Stirring the Pot

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.