So many of these patients are near the end of their lives--whether anyone likes that idea or not is irrelevant. The fact is that no amount of medical care, no amount of love, no amount of knowledge or technology can keep these patients alive forever.

Why subject a patient to serious surgeries, organ transplants or other aggressively invasive procedures when even the most optimistic outlook is a partial recovery with little benefit to the patient?

Here's a crazy hypothetical I encountered a few months ago: a 42 y.o. female with a stage IV atrial sarcoma comes in for a PET scan. She has a history of brain tumors and says she "feels" a tumor growing back in her brain. PET scan is positive for a re-growth of the brain tumor.

Now, if you know anything about atrial sarcomas, once they reach a certain mass and have spread a certain degree, there is very little that can be done to increase the lifespan of the patient. It's been tried. Combinations of surgery, radiation therapy, chemotherapy, diet and medication have been studied closely to reveal that there is no statistical difference in lifespan for those who undergo the most painful, aggressive therapies and those who get palliative care.

So, do you opt for brain surgery to remove the tumor or just let it grow and treat the symptoms?

What gets me most is that the whole "left/right" dichotomy is just used as a wedge for the powerful to keep us at our throats. Just like powerful countries throughout history have fomented dissent between neighbors in order to keep their foothold, so we are being used.

If you drive a hummer and live in a $400K home, I at least understand why you are a replublican. But it confuses me to no end to see someone in a beat up 1987 toyota corolla with a "Bush/Cheney 04" sticker on it.

It seems like the Teabagger-Bachmann people are just a protofascist group whose main identifying feature is that they're willing to not give a shit about anyone but themselves. Maybe that's a bit hyperbolic, but maybe not.

I feel your pain, Thera.

That is most definitely a well-founded fear. Back when Kevorkian was news, I was full of strong opinions on the subject and thought it would be best to enact legislation in favor of assisted suicide.

Little did I know at the time, but my mother, who had suffered from an aggressive, metastatic breast cancer, and died about 8 years earlier, had asked to die.

The conversation took place between 3 people: my mother, father and the primary care physician. After about 5 years of aggressive treatment, she was not getting any better and she was tired of the pain. She was just plain tired. She was conscious enough to have the conversation and her intent was unambiguous: please kill me.

So, with my father at her side, the doctor infused her with a cocktail that ensured a painless death. This is not something that doctors talk about in passing conversation as the legality of it is grey at best. I'm ok with it, and even at the time, I never felt that anyone had taken these decisions for the wrong reasons. She had suffered enough, in her own opinion, and none of us ever doubted her love for a moment.

The point is that the moment these decisions become legislated, they lose an essential bit of the humanity involved in such a personal decision. That's why my core feeling is that these decisions need to be made within the families involved. I fear the state in these issues. Hell, I fear the state's ability to fairly maintain property rights. No way I want them involved in anything more personal.

There are always people who are wards of the state, etc. where the state is obligated to have a say in these issues. But I don't think it could get any more expensive because as it stands, the default position of these institutions is to keep patients alive regardless of quality of life. And I'm not sure there should be another option for those people.

It's tough any way you look at it.

And that hypothetical I proposed is EXACTLY what I encounter on a regular basis. It's very far from hypothetical for a lot of people.

Again, I think you are not understanding what I'm saying. I want to lead people into having this conversation--NOT one conclusion or the other. I truly believe that if the families in these situations have these conversations out loud, with each other, and with the doctors involved, some of them will opt for palliative care in place of therapeutic care.

BTW, my OP set up a discussion--not an argument--based on my experience with the patients as well as reading their medical histories. Please don't rewrite my post to assume I'm in some ivory tower far removed from this reality.

But you never answered my outlandishly hypothetical question: is there ANY point at which you would say a person's quality of life is unreasonably low and will never get better--by your own standards?

Of course you do. Now what? What can be said from that point?

What have you been writing about this? Is it academic? Essay? From what axiological foundation are you building? This is the discussion I'm looking for.

"Quality of life" is most definitely a subjective concept.

Tell me, if you saw someone contracted, unable to speak, who screamed in pain every time he was moved from one bed to another, whose medical problems were so severe and so many that he stood no chance whatsoever, in the most optimistic outlook, of ever recovering, would you at least think that person might deserve a conversation BY HIS OWN LOVING FAMILY about his "quality of life" and the possibility of palliative care in place of therapeutic care?

Lots of people don't like to talk about this and would jump on the opportunity to accuse those who bring it up of being callous, but tell me RTBG, do you have a minimum standard by which you could say "Yes, that person is definitely suffering beyond any reasonable measure. That person has a low quality of life that will never improve."? Or do you just want this conversation to go away?

My hope is that at some point, if we can learn how to have this conversation with our families, we can start to step in the right direction of patient care. I truly believe that the sooner we can make these tough decisions, the better everyone involved will be.

I guess I'm dancing around it: the sooner we start to make decisions about ending the lives of people we love who have lost any possibility of a decent quality of life (whatever that means), the better for everyone. Some people will still want to keep their family alive regardless of the perceived quality of life, but nonetheless this just seems like the right way to start thinking about it. No one wants to willfully end the life of a mother or father, or God forbid, a husband or wife, but everyone deserves the consideration of this possibility.

As it stands, people can avoid that difficult decision BECAUSE they have no financial burden to bear. Is there a way to motivate someone to have that conversation even though they have no financial stake?

That's the direction this conversation needs to go, I think.

But we have to start somewhere. I think right now, we don't necessarily HAVE to have the conversation, yet. I say that because the medicare/Medicaid system has not YET broken the back of our country. But at current rates, it most certainly will, and you probably know this.

The difficult part is putting a cost on peoples' lives. No one wants to say what the maximum cost of a person's life is or isn't, that's why people with very low qualities of life are kept alive WAY beyond any reasonable measure--because no one wants to go to sleep with the idea that another uncaring institution could put them or their grandma "out of her misery" when it would be against the person's wishes. That's horrifying.

But at the same time, the current situation is unsustainable over the medium and long term, meaning 15 to 40 years. We simply cannot afford it. And no, I am NOT an advocate of letting the state decide when someone's quality of life is low enough to pull the plugs. A AM an advocate of families and outside agencies (like, uh, I don't really know, but not the state) having input on that issue about specific circumstances as they happen and when the family is not there to make that decision.

How can we start to evaluate "quality of life"?

Honestly, there were only 3 reasons we went to Afghanistan, and of those only one good reason.

1. To dismantle al Qaieda
2. To get revenge for 9/11/01
3. To reinstate a pipeline deal for Central Asian resources

Of course, we never really got any closure as a country because we never got Bin Laden--as if one person's death could make us actually feel better. But nonetheless, it never happened.

The dispersement of al Qaieda happened, but since they're not a national entity, this is hardly a "cure" to future attacks.

And whatever's happening with the energy deals of Central Asia, you can bet that it will come back to haunt the American people. Chalmers Johnson wrote the bible on this phenomenon aptly titled "Blowback".

The fact is that the Taliban did one thing well: they eliminated 95% (by UN stats) of poppy cultivation under their rule. As soon as they left power, poppy cultivation exceeded its previous highs. If anyone doesn't realize it, opium production (estimated by the UN) accounts for the MAJORITY of the Afghan GDP. We--the US military, DOD agencies and PMC's (Private Military Contractors) have an active (and likely profitable) hand in the delivery of opium to Turkey and on to Europe for consumption.

Basically, we are not helping the situation by being there. We are just allowing hand-picked warlords to control a massive, nearly exclusive drug trade.

People are just starting to question the wisdom of a long-term ground war in Afghanistan. Fucking idiots.

Maybe, just maybe, if the televised media had attempted to tackle difficult subjects, unpopular subjects and said something other than "Buy, buy, buy!!" "Take out that loan NOW" and "There's never been a better time to hold onto your investments" then it's possible we would be in a different situation. Sure, it's a Monday-morning quarterback comment, but this echoes a series of conversations between a group of friends about the different media messages being portrayed back in January 2008.

The Economist had issue after issue proclaiming the coming "credit crunch". They are certainly not the only ones to be ahead of the game on that one, nor were all their authors' predictions accurate. The point remains that the information was out there for the taking for anyone willing to look for it. The call for "PANIC" would not have changed the reality of the off-books dealings of the banks, but it would likely have brought them to light sooner. I am in agreement with those who speculate that we have just scratched the tip of the iceberg of undisclosed losses the major banks really have.

At the bottom of our current economic woes, as has been pointed out, was the easy money to be made in the derivatives markets, coupled with the loose standards for taking out a mortgage. The "Commodities Futures Modernization Act of 2000" was pushed through congress by Phil Graham and Dick Lugar without so much as a whimper from the televised media.

If there is a lesson to be learned from this economic crisis, it's DON'T BELIEVE WHAT THE SHITBOXES ON TV ARE TELLING US. They are NOT in the business of exposing the reality of the world in which we live.

This is true for the majority of what passes as news.

Of course, TPM is doing the greatest service possible. That's presumably why we're all here. Please keep up the fine work.

However, I'm much more concerned about the "black budgets" that not only undermine the fiscal integrity of our economy, but ultimately turn the Constitution into a "quaint," historical document.

I need more hard figures and estimates, but it's not controversial that the numbers hover around several hundred billion dollars per year. Intelligence is where our defense efforts should indeed be concentrated, but because they are concealed from public scrutiny, I have no good idea as to how they might be tamed.

As for nuclear weapons, call me "old-fashioned," but I like the idea that the rest of the world's leaders know that they will turn to ash if they even think about associating themselves with a nuclear attack on us or our allies. I'm the furthest thing from a hawk without being an anarchist, but deterrence is tried and true.

It just doesn't make sense to ask anyone else to "trust" us that we are disarming, nor does it make sense for us to trust other nations in this regard. We have not left the nuclear age just because the cold war is officially over. As long as nuclear weapons exist, we run the risk of detonation on this planet.

Fundamentally we agree: the defense budget is out of control. And I actually agree with shooter about closing a majority of the 732 bases we have overseas. According to Chalmers Johnson, they cost about $50 billion per year to run.

Anyway, my education on these complicated issues is incomplete, to put it kindly, and I thank you for your contributions.

CAM