Conservative political and social commentary
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First they came for the communists,
but I was not a communist, so I did not speak out. Then they came for the socialists
and the trade unionists, but I was neither, so I did not speak out. Then they
came for the Jews, but I was not a Jew, so I did not speak out. And when they
came for me, there was no one left to speak out for me.
– Pastor Martin Niemoeller.
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|What If the Single Payer Won't Pay? - Tuesday, February 22, 2011
The House is about to take up a budget proposal that would block funding for ObamaCare. If you believe as I do that nationalized health care is unsafe as well as unnecessary, contact your representative now and make your views known.
At this critical time, it might be useful to update and bring together some of my columns on this topic. This is the fifth.
What If the Single Payer Won’t Pay?
David C. Stolinsky, MD
When asked about hip replacements, the president replied, “Maybe you’re better off not having the surgery, but taking the painkiller.”
When asked about pacemakers for the elderly, the president replied, “If we’ve got experts that are advising doctors across the board that it will save money...”
“The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy, and the handicapped.”
President Obama was educated as a lawyer. He tends to think in legal and economic terms. The late Vice President Humphrey was educated as a pharmacist. He tended to think in human terms. Obama rose higher in politics, but which one would you trust to direct the health care of yourself and your loved ones?
Obama referred to his grandmother, who had “terminal” cancer, then fell and broke her hip. It is unclear whether she actually had the hip replacement, or how long she lived after being declared “terminal.” According to reports, she was “given” nine months to live, though the usual definition of “terminal” today is “expected to die within six months.”
I see several problems here:
“The last year of life.”
Proponents of rationing health care tell us that a large percent of costs occur in the last year of life. Yes, but so what? “The last year of life” is clear in retrospect, but can anyone predict what it will be? I can’t, and I spent 20 years practicing, teaching, and doing research in medical oncology.
I can quote statistics for a given disease, but I can’t know whether they apply to a specific patient. Doctors treat patients, not statistics. At least they do now.
“The last year of life” can mean the peaceful end for very old persons who were lucky to have lived that long. Or it can mean the tragic end for young or middle-aged persons who were struck down by illness or injury − but who might still have decades of useful life if they received effective and perhaps expensive care. “The last year of life” for 45-year-old actress Natasha Richardson was determined by the Canadian government’s decision not to buy medevac helicopters. But think of the “cost savings.”
“The last year of life” can be a self-fulfilling prophecy. If we stop active treatment of a serious injury or illness, we can almost guarantee that it will be “the last year of life.” Death then becomes not a tragedy, but a bureaucratic decision.
We will then face the absurdity of a government so solicitous of convicted murderers that it declares lethal injection to be “terribly painful,” but a government so unconcerned with innocent citizens that it sentences them to death if their illness or injury doesn’t fit rigid, bureaucratic guidelines.
When I was in medical school, the word “terminal” meant that the patient was in the actual process of dying. It didn’t mean that he was expected to die sometime in the future – everyone is. It didn’t mean that she was expected to die within some fixed time – no one could be sure.
All doctors have seen patients who seemed to be near the end, then recovered to live long lives. But now “terminal” has been extended to mean “expected to die within six months,” or in the case of Obama’s grandmother, within nine months − or in the era of rationing, perhaps within five years.
Let me tell you about Fred. He was a young man with a rapidly growing cancer of uncertain origin. When I first saw him as a trainee in medical oncology, his neck and upper body were covered with lumps. Neither of my professors had seen such a rapidly growing cancer, and they expected him to die in a few days.
Nevertheless, he was given large doses of chemotherapy. His tumors began to shrink. Ultimately they disappeared. All evidence of disease was gone. The biopsy slides were reviewed to be sure it really was a cancer. It was.
Fred went on to finish college, get married, and father a normal child. Yes, his case is unusual. But if we had gone along with our predictions, we would have given up. We would not have treated him vigorously. He would have died, fulfilling our prediction. We never would have discovered our mistake.
It is dangerous to predict a bad outcome, when your prediction leads you to do what makes that prediction come true. Then you never realize you made a mistake, and you make the same mistake next time.
Doctors are often wrong in their predictions of life expectancy. (Click here and here.) We were. Yet those inaccurate predictions are now the basis of declaring someone “terminal” – and therefore suitable to be taken off treatment.
Obama’s health-care plan covers over 2000 pages, but he is on record favoring a single-payer plan − that is, government-controlled medical care. But the “stimulus” bill, already in effect, mandates that care be “cost-effective” − as decided by unelected, unaccountable government officials.
But what is “cost-effective”? If we cannot define “terminal” with accuracy, how can we expect to define “cost-effective,” which is a subjective judgment? What you think is reasonable a bureaucrat may decide is too expensive. How much is a year of life worth? How much is a year walking versus a year lying in bed worth? And since we all die eventually, any care could be called “not cost-effective” − if that suited the whim of a bureaucrat.
“Removing life support.”
During a discussion of the Terri Schiavo case, a doctor described removing her feeding tube as “removing an impediment to death.” This doctor headed the ethics committee of a prestigious hospital. He was used to dealing with patients who were at the point of death, and deciding whether to stop active treatment. Of course, pain medication, food and water, and nursing care should always continue.
This doctor was used to withdrawing advanced medical treatment, so it was only a small step to withdrawing food and water. He pointed out that unlike Terri Schiavo, we normally take nourishment by eating, not through a tube.
Yes, and we normally breathe unaided. Surely he wouldn’t take an inhaler away from an asthmatic patient. We normally move by walking. Surely he wouldn’t take a wheelchair away from a paraplegic patient. At least we hope he wouldn’t. The opposite of “normal” is “abnormal.” It isn’t “dead.”
Terri Schiavo wasn’t on “life support.” She was receiving water and food. Death wasn’t approaching. We can’t “remove an impediment” to what isn’t coming. We can kill her. We can tell ourselves we didn’t. But we did.
This term should refer to patients who are near death, and want some control over the way they leave this world. The problem arises when we use the expression for people whose lives are not ending.
Articles about Terri Schiavo, and patients like her, refer to “end-of-life” issues. But her life was not ending until someone else decided to end it. She might have lived for many years.
That may, or may not, have been a good thing. But we needed to be clear about it. We needed to say plainly, “Terri has already lived like this for years. Should we allow her to live for more years, or should we kill her now?” That would have been blunt, but it would have been honest.
Terri wasn’t “brain dead.” She may not even have been in a “persistent vegetative state.” She wasn’t “terminal.” She wasn’t on “life support.” There was no “impediment to death,” because death wasn’t approaching. There was no “end-of-life” issue, until her estranged husband decided to end her life. We can’t think clearly about serious problems if we use confusing and inaccurate terminology.
We must not allow people to use elastic definitions that stretch to cover whatever they want. We must not allow people to push abandoning treatment, or even euthanasia, for a wider and wider group of patients. Who’s next? Homeless schizophrenics? Disabled people on Social Security? Autistic children?
Without drastic rationing, how can anyone hope to provide health care for everyone at lower cost − and at the same time allow massive immigration? This isn’t a logical plan on which to base national policy. This is an irrational fantasy with which to take control of an additional one-sixth of the economy, as well as take control of people’s lives.
Is that what we want?
Dr. Stolinsky writes on political and social issues. Contact: email@example.com.