A friend of mine posted a very thoughtful article on end of life care written from a physician’s reflections upon his own demise. Doctors know the odds and some of them sometimes choose to forego further treatment and make their peace.
In the case of many diseases the probability of remission is poor. And as we approach the implementation of Obamacare, one of the key takeaways is that many of us will no longer receive the level of care that we had under our old policies.
We are seeing corporations limiting coverage and limiting working hours in a desperate drive to reduce exploding insurance costs. Already, the insurance companies battle every step of the way in approving many treatments. This is done in the name of cost management.
Now the government is stepping in adding another layer of cost and more roadblocks between patient and doctor. As a part of Obamacare, the Independent Payment Advisory Board is being formed to control costs. In the UK, the Liverpool Care Pathway has caused an uproar with the abuse of its principles by doctors and bureaucrats. Worse, the British bureaucracy has a direct function in approving and denying specific treatment.If a patient is determined to not deserve a certain treatment, it is not performed, resulting in death in many, many cases. It is not isolated and it a part of the system. There is extensive evidence.
And this is what is now being implemented here. Both Howard Dean and Paul Krugman have fessed up to this reality. Costs are out of control and growing exponentially. People are living longer. The technology to help resist disease and prolong life has grown immeasurably, along with costs.
And within all of these arguments and issues, the relationship between the patient, their doctor, and with the Great Beyond has become lost in the shuffle.
In the end the decisions must be between patient and doctor; not between patient and bureaucrat.
I had two friends who were told they had pancreatic cancer within a year or so of each other. Peter used every tool in the toolbox to fight back. He had radical surgery and highly aggressive treatment. He came back to work eventually, but 18 months later he was dead. He had bought himself two years and lived those years well knowing the eventual outcome.
Not too long thereafter I found out my friend Paul also had contracted pancreatic cancer. He was diagnosed in August and by mid-October he was dead. He had made his peace with God and chose palliative care and the first his friends knew of his condition was when we received a call or an e mail inviting us to the funeral.
Each of them chose their path as they saw fit. each of them were faced with difficult and life threatening choices. They made these decisions without bureaucratic intervention.
These are the most personal and agonizing of choices. And sometimes the patient is unable to choose as when they are on life support and unconscious.
In “The Ends of Human Life” Ezekiel Emanuel examines medical ethics on a spreadsheet and posits communitarian examination of the issues and the just distribution of medical resources. He discusses the politics and the justice of medical care. But he does not discuss how to frame the discussion that matters the most in the end. The ethical discussion. The discussion of choices to be made. As with the NHS and Obamacare, the assumption is the rationing of resources by the state.
The governmental medical bureaucracy has grown from the implementation of Medicare in 1965 to a behemoth today. Include programs such as the military TriCare program and the Veteran’s Administration hospitals and state programs and one can readily agree that there is already a massive public sector bureaucracy in place. This will be layered over by more indirect costs from the new bureaucracy being built. And the patients will get even more lost in the system.
How is this beneficial to our society and to the individual?
Today’s health care system is driven by spreadsheets and first, second and third tier case management. How does this deliver the best care at the lowest unit cost?
End of life care is expensive. CBS News stated that care in the last 2 months of life in 2010 cost the nation $50 Billion. The total size of the Medicare budget alone for 2012 is estimated at $536 Billion. Medical spending was estimated by the UN at 17.9% of the GDP of the United States in 2011; $2.8 trillion. So why are we having this conversation in the first place?
There are many problems to discuss about health care management. But government intervention in end of life care is not one of them. The issues are bureaucratic and administrative and there are many, many fingers in the pie. The other issue is control. Holding Grandma hostage is a powerful weapon. Statists like control. Single payer health care has been the stated goal of the left-wing of the Democratic Party for the past 50 years.
The conversation is really about control. And when doctors start talking in spreadsheets and when bureaucrats in both the public and private sector have financial stakes in the game and the decisions are made by corrupt and venal politicians who do not live by the same rules, it is wise and prudent to be very, very skeptical.