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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Doesn’t it depend on the basis for the survival rate? It says that in Kennedy’s case the rate is the same with or without surgery, but certainly in many cases spending more money to get better treatment leads to higher survival rates. And if a hundred thousand dollars is the difference between a 25% chance of survival and a 50% chance, who’s to judge? When are the percentages too close or the money too much?
For me, this is a perfect illustration of the biggest issue nobody wants to talk about. Universal health care would be a wonderful thing. However, the real challenge comes at establishing a cap on care. As a society, we simply cannot afford to give our best possible care to all of the people suffering life threatening conditions. It is simply too expensive.
For how many people could we provide routine care at no additional cost to the system if we weren’t also trying to fund treatments costing 100s of 1,000s of dollars to provide a marginal chance of greater life expectancy and/or quality.
Our society seems to approach death as something to avoid at all costs, literally, rather than accept it when it comes. That’s not to say we should simply let people die, but I have to question the efficiency of our system. We should be focusing on public health care dollar on raising the floor, not the ceiling.
Decisions of people like Kennedy to throw their money into fighting for a few more months of life:
(1) help attract investment in the medical field;
(2) help attract more people into the medical field, as there is money;
(3) advance old age research, benefitting everyone who plans on getting old eventually;
(4) represent a luxury which these people have FULLY PAID FOR with their life of work, and of which they should not be deprived unless they choose so.
People should stop believing that everyone’s life should be valued the same. Money is a measure of how much one contributes to one’s society. Inability to pay, or get a loan, indicates that a person’s past consumption has already reached or exceeded their past and future contribution.
If the world consisted solely of people with a net negative contribution, the world would be full of beggars with no health care for anyone.
So please: let people who have worked for this their whole lifetime, have what they have worked for, if they so choose!
I think it’s nice that Mr. Kennedy had the option to go where his surgical care was top-notch, although one could argue about the wisdom of this approach given the overall poor outcomes, etc. But for most of us common folk, our “health insurance” does not cover Duke, which would make this a non-starter as it would be out of network. If I were to develop Mr. Kennedy’s condition, and I chose to have surgery at Duke, I would either pay out of pocket or petition my carrier to let me go out of network and by the time the approval process went through the bureaucracy, I would very well be dead. This in a nutshell is a part of what is wrong with US healthcare – we are essentially in a two-tiered system that is rationed, and if we have the means and werewithal to get top notch care, we do. So these philosphical discussions often run smack into the reality that is our current healthcare system–if we could call it that.
Can we really apply cost-benefit analysis to someone’s life?
We already implicitly do, when the burden is imposed by financial constraints. Greg Mankiw discusses the subject of how this works in many insurance fields in his textbook, Principles of Economics.
On a side note, I’m going to get Hospital, if for no other reason than its author, as The Devil’s Candy: The Bonfire of the Vanities Goes to Hollywood impressed me as few books do.
What about the “end of days” for newborns who are cursed with high mortality rate conditions? If the chances of survival are say 10%, why spend the money on treatments? What’s the difference here?
Life is a perfectly inelastic good. When it is in danger and there is something you can do about it, you should go for it.
This is certainly not the first time a politician takes a stand relative to their party affiliation and then in their personal life, contradicts that value with their actions.
And they wonder why we don’t have faith in the political system?