We recently featured a Q&A with Julie Salamon, author of Hospital, and last week Julie wrote her first guest post for us. Here is her second. It touches on a subject of great interest to me, something we hope to address empirically in future writing: the cost/benefit dilemma of end-of-life medical care.
End of Days
A Guest Post
by Julie Salamon
The law of diminishing returns is hard to accept when confronted with our own mortality.
When Teddy Kennedy was diagnosed with malignant brain cancer a few weeks ago, the senator who championed universal health care opted for the rarest and most expensive treatment — surgery followed by radiation and chemotherapy. But with or without surgery, the prognosis for patients with glioblastoma like Kennedy’s is poor, with an 18-month survival rate for those over 60 less than 10 percent.
Kennedy’s decision reminded me of Susan Sontag‘s terrible last days. Her son David Rieff recalled the moment when physicians told Sontag, then 71, that a bone-marrow transplant had failed and her virulent leukemia had returned. In the New York Times Magazine article that became a book, Rieff described his mother’s reaction. “She screamed out, ‘But this means I’m going to die!”
Sontag was shocked even though she had been told survival rates for myelodysplastic syndrome, or M.D.S., were slim — 20 percent across generations and much worse for someone of Sontag’s age, who had already survived two previous cancers.
Yet she chose to endure gruesome treatment (which her insurance didn’t cover) at her own expense — at least $300,000.
Robert Cohen, a New York City internist involved in public health issues, told me he wished Teddy Kennedy had issued this statement instead of opting for surgery:
“Because I am not a young man, the cancer in my brain will progress rapidly and is likely to incapacitate me in the near future. I trust that my doctors will do everything they can to prevent further seizures and to keep me in comfort. I will not endure extraordinary excess pain and suffering, while hundreds of thousand of dollars will not be spent on surgical debulking, radiation, and chemotherapeutic regimens which do not work.
Modern medicine cannot cure my cancer, but it can keep me comfortable and free of pain. I have already contacted the Massachusetts General Hospital Hospice program.”
Dr. Cohen added, “I’m not suggesting that Kennedy has an obligation to choose hospice rather than therapy, but I do think it would be very reasonable for him not to adopt the false ‘struggle against cancer’ model.”
Dr. Michael Salcman, former chairman of neurosurgery at the University of Maryland School of Medicine (and for full disclosure, my step-brother), had a different view:
“It is true that we spend most of our health care dollars in the last 6 months of life, but who or what is to tell a relatively intact, feisty, willing-to-fight, rich person that he is supposed to simply go into hospice in a free capitalist country like ours.”
The choice, he argues, is a philosophic debate between two competing visions.
“… an individual’s right to his personal freedom of choice and life (in the logical extreme, the freedom of the American frontier) vs. society’s right to limit the economic damage from such choices and life-styles (in the logical extreme, socialism). As usual, Aristotle is correct when he says that the true answer to most problems is somewhere near the mean.”
What is the appropriate cost/benefit analysis — financial, medical, and emotional — to apply to the ebb tide of life?
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. You can also watch it on 
Does one consider also that by going to these extreme measures, the doctors gain knowledge that can benefit future people with the same condition?
Why can’t Kennedy choose the best care we can afford? Everyone should be allowed to choose to fight, or not to fight.
Even the Vatican is hypocritical on end-of-life issues. In 1951 a statement was made by The Church re: futility of treatment at less than 50% cure.
When Pope John Paul II arrested from respiratory complications of Parkinson’s, his henchmen propped him up like a half-dead puppet.
to doug (#2)
Kennedy chose futile, extreme care —-not “best” care”. He chose to be an example of futility, not of
cost-conscious care.
I say- Do what’s right by you-
But then when you get into more complicated matters as two patients enter the hospital emergency at once, a 90 year old woman and 25 year old man- things get so much more complicated- who should benefit first? This is an ethical question and not one that can be addressed or should be addressed by science- if one speaks of true equality and fairness- all should benefit equally- I do hope someday- our hospitals are so well equipped. Putting so many people to work- there are hidden benefits. But until then, if then, it still seems to come down partly to differences of who is capable of benefitting and attitude (rich over poor, youth over elderly– i have seen it too often in the way older people are treated (even if they do have money and active and working brains).
Can we really apply cost-benefit analysis to someone’s life? From a third-party perspective, maybe, but it must be different to be the subject itself. From my limited view, it seems like our culture views life as a sort of perfectly inelastic good–IE we believe that pursuing life is valuable at any cost.
I agree with post #1. Maybe to ease your own conscience and that of your loved one’s you should spend the most money and try to get the best procedure done, no matter how small the survival rate may be. And it could help the doctor with later procedures.
The issue isn’t should someone be allowed to spend their own money on an expensive, painful, and most likely fruitless quest, if an individual wants to waste $300,000 that is fine by me. The issues are can I spend $300,000 of your money on an expensive, painful, and most likely fruitless quest, and should Drs. even encourage or promote such quests. The first is a redistribution of wealth issue, and those that seek such treatment have every incentive to ask for others to pay for it, while most of us cannot be bother to complain about it. The second issue is purely a medical ethics issue and one I think Drs. get wrong a lot more than they would like to admit.
As for Ted Kennedy, I don’t know if he spent his own/family’s money or if his treatment is being covered by US government health plans. If it is the later then we all have a say, and I think he should have opted differently. If it is the former, the downside is that others might think they are entitled to the same, even if there is no money.
As for the argument that we gain knowledge. This is about the most wasteful way to learn things. If that is our goal there are much better approaches.
Last of all, yet we can apply cost-benefit analysis to someone’s life. The problem is while it is easy to do in the aggregate (and we do it all the time), it makes people vary uncomfortable in the specific. Hey, that is what a health care market does.