Health Care — A Curse or a Cure

 

images-1As recently as 200 years ago, if you stopped breathing, you were considered to have died, whatever the cause. There were few scientifically-based options to prevent or delay death.

A watershed moment in the history of health care came with the invention of the stethoscope in 1816 and the ability to register a heartbeat. But scientifically-based treatment protocols remained out of reach. For the next century, death continued to be, as it had been for much of western history, a part of “God’s plan” or—if you were of an atheistic or pagan persuasion—a matter of fate.

Until 1928, that is, when Alexander Fleming discovered penicillin. For perhaps the first time in history, man no longer had to rely on God or fate to determine the outcome of an injury or an infection. Over the last 90 years, our ability to triumph over illness has expanded exponentially.  Today, we can prevent most infectious diseases (even Ebola, it now seems), repair a faulty heart, excise a malignant tumor, or replace a failing kidney.

For much of the 20th century, medical advances focused on preventing “premature” death from infection or trauma. But these often seemingly miraculous discoveries had unintended consequences.  Most notably, our success in preventing or curing acute illness has led to steadily lengthening life spans, but also a greatly expanded population vulnerable to chronic—and costly—illnesses such as diabetes, COPD, cancer or Alzheimer’s.

Another unintended consequence is that the wonders of modern medicine are increasingly used to “manage” or delay conditions that were once considered normal signs of aging, e.g., sagging skin, declining fertility or loss of muscle tone.  Where is the boundary between preserving a healthy but age appropriate body and defying the natural process of aging? When does the effort to retard aging morph into an outright denial of the inevitability of death?

This urge to deny the inevitable has consequences to be discussed in a later blog, for long term trends in employment and education for our economy as a whole.  More immediately, it is reflected in the frequency with which high cost and often-intrusive medical interventions are employed to keep an aged body alive long after the will to live has gone and all-too-often in violation of the patient’s expressed wishes to be allowed to die.

As many people interpret the Hippocratic Oath (show the “utmost respect for human life”), doctors and hospitals feel they have an ethical obligation to treat your illness if they have the tools to do so. This prescription made perfect sense when there was little the medical profession could do to actually heal an illness or injury, when the role of health care professionals, like their clerical counterparts, was largely to give the patient comfort until God or the fates stepped in.

But what does “utmost respect” mean when science and technology allow the doctor to second-guess God or the fates … to decide, for example, that a failing heart is not a sign of God’s will, but a mechanical problem that should be “fixed” by implanting a pacemaker? Should a pacemaker be implanted in an otherwise healthy 35-year-old father of four? Most of us would instinctively say yes. Should one be implanted in an 85-year-old stroke victim whose mental capacity is permanently impaired? The answer is not so obvious.

These are not new questions, but they take on a new urgency as the baby boomers age. There are not enough health care resources—caregivers and care facilities as well as financial resources—to treat all the “ailments” of the over-65 crowd today, let alone the estimated 90 million elderly that will be clamoring for medical care by 2050.

The issue is not whether we should ration health care … we already do so, based primarily on ability to pay and/or seemingly arbitrary guidelines on what health insurance will cover.  The issue is how should we allocate limited resources in a way that is equitable and fair.

How should we, as a society, decide what kind of health care people should receive, and under what circumstances?  Should the decision be based on spiritual / religious precepts that are often ambiguous and controversial … or on a rational cost-benefit analysis that ignores the question of human dignity and the intrinsic value of life?  Who should make that decision?

What would you do?

Comments

  1. Mary, You ask the toughest questions. But alas, this is what we are faced with. I would say that the young father should definitely be given a pacemaker. If I were the aged one who had just had a stroke and was able to, I’d opt out and let fate takes its own course. The right to die when one’s time comes is what would live me dignity. In this time of a growing elderly population I don’t think we can afford to keep everyone alive especially if they cannot contribute to society. That we all are going to die is a fact. I vote for giving up special options that won’t benefit me and would pass those benefits on to someone who can continue to contribute to society in some way.

    • Mary Gottschalk says:

      Joan … like you, I do not want to spend thousands of dollars to stay biologically alive but emotionally or socially dead when that money could be used to educate a child or help someone who is mentally ill. But you have touched on the heart of an issue I will deal with in coming weeks. How do you decide when there are only so many kidneys or hospice beds available.to go around? How do you decide when the only difference between two very elderly sick people is their ability to pay for their care? These are horrific decisions … but they are being made every day in hidden ways that most of us never see.

  2. I believe the choice should be between the patient and the doctor and if the patient is unable to choose it is up to his or her health advocate. In no way shape or form do I feel someone should be denied healthcare simply because of their age or ability to contribute. There are 75 year-olds that are healthy mentally and physically. Who are we to deny them the right to have a tumor removed when their prognosis for a full recovery is high?
    My father had a brain tumor removed at 70. He lived 6-great years after that. Those 6-years were a blessing to our family.
    This is going to be the next ‘right to choose’ issue.

    • Mary Gottschalk says:

      Doreen … I agree that patient choice is paramount in both a legal and moral context. The question, as I noted in my response above, is when we are faced with resource constraints. How do we decide? Your example captures a critical element of the decision process — if the prognosis is good, ability to pay should not be an issue. But all too often it is. Someone who might do well is deprived of treatment, while someone with a poorer prognosis but more money gets top notch care.

  3. You’ve hit on some hot topics here, Mary with varied access to care and financial resources. Age, quality of life and individual choice all play into the decision but I wish it was all that simple. I certainly want access to life-saving measures at this point in my life but I do hope I will be able to bow out gracefully if and when the time arrives that all options to provide an improved quality of life are depleted. That being said, the individual relationship between a patient/family and provider will be the key in coming up with reasonable solutions. You bring up so many important questions to ponder, especially the ability to pay issue.The answers are not as clear.

    • Mary Gottschalk says:

      Kathleen … I can’t believe I missed this, but was ensconced in the final days of my comparative religion class. I look forward to having your wise commentary as I continue this journey through 2016.

      Have a wonderful Christmas!

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