Am I Nominating Myself for a "Death Panel?"

I got a pretty good amount of push-back (thankfully no hate mail) for my last post around my hesitancy to support comprehensive health care reform.

I still want to suggest that the best remedy for improving our health care system is not a "massive overhaul." It is equal parts common sense and compassion. I'm not talking about common sense and compassion by the government or big insurance companies--I'm talking about common sense and compassion in our own experiences with the health care of our families and even ourselves.

If high costs are the primary issue, a little common sense would go a long way to reducing costs, especially in the cases of the 20% of patients who produce 80% of the costs. Common sense could interrupt the process by which doctors suggest, patients accept, and doctors are then reimbursed by insurance companies for ineffective and highly expensive procedures. Take, for example, bypass surgery, angioplasty, and stenting for people with coronary artery disease. Research suggests that drug-based therapies can be just as effective in extending the health of heart patients at a fraction of the cost. In treatment of cancer, expensive late-stage cancer treatments are common and basically ineffective; common sense says don't pursue, prescribe, or reimburse for those treatments. Expensive diagnostic tests, like CAT scans and MRIs, are often unnecessary (and over-used) for determining a course of treatment.

I know I end up sounding like a shadowy Kevorkian--a 1-man "death panel." But our system of health care provision is expensive in part because doctors, patients, and insurers conspire in the absurdity of "doing whatever it takes" to extend a patient's life, when doing less (or doing more with less) could achieve much, much more for the patient and the health care system as a whole. Doctors are chiefly responsible for the malpractice of authorizing expensive and unnecessary procedures, but if they're getting pressure/compliance from patients to do the procedure/test and if the insurance companies are authorizing them... who can really blame them for wringing profits from that flawed pay-per-procedure system?

To interrupt that mania, to me, is "common sense." But maybe it's deeper than that... maybe it's also the truly compassionate thing.

When I interned as a hospital chaplain in 2003 (my deepest and most revealing look at health care in action), I was stunned at how little the subject of death and dying came up in critical care situations--even when death was literally "in the room." A patient would by lying there, dying. And when the doctor or team of doctors would come to speak with the patient and/or family, there was always a predictable dialogue that went: Docs--"We have done all that we can." Patient--"Is there anything else you can do?" Docs--"Yes, we could still try... but the effects would be... and it is doubtful whether it would change the underlying condition." Patient--"Well... we need to try." No conversation about quality of life. No conversation about costs and benefits. No mandatory hour to sit with options and discuss (or pray?). Just a reflexive "we need to try whatever we can do."

Common sense--and compassion--say yes, of course you need to try to preserve the life and health of any person who is sick. But common sense and compassion also say that "whatever it takes" as a treatment plan is a morally lazy way of avoiding hard conversations about eroding quality of life and impending death. Death happens; to everyone. No one in any hospital room wants to be the first person to say, "is it time to let this illness run its course?" No doctor, no family member wants to be the one to recommend the less aggressive treatment plan, because the subtext of any such proposal is, "you will die." But when, for example, a person's heart no longer pumps oxygenated blood to the body, hasn't the body already sent a clear signal that it's time to pack up? Why are patients still seeking aggressive, excessive treatment? Why are doctors still offering it? Why are insurance companies paying for it? It is an example of a kind of "innocent" selfishness (or tragedy of the commons?) that, multiplied millions of times over in separate hospital rooms, has weakened our nation's ability to provide affordable care. A moral health care system is one in which patients and doctors have difficult conversations with real choices; conversations that explore issues like quality of life and the cost of a treatment plan versus its potential benefit. To beg off these questions turns the sacred practice of health care into a purely technological effort to "extend life at any cost"; extending life becomes the only acceptable end--until, of course, death finally asserts itself into the conversation, always in its own inimitable way.

Our health care crisis (as with the housing bubble that initiated the current recession) is not sufficiently explained by a systems breakdown--it is also a consequence of people doing things that are either ethically lazy or plainly wrong. The solution, to me, is not government control over health care, but a combination of better governmental oversight over private industry combined with people at all levels of the system acting with sufficient common sense and integrity.

The issue of health care is a moral issue. But I don't accept that that only moral solution is universal care--there's ground to argue at this point that universal care is a more immoral solution if it exacerbates our groaning debt crisis and cripples the capacity of the next generation to pay for emerging social needs. The market can work exceptionally well and government can, as it does now, offer care for those the market does not serve. But this balance requires two pieces to work: 1) good, thoughtful government regulation of private business and 2) human beings, at all levels of the system, acting morally and ethically.

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I've found good discussions of the issues surrounding health care on:
The Health Care Blog
Prescriptions, a blog of the NYTimes