costs and benefits relative to their resources, or it can be by governments—whether directly or by regulation of insurers and providers. Between those options, I’ll leave it to the wonks. But please, if you’re going to claim an unlimited right to make other people subsidize the understandable impulse for denial and wishful thinking, at least let’s not pretend that it’s somehow a matter of protecting “individual choice.”
12 responses so far ↓
1 Dan Summers // Jun 16, 2009 at 5:03 pm
I heard something on NPR a couple of weeks ago about the misnomer we give such interventions as mechanical ventilation, tube-feeding, etc. They are known collectively as “life support,” when (as the commenter correctly stated) all they really do is take over the functioning of various organs that have ceased to work on their own. Sometimes they resume functioning on their own, sometimes they don’t but life otherwise goes on relatively well (as with dialysis), and sometimes there will be no return of either function or quality of life.
From what I understand, medical schools are doing more to get students accustomed to the idea that their patients will eventually die. However, the culture of medicine is still such that death is treated very much as a failure. Add in our societal aversion to facing death, the waning influence of religion (which, for good or ill, at least supposedly helped us ready ourselves for death), and the pervasive belief that contemporary medicine allows for miraculous recovery (for which we can, in part, thank the numerous ludicrous medical dramas and reality shows scattered throughout prime time) and you’ve got a perfect recipe for forestalling the inevitable. (Some of us went into pediatrics in no small part because most of our patients get better.)
I, too, hope that when my time comes I’ll be ready to shuffle this mortal coil. But plenty of people aren’t willing to go easily, or to allow their loved ones to go. That their choices are monumentally costly is a perfectly valid point, but won’t sway people who are acting out of emotional extremis rather than rational thought.
2 First We Kill The Boomers, Then We Take Berlin « Around The Sphere // Jun 16, 2009 at 5:36 pm
[…] Julian Sanchez: In the real world, the decision to do throw the kitchen sink at every ailment is either funded by the government, or by private insurance. A fair amount of the time, it will be made not by the actual patient, but by family members for whom “do whatever it takes” is a low-cost salve for the guilt of never actually visiting grandma at the home. The insurers are substantially constrained in the range of treatments they need to cover, which gives doctors little enough incentive to control costs or limit tests or treatments themselves. (My impression is that this is partly a function of an increase in the increasingly cozy relationships between referring doctors and testing facilities.) These “choices” are not free. They are not a noble reflection of the infinite preciousness of life. These socialized costs—and they’re effectively “socialized” whether it’s the government or private insurers picking up the tab—raise premium costs, make it more expensive to employ people, push some people out of coverage entirely, and otherwise divert scarce resources from things that might actually help somebody. The notion that this perverse result is somehow required by “medical ethics” is simply grotesque. […]
3 Steven Maloney // Jun 16, 2009 at 6:27 pm
Julian,
I was struck by your characterization of family motives in making medical decisions and health care costs because it sounds very familiar to the characterization of corporate decisions and the increased cost in legal fees. Decision-makers want to be able to say they did their best with the least path of resistance. Hire Kirkland & Ellis and you can tell your boss, “I picked the best, it’s not my fault.” Pay for medical expenses all the way to the bitter end and you have washed your hands of any guilt in a similar fashion.
4 southpaw // Jun 16, 2009 at 6:51 pm
“A fair amount of the time, it will be made not by the actual patient, but by family members for whom “do whatever it takes” is a low-cost salve for the guilt of never actually visiting grandma at the home.”
Don’t you mean a high-cost salve?
5 Kevin B. O'Reilly // Jun 16, 2009 at 10:09 pm
Many medical ethicists seem to take as a premise that patients’ medical decisions — emergent and life-and-death decisions if not the generic versus brand-name drug-type choices — should not be made under the influence of personal financial considerations. Patients are vulnerable and should not be put in that position, they say. What’s your view? Why?
6 RickRussellTX // Jun 16, 2009 at 10:28 pm
“Don’t you mean a high-cost salve?”
He means low cost… to the family. The cost to insurers, or society at large, is high.
Mr. O’Reilly makes a point, however — the patient may not be in a very good position to make an informed choice. People near death are not likely to be in full possession of their intellectual faculties.
That’s why it is probably a good idea to write down, in durable and witnessed form, precisely how far you want doctors to go.
7 Julian Sanchez // Jun 16, 2009 at 10:55 pm
So, apropos the last two comments, one of the links above points out that people who talk about their end-of-life plans with their physician earlier in the process typically end up going with much less aggressive last-minute interventions. They live just as long, but seem to have somewhat more comfortable deaths without a lot of intrusive, ultimately futile, and massively costly “heroic measures” at the very end. So I think that’s a strong data point in favor of thinking seriously about these questions in advance.
One reason is that I’m very much sympathetic to the concern that people who are justly frightened and often also suffering severely diminished capacity may not be ideally situated to judge their best interests, part of which is the risk of exploitation by family or physicians who, from good motives or bad, have different agendas. But I think there’s no reason *per se* that financial considerations shouldn’t play in. To the extent we think this is the case, I think it’s because we have doubts about the justice or fairness of people’s financial situation. If you factor that out by imagining someone fairly wealthy, I don’t think its that troubling to imagine someone thinking: “Well, there’s a 20% chance this procedure would get me another 3 months, but I’d really rather use the million dollars to endow a scholarship.”
Or put it another way: People probably sometimes take punishing but remunerative jobs that shorten their lives at the end to some extent. People DEFINITELY take demanding but remunerative jobs that, in the aggregate, take months or years off the time they might spend enjoying the company of friends and family. If that’s not some kind of moral abomination, I don’t know why the same tradeoff made more obviously later on should be.
8 Klug // Jun 16, 2009 at 11:47 pm
I can attest to the “high-cost salve” aspect of this. When my grandfather was near the end, my aunt and father attempted to talk him into a set of ‘advanced directives’, as they are euphemistically called. My grandfather pretty much refused to cooperate (out of superstition, I speculate.) In the end, other relatives insisted on the “whatever-it-takes” approach and my grandfather suffered another 2 or 3 weeks.
Julian, if the patient gets irritated at having that conversation, what are you going to do?
9 Julian Sanchez // Jun 17, 2009 at 1:25 am
Maybe there’s nothing you can. But it’s certainly understandable that people least want to think about death when it starts to look like it might be getting close. Better reason, I suppose, to make some preparation when we’re younger and the process itself is less painful.
10 Will Wilkinson // Jun 17, 2009 at 2:06 am
Great post, Julian.
11 Stones Cry Out - If they keep silent… » Things Heard: e72v3 // Jun 17, 2009 at 10:23 am
[…] right. Re-read this realizing that “private insurance” is what you pay for not some magical […]
12 Paul Wright // Jun 18, 2009 at 4:21 pm
… “That’s why it is probably a good idea to write down, in durable and witnessed form, precisely how far you want doctors to go. …”
Have you ever tried that exercise? “If there is a 50% chance of full recovery, use every machine you have. If only 10%, use only respirator and oxygen. If my recovery is likely to leave me paraplegic do this but if I will only be paralyzed from the waist down then …”
Too many variables.