Stirring the Pot

>> Sunday, June 14, 2009

Talking about healthcare is a big deal right now. I think it's a conversation that needs to happen. When Obama says, we need to do something about healthcare and their costs. Every day, people die needlessly because of inadequate care, because of poor preventive care because of lack or inadequate insurance.

We spend more than most industrialized nations per capita for healthcare yet we have a lower life expectancy and infant mortality. There are a lot of things I think might help (doesn't everyone) and I don't pretend I'm an expert. But I'm a potential patient and I know things will not get better unless I demand better. But I don't want to make doctors into assembly lines or to put them in a position where they can't make a living. In fact, pretty much none of my ideas are designed to do that.

But, my friend, the Mother told me that to talk about making a real difference in the cost of healthcare is going to address some of the big cost drains that skirt some ethical lines. She's right.

So, here's the question: is it always the right thing to fight for life no matter what? And, if not, where does one draw the line? You might be confused by the question - what does she mean? I'll explain. I'll also add that I'm not sure where to draw the line, whether there are two many variables to determine it legislatively or if that's something that needs to be determined by expert (i.e. medical - NOT insurance) opinion, but I do think the line exists. I personally think the answer to the first question is no.

Now, I said I'd explain what I mean. In some people's idea of a perfect world, everybody's have a monitor that would pop and say "Your liver is failing. Schedule liver transplant? Y/N" Then you'd stop by on your way home from work and get a new one and still make it in time for your three martini dinner engagement. But effective medicine isn't like that. Many times, a disease or a condition takes time and effort to overcome. It's painful and and requires sacrifice from the patient as well as time and care from the doctor. And sometimes, all that time and care and sacrifice will do nothing to change the end outcome except make the intervening time horrific.

So, here are some questions.

How much time and effort (and cost) should be considered necessary when there is no hope of doing more than prolonging the inevitable? Is it reasonable to spend, say, a million dollars to prolong someone's life for a year in the hospital on life support when that same million dollars might mean the difference between a productive life or an early grave for someone else. Or several someones?

What if that someone doesn't WANT that last painful and undignified year in the hospital?

How much should be spent providing care to someone who refuses to change their habits so that it has no chance of success. Does someone who drank his liver away deserve another one? Does someone who refuses to lose weight or rein in other habits has heart attack after heart attack? Should he get first dibs on a replacement because his is so much more damaged than another? This is actually a question that applies to me. I'm overweight and have several significant risk factors for type II diabetes. If I don't take steps now to address my weight and eating habits, should someone else be responsible for helping pay for my care?

Here's a hard one. What about children too malformed, too tiny, too underdeveloped to be truly viable. Children who are likely to be on full life support for months if not years if they live that long. Children with tubes and needles in them, children so delicate they can't be handled, who many never even know the comfort of a human touch. Or children born without brains or so severely damage they face years of surgery so they can limp through the remainder of their lives just severely handicapped.

It's not an easy question for me to ask as a mother, a situation that's heartbreaking. But is less hearbreaking to see your child only through a glass wall when there is no hope that the child will ever go home with you?

I don't know the answers to the questions and I suspect the answers depend on a variety of variables not here. But I'm not sure we're making these decisions today the right way. I know my father, who was a healthy man in his sixties when he was diagnosed with stage 4 colon cancer, would have preferred to just go home and spend his last days with his family. He fought at their insistence until his liver gave out and, though the doctors encouraged him to come back for more treatment, he went home. That was hard for me, but I respected his decision, understood his decision, admired the way he saw it.

Perhaps some people would choose to have herculean efforts in place to keep them alive until the last possible minute, no matter the pain, no matter the discomfort, no matter the financial burden on the system and on their families.

But many, I think, would happily trade those months or years of pain for a peaceful escape, would trade losing that family and their memories to Alzeimer's for a loving goodbye with the faces they know and love, would trade a few months in the hospital for years of working through debt for the people left behind.

So, once last question. In many states, people don't have the choice to decide to live or die when they face nothing but pain with an inevitable conclusion. Should they have it?

You know, it occurs to me I just don't stir up controversy as often as I should. I expect this will, hmm, stir something up.


  • Roy

    For me, personally, I would opt out of extensive care for no reasonable gain. My Dad did that; he had liver cancer, the chemo turned out to be more painful and debilitating than the disease itself, so he opted for stopping the chemo and called in hospice. We were all there with him, at home, when he passed on. For me, that's the only logical AND merciful solution.

    Many people these days are opting not to continue life for non-viable newborns. I'm particularly speaking of the ones so damaged and deformed that they could never have what any reasonable person would call a "life". But I think that has to be a personal decision between the parents and the doctor. I would hate to see that legislated, by state or federal, for or against. That's just too personal a situation to put in the hands of government.

    As for the last part, about refusing care for those who won't care for themselves. that's a way sticky situation that I don't think you'll ever solve. I have a feeling we're gonna keep on caring for people no matter what they do to themselves because our ethical/moral environment just won't let us do otherwise. I think we're stuck with it.

  • The Mother

    Pot stirring is good for the soul. And bad for politics.

  • Quadmama

    When my mother had breast cancer she told us she wanted quality of life over quantity of life. It's something that became harder for me to stick to as she became sicker and sicker and finally went to hospice care. But I was finally able to grasp what she meant... for her life wasn't worth living if she was miserable. I don't have any answers on where to "draw the line" because it's such a personal and emotional decision. I think everyone when they're healthy needs to voice their wishes to their family, though, because there's nothing more heartbreaking than seeing someone who has clearly given up but whose family simply won't let go.

  • Jude

    My Son chose to fight till the end, but at least he had good insurance, Cobra and that was his choice, but I so hated seeing him suffer so much. I on the other hand have made my wishes known and I certainly do not want to live on machines nor will I choose to take chemo if cancer is in my future. These decisions are always going to be difficult for family members to make because it's so hard for us to let go. I think we should all have the choice to fight or let go. It would be so hard in the case of babies to let go. I'm so glad that is a situation I have never been faced with.

  • Patricia Rockwell

    Most people, when confronted with the decision to euthanize a terminally ill pet who is suffering, will do so, yet they would never consider doing the same for a person in the same situation. To me, it often seems pets are treated more humanely than people.

  • Stephanie B

    Wow, my readers are so civil. I love you guys.

    What I'm talking about is not the perfect world, where there's an infinite amount of resources to do any and all medical treatments, but a world where there is a finite set of resources to treat most people. There are a finite set of replacement organs, for instance. If I use one on someone who ruined their own, that's one less for someone who didn't.

    I'm a huge advocate for a patient being able to say, "No thanks," to years of painful treatment that won't change the outcome (I'm with you, Patricia). But here's the thing. We all pay for the infants born who will never have a real chance at life, for the people fighting hopeless battles, both battles that can cost millions of dollars, whether it's through health insurance, higher hospital fees (as they absorb the cost) or as taxpayers if these are being paid from a public fund.

    Call me hard-hearted Hannah if you want, but isn't this going to have to be reviewed and reevaluated if we are ever going to rein in healthcare costs? I know there are many other areas to be evaluated, but I wonder how effective any will be if we don't examine these questions.

  • Aron Sora

    Watch this video:

    If I can't do the 6 things Tony Robbins points out the I should die.

    Then again, my mom told me the story of my birth. I wasn't breathing when I was born. My mom said I was black and blue and she thought I was gone. The doctors saved me, but they should have given up on me. I have no idea why they keep fighting for me. I'm thankful and if my mother's story is true, really lucky.

    It's a sticky question for me.

  • Stephanie B

    Why should they have given up on you? Clearly, you had a full and capable life ahead of you. That's well worth fighting for.

    I believe in CPR (and reup my training frequently) and am all for emergency medicine and don't begrudge a penny saving people who can be saved with a timely intervention. My husband was born at just over five pounds. That's small but no so small he'll never have a future (as he's demonstrated). His brother almost died during childbirth and was only successfully delivered by dislocating his shoulder during birth. There's nothing wrong with that either.

    It's when there's no hope, no chance of a reasonable future that I wonder if we're doing the right thing.

  • Relax Max

    Your questions go far beyond the world of medicine and health care and who pays for what; they are in the realm of ethics and "morality" - even spirituality. If your questions seem hard to answer, it is because they have no right answers. That fact is difficult for a black and white test-taker to accept, but there are some things in life, I think, that we simply have to do the best we can in a given situation, and learn to accept the things we cannot change. One need never feel guilty if one has truly done the best he can in a given situation, even if he could have done better tomorrow. Some people disparage the word "try", and say there is only "do" or "not do". I am not one of those people. One must grapple courageously with whatever one faces in life, and realize that some will fare better or worse than himself. In my opinion, your questions are mostly ethical and not medical, and therefore as uncertain as the human condition itself.

    You are not really stirring the pot; you are simply voicing the frustration and impotence that have perplexed humankind ever since there have been humans.

    Yet some of your questions ARE really medical and DO probably have answers. Certainly I have my own opinions and thoughts, same as the others. But it is so easy for me to lapse into lengthy essay mode, if I haven't already, that I will simply stop.

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