Monday, August 24, 2009

Heroic medicine vs. public health, part I

Grandma Smith is 80 years old, has chronic kidney failure, and requires dialysis three times each week to stay alive - treatment that she doesn't have money to pay for herself. A government-sponsored "death panel" determines that her life isn't worth what it would cost to continue her dialysis. This is the imaginary nightmare scenario that just doesn't seem to go away, even though its basis in the current health reform legislation is flimsy at best. No wonder so many people are outraged! Seen in isolation, this sort of callous decision seems to be emblematic of an unfeeling, bureaucratic health-care system that no sane person could possibly want.

But what if the trade-off for continuing Grandma Smith's dialysis was that we couldn't pay for yearly influenza vaccinations for 10,000 other grandmothers and grandfathers, protecting them from an infection that leads to death from pneumonia in thousands of Americans each year? Or what if paying for her dialysis machine, the technicians to run it, and the doctors to supervise it meant that your children didn't receive antibiotics for tuberculosis, or your community had to make do with inadequate water filtration? Balanced against the health of the public - that is, the health of countless others who are no less deserving - Grandma Smith's treatment begins to seem selfish at best.

Of course, health care isn't a zero-sum game. In fact, when dialysis machines were first invented, there were so few of them to go around that some municipalities formed committees who, much like the mythical Obama "death panels," determined which of their citizens with kidney failure would be able to go on the machine and whom would be left to die. The result was that eligibility for Medicare, which is primarily a government-run insurance program for the elderly, was extended to cover all patient with kidney failure severe enough to require dialysis, regardless of age. As a result, no person in the U.S. today goes wanting for dialysis.

But this is a double-edged sword. During my family medicine residency, I cared for a 45 year-old otherwise completely healthy man who, through an unlucky roll of the genetic dice, suffered catastrophic kidney failure and whose life was certainly saved by immediate access to the Medicare benefit. On the other hand, I've also cared for many other patients with irreversible brain, heart, or lung damage whose kidney failure was clearly part of the process of dying, and whose lives were merely prolonged ("saved" would imply that there was some purpose to continuing treatment) by dialysis while their loved ones avoided meaningful end-of-life discussions.

In my next post, I'll talk about the negative effects that spending on this type of "heroic" medicine has on the public health.