I’m a great admirer of the thoughtful, literary style of Atul Gawande. He writes sincerely and movingly about the trials and tribulations of modern medicine. It’s when he tries to extrapolate public-policy recommendations from these stories that he falls flat, kind of like a Steinway piano whose middle C is badly out of tune.
His most recent article, titled “Letting Go” and published in the August 2 issue of The New Yorker, is exemplary of his work. In the article, Gawande tells the stories of several patients, young and old, who are dying — typically of cancer — and how doctors, nurses, patients, and their families struggle with the challenge of facing death.
As he notes, end-of-life care was a prominent element of the Obamacare debate. “Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.” Why is this a matter of concern? Because Medicare is a taxpayer-funded entitlement, spawned by Congress 45 years ago today. But Gawande thinks that certain politicians have got it all wrong:
The subject seems to reach national awareness mainly as a question of who should “win” when the expensive decisions are made: the insurers and the taxpayers footing the bill or the patient battling for his or her life. Budget hawks urge us to face the fact that we can’t afford everything. Demagogues shout about rationing and death panels. Market purists blame the existence of insurance: if patients and families paid the bills themselves, those expensive therapies would all come down in price. But they’re debating the wrong question. The failure of our system of medical care for people facing the end of their life runs much deeper.
By “deeper,” Gawande means that patients and their caregivers aren’t trained to face death; instead they’re trained to fight on, adding more and more treatments, even if many of those treatments are futile. Of course, these problems are rare in other parts of the world. In Britain’s National Health Service, for example, terminally ill patients are incorrectly classified as “close to death” so as to allow the withdrawal of expensive life support.
But there is something to be said for dying with dignity and for making considered decisions about how much medical intervention is enough. What Gawande doesn’t get — what he calls “demagoguery” — is the understandable fear that Americans have that, in a state-run system, those decisions won’t be theirs. We only have to look across the pond to see how that could play out.
Gawande believes, as we all do, that the practice of medicine would benefit from patients’ thinking ahead about end-of-life care. He cites the example of La Crosse, Wisc., where, since 1991, anyone admitted to a hospital, nursing home, or assisted-living facility was required to fill out a form asking: “Do you want to be resuscitated if your heart stops? Do you want aggressive treatments such as intubation and mechanical ventilation? Do you want antibiotics? Do you want tube or intravenous feeding if you can’t eat on your own?” Gawande notes that the mere act of asking patients to think about these questions in advance led to more humane, and more effective, treatment later on. It’s a good idea, one that other hospitals could learn from.
But to Gawande, it’s not enough that other hospitals adopt such procedures on their own. A provision in Obamacare was to provide government funding for doctors to have end-of-life discussions with their patients; to Gawande’s dismay, “it was deemed funding for ‘death panels’ and stripped out of the legislation.” The obvious question doesn’t seem to occur to him: Why do we need a government program to pay doctors to have thoughtful conversations about their patients’ eschatological desires — something they should be doing already, and that doesn’t cost a dime?
Amazingly enough, there are ways to improve the quality of end-of-life care in America that don’t involve a government program. Gawande knows this, for he writes compellingly and often about the successes of people like the doctors in La Crosse.
But it is a constant struggle for Gawande to see what is in front of his nose: that such improvements come not from Olympian government officials, throwing lengthy pronouncements down from D.C. office buildings, but from the accumulation of thousands of small innovations by individual doctors, nurses, and administrators.
One of the great slanders of the last year was that conservative opposition to Obamacare’s end-of-life provisions was demagogic and dishonest. It is true that we often try too hard to extend life at times when it is futile to do so. It is true that, thanks to unwise government policy, we often expect care we don’t need, because we are insulated from its price.
There are legislative reforms that can help address these problems. But they involve reducing, not expanding, government control of the health-care system. They involve letting patients decide for themselves, with the aid of their doctors and their families, how best to negotiate their last days on earth. If a free country can’t be about that, it can’t be about much.
– Avik Roy is an equity research analyst at Monness, Crespi, Hardt & Co., and blogs on health-care policy at The Apothecary.