My favorite is "unnecessary tests". I can't tell you how many people I knew (note the past tense) whose doctor wouldn't do the "unnecessary test".

Seconding hoppycalif2's observations. I watched my father die from pancreatic cancer a few years ago, and think it's worthwhile to contrast the expectations of different generations.

He looked around, talked to specialists, and investigated some experimental programs at a big state university medical center.

In the end, he decided that there wasn't enough of a chance of any reasonable outcome to offset the horrible nature of chemo and radiation. (My wife has had cancer three times, two times with these treatments, so I know a lot about what it does to a person. She survived all three times, thank God, but it was awful for her, and for those of us who had to watch.)

Back to Dad...

He went home, called Hospice and went on morphine to manage the pain, and died within a short time in his own bed, with my mother, brother and I there. Was it terrible to lose him? Sure. But the point is that he got to decide how he went out, and chose the most dignified path possible.

He was born in 1907, and lived most of his life without all of the amazing medical technology we take for granted now. Maybe that made a difference, as he and his generation were more familiar than are we with death and a certain kind of acceptance that comes with not having a lot of options, sometimes. I don't believe suffering is automatically enobling, but it is also part of life and death, and we ought to try to keep it real as much as possible.

They'd also gone through the Great Depression and WWII, and knew a lot about sacrifice and the things that make a life worth living. I think we've lost something important in that regard, with too many comforts and the expectation that our medical system is able to do just about anything. Maybe there are too many doctor shows on TV, with actors trying to look too heroic.

As to my wife's experience, we'll go the whole nine yards if there's a hope of success. What's one more time? But we've talked about this issue a lot, as you might imagine, and have decided that neither of us is going to assume that we're going to live forever, and that heroic measures to save us from the inevitable just aren't all that smart. Quality of life, and the dignity that comes from facing one's fate with a clear eye and some courage at the end, is worth more than all the high-tech futility around.

Rotwang - the vexing nature of this issue is illustrated by the fact that many thousands of pages have been devoted to it. For a sampling, visit the wikipedia article - http://en.wikipedia.org/wiki/Evidence-based_medicine - and some of its many links. One good one is the first external link - to the Institute of Medicine.

I would just make a few points.

1. No proposed reform would deny a treatment to anyone. What a reformed system would necessarily do is refrain from paying for all treatments in all circumstances. If reforms are adequate, however, the denials of payment will be fewer than currently.

2. In a world of limited resources, a decision to provide something for one person is a decision to deny something to someone else. No philosophy can circumvent that reality. Reform proposals that minimize ineffective interventions - whether totally ineffective or merely not very effective - can in some cases free up resources to provide interventions that do a better job. For some individuals, this will be a loss, but if reforms are prioritzed equitably, the overall result will be a net gain. Equally important, it may permit some individuals to receive treatment for an intervention that is vitally important, at the expense of another individual who then must either do without something less critical or pay for it out of pocket.

I will not share my experiences, but feel qualified to say I have been there with death.

Rotwang seems to have a completely garbled message, partly, it would seem, because he is ignoring basic economics and partly because he seems not to realize how crappy private health insurance has become.

No one, let me repeat that no one lives "in the comfortable womb of good private insurance." No such thing exists any longer. Wealthy people can afford to pay out of pocket for an indefinitely long time and members of congress provide themselves luxurious health benefits, but the rest of us are already at risk, even those who have the semblance of "good private insurance."

The opponent is not the merciless economist (god how I hate to ever defend economists), it is the utilization review analyst, usually a nurse, who will deny your care for a poorly completed form as quickly as for the fact that it is quack quack quackery from Quacksville. Ironically, the UR analyst also has crappy health insurance.

This is not a new phenomenon to anticipate under a new government health plan (tightened to the bones by the anti-tax crowd), it is what we have had for 40+ years and it has been getting worse every year. When, 40 years ago, your doctor or your parent's doctor asked you to sign a form allowing him to receive assignment of your health insurance payment, you should have said "Hell no, I will pay you and deal with the insurance company myself." That would have delayed, if not blocked, the UR analyst development.

That water is way past under the bridge. And, THAT is why we need single payer. Single payer can free competent health care professionals to perform their services without the constant insolence of UR analysts, who should, collectively, be relegated to one of the lower rings of hell.

Now, having said that, that only scratches the surface of Rotwang's nonsense. As Rotwang well knows, societal decisions are based on allocation of scarce resources. The scarce resource in this instance is not health care, it is economic power, otherwise known as money. Despite our individual desire otherwise, there is a point where society cannot put more resources into health care. To do so takes resources away from other vital matters. I personally think we could easily take $1-200 billion a year out of the military budget, maybe more, and spend it on health care. But, I do not have the clout to make it happen.

When we max out on our willingness to pay, all other health care finance decisions are zero-sum between health care beneficiaries and vendors. For example, in my long ago job in public health finance, we were concerned that fast growing costs for certain elderly would be spent in the opportunity cost of immunizations and other relatively inexpensive but very effective health care for children.

The low hanging fruit in the health care pie is the excessive overhead of insurance companies (including all those UR analysts). The next, not quite as easy to get at amount is the profiteering by nursing homes, hospitals, pharmaceutical manufacturing companies, medical appliance companies, and others in the health care production function. Yes, that includes physicians who, understandably, make up the most bizarre excuses possible for their extraordinary pay relative to other similarly skilled professionals. Then, there is the matter of what to do with momma (or pop), the very existence of the entire nursing home industry reflects a disgraceful failure of the family.

All of that comes before deliberate rationing. I say deliberate, because we have had de facto rationing for quite some time.

I hope Rotwang does not repeat this sort of column. I have long been a fan of his, but scare mongering is no more attractive among progressives than it is among the right.

As someone who has been there and worked in an ICU I can tell you that there are three huge variables in the "last week"; the individual, the immediate family and the attending physician and the choices of treatments that they choose to present.

To grossly oversimplify it, if the patient wants to push the limits then they will get the 1% choice, if not they will get the 5% choice. But it also depends on the attending. Is she participating in research in a 1% choice or did he recently have a horrible experience last week with the 10% choice? The biggest variable may simply be on how the physician presents the choices to the patient. But there is always always a bias towards trying everything if the patient or the family insist on it.

I don't see reform changing any of those dynamics in terms of what choices are offered unless hospitals put increased restrictions on physicians when insurance doesn't cover it and doctors would fight that tooth and nail. "Hail Mary" and long shot treatments are often the leading edge of medical practice and yesterday's long shot is often tomorrow’s standard. Hospitals who limit that loose doctors and patients.

But there is one aspect of reform that does have the potential to cut costs in the last week in a major way. If the fee for service model is changed to a team oriented salary model for physicians then the cost of that last week would be greatly reduced at the physician’s expense. I don’t think that would alter the choices of treatments for the most part but it may change the type of physician who would choose to be an intensivist or hospitalist.

I have worked with both types and I want my doctor on a salary, if he’s in it for the money let him go into plastic surgery or to Wall Street.

My mother died of a form of leukemia. There were treatments to prolong her life for years (mainly blood transfusions) and she had good insurance.

She chose not to wish for a hero. She was tired of being medically messed with. She was tired of feeling really crappy for a large percent of her time. And on and on. Family-members tried to do it for her, but she more and more steadfastly resisted treatment. And that's pretty much how it ended.

I only mention this as an alternative to the scenario that Rotwang depicted.

I think this post is brilliant and that it's a shame that what Rotwang is talking about here isn't part of the debate.

The problems we have with our health care system in America can't all be summarized as problems of cost. The cost of health care and health insurance is too high but you can only say that something costs too much in relation to... what you get.

If health care in America costs too much then the corollary is also true -- we get too little for what we pay.

The focus of this debate has been about bringing costs down. That's a mistake. We should be talking about making more and more generous service available.

As Rotwang illustrates quite well... this notion of expenditures in the last year of life is all bunk. Heck, up until the point that the patient agrees to hospice and end of life pain mitigation, the medical establishment should be spending huge amounts to set the patient back to healthy. We should be doing more and thus paying more when the patient is in trouble. That's... um... the point.

Health care doesn't "cost too much." The problem is that we pay and we get too little.

I reject the idea that you can't have an opinion unless you have faced death. It reminds me of a conservative friend who said all pro choice people are hypocrites because they weren't aborted as fetuses. I may change my mind as I face death, but I just may be more rational now.

Society has limited resources and no obligation to provide heroic (i.e. far beyond standard) health care. It is an oversimplification, but every million dollars spent on heroic health care in the last years of life is a million that can't be spent on child nutritional programs. I'm not insensitive, but I was appalled when my wife got into an argument with a surgeon about performing a total mastectomy on her 90 year old grandmother. The surgeon won. The operation was successful, the surgeon no doubt chalked it up as a "win", but she did not have another coherent day in the remaining year of her life.

Oh, bullshit. Codswallop, from beginning to end.

No, you don't have to have been there. When my mother was dying, we all, including her, made the same decisions we said we would when she was healthy. In the end, she looked at the quality of life she had to look forward to, stopped dialysis and died peacefully.

Moreover, just because someone wants some hugely expensive treatment doesn't mean they are entitled to have someone else pay for it. They need to deal with the fact that they, like everyone else, are going to die of something someday. Maybe people WOULD want another week to smell the roses even if it cost 100,000 poor children their dental care. Tough shit. People need to grow up.

Medicare's estimated costs for 2009 is $420 billion. Approx. 70% of Medicare costs are spent in the last 30 days of life. Nearly $300 billion will be spent this year alone for the last 30 days of life for just the Medicare population.

Note that these numbers represent the last 30 days of life, i.e. the costs may have extended the patient's life for a maximum of 30 days. These data do not reflect costs incurred to lengthen life by 31 days, or 60 days, or a year. And obviously the numbers don't reflect successful treatments that extended life indefinitely.

With 50 million unisured today, that's $6000 spent this year alone for every man, woman and child who is not insured during the last 30 days of life for Medicare recipients.

Yes, I've been there with parents.

PEACE

"You are definitely asserting moral authority, however.

Just like everyone else.

That's not an inherently bad thing.

It just gets us nowhere."

On the contrary. It gets us everywhere. It's the absence of moral authority that leads to nowhere. That is why the post that started this discussion is so valuable. I want to thank that poster for starting what I regard as very likely the best dialogue about anything I've ever read on this page.

Here in Europe, statistically, we are at least as healthy as Americans are but spend only half of what Americans spend per head.

People will be justifiably wary of any new method of managing health care. Politically, it will very easy to garner opposition to any new arrangement that withholds treatment -- even if it withholds treatment less often that the current system does. Morally, I don't see how anyone can justify a health care system that withholds treatment.

If you want people to support a new system, that new system will have to give everyone complete freedom in their medical decisions. It is going to have to pay for the riskiest, most experimental treatments for everyone's kid, spouse, or parent. If it won't do that, then people will hate it just like they hate private insurers now.

There is really no difference between an insurance company letting a loved one die in order to save money and the government letting a loved one die in order to save money.

Did anyone else find this blog post offensive? It begins as if it's using economic logic to analyze the issue, but quickly veers into arguments appealing solely to emotion. In particular, the refrain of "have you been there?" suggests two things:

1) People who have seen end-of-life situations firsthand ("faced Death") have a more valid perspective on spending on end-of-life treatments and tests for life-threatening conditions. Faced with a policy argument, simply say, "Have you been there?" and, if the answer is no, presumably, argument over.

We should all acknowledge there are strong, deeply personal emotions and stories in the health-care debate. Using them as rhetorical clubs to beat those who have different opinions cheapens everybody.

2) The author seems to assume that everyone who has "faced Death" will agree that there's no treatment not worth trying. In fact, as many comments have pointed out, that is not the case.

My grandmother, who passed away last month at the age of 87, made it abundantly clear repeatedly that she did not want treatments that would extend her life if it meant she could not live independently. "Call Dr. Kevorkian!" was her repeated refrain. (In fact, she died of sudden deteriorative brain function that lasted about 6 months and for which doctors could do very little.)

Of course these intensely personal decisions need to stay with patients and families, in consultation with their doctors. Still, this is something we need to talk about when discussing health care reform. IT seems that sometimes those who want to preserve the status quo argue as if mentioning that these difficult situations exist is the end of the discussion. It's not, and we need to acknowledge the difficulty and sensitivity and move forward with the discussion.

Argument that appeal primarily to emotions must be treated with caution.

M.

The problem with this argument is that it doesn't examine the premise that "cost containment" means limiting treatment for existing illness.

In fact, true "cost containment" comes about by implementing preventive measures. A healthcare system that funds preventive measures reduces the illnesses for which expensive treatments are required. The current "for profit," "fee for service" system is actually providing broad-based disincentives for preventive measures that improve health, because all the profit is in providing treatment.

I refer you to the example of Singapore, which has mandatory insurance (HSA's, actually) and a public option. Singapore has the lowest infant mortality in the world and the fourth longest life expectancy. Those ought to be the measures of a healthcare system's effectiveness. Oh, and in Singapore, per capita spending on healthcare is about 1/7th what it is in the United States. That's "cost containment" with a vengeance.

Thanks.

mp

1. A treatment has zero chance of being effective, or a positive probability of being harmful.

The assertion that there are no such treatments is certainly wrong. The Fen-Phen diet pills is one recent example, but there are a myriad more out there.

If the statement is changed slighly, to include treatments that are less effective than alternative treatments, there is a strong case to be made that many treatments would fall in the less effective category.

For example, there are studies that show that heart bypass, stents, and drugs are equivalent in outcomes, but that bypass is far more expensive than stents, which are more expensive than the drug therapy.

Aaargh, while giving thanks to Rotwang for making important points, I feel the need to rant.

It always amazes me what happens with this topic on liberal blogs. So many pat flippant stories lauding the noble "he/she died with dignity" example, With nary a recognition how offensive and scary they might sound to others.

Just like in the movies, the noble Eskimo elder, no longer able to hunt or gather or skin a seal, going off to starve on the ice floe in order to save valuable resources for the next generation, is the great hero to be admired.

So much cluelessness, so flippant, so many seem to have absolutely no recognition how much their "please older people, die with dignity like this other person did" stories have in common with those who would like all women who get pregnant to accept nature as it comes, to follow through with what nature wants for them.

Nor do I see any recognition how frightening it might sound to someone like a 30-year old cerebal palsy victim to read the "please die with dignity" advocacy, things like lauding those who chose to forgo dialysis as someone to be admired and also thereby inferring that those who chose to partake of it, especially past a certain age, are parasited on society. The cerebal palsy victim reading must think: geez, my medical care is far more expensive than dialysis and my life is far more limited than the lives of those on dialysis, so what must these people want of me? What age do they think I should have given up the ghost at and quietly gone off on the ice floe? And what quality of life is good enough for them? Do I have to go through some testing to prove that I am having quality of life to meet their standards?

Seems to me it's as if people who talk like this haven't gotten around very much, haven't gotten outside their own Eskimo tribe as it were. Don't realize that there are other kinds of people out there, many of them, people who have an incredible drive to live as long as possible, even in pain, even with severe illness and handicap. And it was people like them that cause life expectancy to raise over the centuries. (BTW, I don't happen to consider myself one of them, sometimes my midlife aches pains and problems seem to be too much for me already. But at least I acknowledge that there are others out there who love life far more than I do and would put up with far more to keep just a sliver of it.)

Here's the thing, gang: all this "die with dignity" talk is REAL COUNTERPRODUCTIVE to health care reform. It scares a lot of folks out there, folks who think people like you might end up in charge of what health care they are allowed, maybe you will even someday limit what they can pay for our of pocket. The way some of these "die when it's your time" stories are just plain scary. Just like some of those right wingers scare the bejesus out of you when you think they might be in charge of who can get an abortion.

Not only that, I wonder what happened to twist some supporters of "progressivism," as in progress, scientific progress (with results like raising life expectancy levels,) into negativity as to life extension. Ya know, it wasn't so long ago that heart bypass was a risky, expensive operation available only to a few. So shouldn't you have been advocating all along against heart bypasses and for "dying with dignity" instead before it became a common thing and before they all could continue to collect Medicare and Social Security, thereby saving the rest of us a lot of dough? If you had, maybe we wouldn't have all these seniors with heart bypasses playing cards, reading, doing crosswords, surfing the internet, and watching TV, with visits to the heart specialist for checkups, leeching our scarce resources with their Medicare payments for walkers, oxygen tanks and meals on wheels? They are not productive members of society, after all, comrades, right? Work and produce or die, is that the rule?

One suggestion to all who like to laud "dying with dignity" stories: preface your story with the word "choice," just like you would do with the abortion issue. (Unless you are the type who likes to make the point that abortions or even sterilization for poor women are good mainly because they save society money in the long run, and lower the number of "useless" lives, if that's the case, carry on.)

I find myself more sympathetic to the "expatjourno2" version of the argument upthread, i.e., "get real, grow up, society can't afford to pay for everything for everybody and if you want some things, you are going to have to pay for them yourself." But implicit in that argument is that the rich will always be able to pay for the experimental, that some of them will be just as into living as long as possible as many less rich, and that we shouldn't prohibit them from doing that, nor laud others for refusing to do it even if they could. Because maybe something will come of it that will benefit all. We didn't all used to have indoor plumbing, you know. Quality of life, it's real relative.

Finally, I am anxious to see what side many of those pushing the "death with dignity" theme will be on the first the new medical review board labels Ted Kennedy's current treatment as experimental for an "ordinary" person. Are you willing to accept a Ted Kennedy allowed a year more than someone else? Are you ready to disparage him as not dying dignified, too? Or will you go the socialist route and say everyone with brain cancer should get it and we should all pay for it?

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