Tuesday, July 17, 2012

Five On Health Care: V - Hidden Message

V Hidden Message
In all discussions of the cost of health care, the amount that is spent on one’s last illness always looms large.  It’s a big number, looking like low-hanging fruit that we could really reduce costs with, if only…

Not that people bringing this up think that all of it is wasted.  But it just smells like there’s a big hunk ‘o cash in there somewhere.

But the hidden statement is “We just spent a fortune on you Jasper, and you were going to croak anyway.  If we hadn’t felt so darn obligated to keep you afloat, we could all have gone to Disney World on that money.”  No, really.  That’s what they mean whenever they say “We need to have an open and honest national discussion about end-of-life care.” Oh yeah, and it has seemed, in practice, to also mean “You Catholics are just gonna have to Get Over It.”

In addition to much of the savings evaporating quickly when you poke at the numbers – if you have something potentially fatal, treatment is likely to be expensive, after all – there are disquieting questions here.  Let me tell you when similar large chunks of money are going in the mental health budget in your state: I can name a half-dozen women soaking up a million dollars of services every year at emergency rooms after repeated swallowings, cuttings, and overdosing.  There is some volition, even manipulation in these acts – though the ultimate causes of their inner demons may not be entirely their fault. How is deciding against attempting care in a terminal person significantly different from the same in a suicidal (or parasuicidal) person?  Or a head-injured adult, or a significantly disabled child? Those are very expensive services, and are essentially humanitarian, not rehabilitative care in the usual sense.  That they might get a little job somewhere is deeply gratifying.  But it costs much more to get them there than they will provide to society by being “productive.”

Not that such deterioration will necessarily occur.  Perhaps none of it will.  But cultures are funny, and can move in the direction of preserving our horror in one area while embracing the monster in another, barely different. Yet there is poison in the future whenever people in authority say we must have a frank discussion about something when their own word choices suggest the opposite.  We’ve seen that happen in discussions about race and immigration already, where speaking truth to power has become the opposite: telling friendly audiences what they want to hear.

I feel the temptation because I share it.  Who among us would impoverish their families when refusing treatment would preserve, not wealth and luxury, but merely modest lives for those who come after?  The dystopic image of societies which teach the honor and even the duty of electing death runs through fantasy and sci-fi literature – the former often rather accurately tying it to pagan human sacrifice.  It all makes sense at first, and then we find ourselves on the far side of some abandonment of Western Civilisation.  (Perhaps most poignantly in Watership Down and The Giver.)


karrde said...

I had a closed-head-trauma wound in an auto accident.

Late in my teenage years.

The prognosis during that first week ranged from "wouldn't ever be able to take care of himself" to "will need lots of help".

Thankfully, all those prognoses were wrong. My social skills needed re-training, as did planning and short-term memory. My scholastic skills remained very high; I graduated when I had expected to and did well in college studies.

I agree fully on distrusting the frank discussions with clouded terms. If we are going to have frank discussions, let's say that we're spending the same amount of money to provide some 70-year-olds with another decade of life, and to keep other 70-year-olds alive for six months.

And that telling the difference between such cases is sometimes easy, sometimes hard, and sometimes a coin-toss.

Texan99 said...

We have a friend whose father explicitly rejected cancer treatment, reasoning that it was very unlikely to do him much good, would certainly be hideous to experience, and would wipe out the savings he had hoped to pass on to his family at his death.

He reached a decision that made sense for himself. I wouldn't have wanted to see anyone reach that decision for him.

When I have been involved in the medical decisions of very old, ill relatives, what has most concerned me was to prevent insanely heroic, intrusive, and expensive procedures that made no sense in terms of quality of life. My late aunt's DNR made complete sense for a 96-year-old woman who had no desire at all to be dragged off to an ER to die with strangers poking and jabbing her.

It's much more difficult, of course, to decide what to do about a young person who may well pull through. But if I had pancreatic cancer, I'd be focusing on how to make the most of the little time I had left, with a minimum of medical intervention, without leaving my husband impoverished, and without expecting total strangers to kick in to support a forlorn hope. But all of this presupposes that I will be making decisions about my own life with my own resources.

dmoelling said...

I've been fortunate in that I haven't had to assist in these decisions. My in-laws have not had this need. But over the years I have had to put down well loved dogs. I found that the difficult part was not that I had to do it, but the worry that I would do this for my convenience and not their welfare.

I've found this cuts to the core of medical care at end of life. We don't know when that end will come so it is astonishingly easy to justify it as for the patient when it is really for our ease. Plus the whole idea of insurance is for such high cost events.

In addition, through most of history medical care was largely ineffective (if not dangerous). But if no one tried, no one would have made improvements and advances. These advances are often made by solo practitioners not consensus (see childbed fever and sanitation for example). A committee that decides treatment A is heroic and not cost effective will forever preclude finding out that a small modification could be a wonderful treatment.

Assistant Village Idiot said...

karrde - we're off the front page, so no one may see this. Maybe I will flag it somehow.

Yes, you touch on the exact problem. We see a pile of money we want to save, and we think we can somehow adjudicate that wisely. But the predictions are poor, and we screw people over. The temptation may cloud our judgement.

It's a terrible thing when that happens, and I fear government being the arbiter - even more than the other groups with similar temptations: insurance companies, school districts, inheritors.