The impossible economics of modern health care.
"It's only when the tide goes out," says Warren Buffett, "that you learn who's been swimming naked."
For a good long time, the American health care system had its drawers down, but it didn't matter too much. HillaryCare was summarily dismissed in the early '90s. The problems it might have fixed weren't felt badly enough. Lately arguments for universal health care have been about the unavailable care for the uninsured. But still, no action. The vast majority in the country have health insurance, even if they pay more and more for it every year.
But now, even doctors can't afford to pay for health care. Oncologists, who have to pay for drugs before they're delivered intravenously to patients at the doctor's office, have had trouble lately paying up. As a result, they've learned to be more cautious about the costs of the treatments they recommend to their patients. The Wall Street Journal reports:
In a survey of 167 cancer doctors reported last year in the Journal of Clinical Oncology, 42% said they regularly raised the issue of costs when discussing treatment options with patients. The study, conducted by Deborah Schrag, an oncologist at the Dana Farber Cancer Institute in Boston, found that 23% of oncologists said costs influence their treatment decisions, and 16% said they omit discussion of very expensive treatments when they know the cost will place great strain on patients' resources. ...
John P. Whitecar Jr., an oncologist in Columbus, Miss., says 89% of his cancer patients are on government insurance. He has watched his income plunge 75% in the past three years because of rising treatment costs and declining reimbursements. He says he's borrowed money to keep his office afloat.
At what point should a Christian say, "This simply costs too much. Putting my family in debt or significantly straining their resources is not worth my life. Maybe God wants me in heaven."
Certainly life is priceless. But is more life equally invaluable?
Dying is different these days. Once, vast resources could go toward treating a man suffering from a heart attack. If he lived, he could continue living for decades, and those resources justifiably provided years of good living. Now, people die slowly, consuming those vast resources over the course of years--and often crippling relatives financially.
Joanne Lynn writes, "One hears people say, 'He's not dying yet,' of a person living with fatal lung cancer. Generally, that means he's not yet taking to bed, losing weight, and suffering from pain, as would be expected when dying is all that he can do. But the category is used as if one is either 'temporarily immortal' - which is the usual state of human beings - or 'dying,' in which case the person is of a different sort, having different obligations and relationships. 'The Dying' are expected to do little but wrap life up and go. But this dominant myth about dying does not fit many people. Many elderly people are inching toward oblivion with small losses every few weeks or months."
We are, of course, all always dying, thanks to sin. Our outer man is decaying. It seems these days its a good thing to remember and a good thing for Christians to try to re-teach our culture.
Economists have begun thinking about the "cost/benefit dilemma of end-of-life medical care." One writer on the Freakonomic blog says, "When Teddy Kennedy was diagnosed with malignant brain cancer a few weeks ago, the senator who championed universal health care opted for the rarest and most expensive treatment [unlikely to be provided by any state-paid insurance] - surgery followed by radiation and chemotherapy. But with or without surgery, the prognosis for patients with glioblastoma like Kennedy's is poor, with an 18-month survival rate for those over 60 less than 10 percent."
Wealthy and not at all ready to give up the ghost, Kennedy -- like nearly every American would who can make the choice -- is "fighting" for his life. Even the very, very old these days are opting for surgery and other risky and costly medical procedures that could extend their lives.
Yet, what is that extra time worth? Any universal health care system seems unlikely to provide expensive and marginally beneficial treatment. The government would decide it's not worth $1 million in taxpayer money to give an 85-year-old six more months of life. But unless and until the state starts making those decisions for us, we Christians need to think this one through: How much is longer life worth?
Here's another one: How should pastors help their parishoners decide? This is enough. It's time to see God.
Posted by Rob Moll on July 20, 2008 8:55PM
Comments
According to the Washington Post, the Environmental Protection Agency has "lowered its official estimate of life's value, from about $8.04 million to about $7.22 million."
Posted by: David Neff at July 21, 2008
It's easy enough to say that extending the life of a very old person by a few months isn't worth the pricetag when that person is not someone you know and love. But what if you are talking about your mother or father, and what if you are not at all sure that the dying relative will be happily welcomed into the arms of God? What if his or her misery will only get worse with death? And why is the extending the life of and old person less important than extending the life of a young person? Do you say life is worth X dollars per year and no more? Does it depend on the "productivity" of that life?
To be sure, there is a time to say enough to trying to extend our lives, but I don't believe that such decisions should be made by the government. Perhaps pastors can help, but focusing on finances would be a rather shallow way to evaluate it.
Posted by: Chris at July 21, 2008
I agree with Chris. There may come a time when you need to let that person go, but the decision should never, never be based on money.
Posted by: Alison at July 21, 2008
Seriously, Chris and Allison? To say that the end-of-life decision should "never, never be based on money" is the embodiment of the kind of American delusion that builds up to bursting bubbles (dot.com, housing, more to come).
Perhaps you two have unlimited resources, but most Americans don't. If some are unaware of it, it's because the credit companies lull us into thinking we can borrow endlessly. We are slowly learning now that it is the society that pays for the more and more expensive and elaborate medical treatments like the one Kennedy's wealth and insurance took care of. (Now, I am not necessarily saying that Kennedy shouldn't have had the treatment, because I don't know enough about his medical case. People have been living longer with cancer.) Bottom line is, we all pay for contestable life-prolonging treatments.
You cannot have it both ways: If you think like an American capitalist (money shouldn't be an issue), then anticipate that bubble of assurance to burst--along with the illusion of immortality by medicine. That's increasingly the economic pattern.
Where does your notion of God come into this picture? I don't know. Except that it's hard for me to imagine that the Christian idea of justice includes unfettered spending of other people's money.
Posted by: Agnieszka at July 21, 2008
What's a life worth. Last I heard it costs $5 to vacinate a child from a multitude of diseases that kill 100's of thousands of poor children in the world each year. I'd suggest we place a value on human life of $5 or less every day based on our decisions not to help. Looking at reality make us uncomfortable, so we can choose to not see.
Let's go back to Genesis and repeat the question posed in response to God's question. "Who am I, my brother's keeper?"
27 years ago I as God for 10 more years....if it was his will. Now, everyday is a bonus. I pray only for 2 things: 1) Knowledge of God's Will, and 2) the courage to carry it out...Thy Will Be Done!
Posted by: wesh at July 21, 2008
Well, you could ignore finances altogether, pay whatever it takes to keep someone alive and go deeply into debt. Even if you have insurance, your policy has a lifetime cap. And there is always something doctors can do to keep the body alive. If money made no difference, you would never have to stop treatments. Even if all modern medicine fails, you can have the body frozen (or just the brain) and wait for when science can make you alive again.
If we should never make these decisions based on money and if life is of ultimate value, well, then we should be freezing everyone for the chance that they could live longer.
But realistically, if you don't want to make these decisions about money, make them about the stress that large amounts of debt will put on a family.
I'm not saying these decisions are easy to make, but it's better for evangelicals to be having discussions about how to make such a decision before they're made by insurance companies, doctors, or the government. And before a health crisis puts us in situations where we have to make immediate and gut-wrenching decisions in the waiting room of a hospital. We could avoid a lot of heartache and the consequences of bad choices with a little forethought.
Posted by: Rob at July 21, 2008
Society pays for nothing. The taxpayer pays the bill. And when it comes to medical insurance, the buyer pays the bill and takes the chances. Insurance bets on whether or not you get sick. Many people are healthy until the day they drop dead. Others get more insurance money than they paid in because they're sick more. That's insurance for you. And, the cheapest procedure started out as a very expensive procedure because costs of any research and development are up front. So,in order to get the cheap procedure and medicines you have to start at the top. Someone goes through the first and most expensive experimentation and those who follow get the cheaper benefits as the costs go down and more development brings the cost down even more. Health has always been that way except now in 2008 everybody gets a chance at treatment unlike in the past for centuries only the very rich got health treatment and even their treatment wasn't exactly science. We get so much more now but just don't appreciate what we have that our ancestors didn't have.Anybody can walk into a hospital and get free help.They're embarrassed to do so unfortunatley. At least we have hospitals.
Posted by: Anna at July 21, 2008
The economics of health care are but one factor, as is my love for my spouse and family. What is lacking in this discussion is theological reflection. In contrast to the Puritans who sought to "live well and die well," our society has a habit of living extravagantly and being equally extravagant in matters relating to our mortality. Mortality is a fact of life. In fact, in the economy of God mortality is more than simply a punishment for Adam's sin, it also points us to God and engenders humility because it reminds us we are not equal to God. It is a shame that we have lost sight of this truth. Rather, we seize technological fig leaves to hide the nakedness (and perhaps emptiness) of our lives. No, I am not arguing for an economic eugenics. There is a place for providing affordable medical intervention for the world's poor who die daily of diseases that do not affect us here in N.A.. Just as there is a place to provide people with an opportunity to live a full life. However, there is also a place for God's people to make choices with respect to their own health care that reflects the hope they profess, namely that this life is not all there is.
Posted by: Fred at July 22, 2008
To clarify my position - I'm not going to say to my mom, "OK, I've spent enough money on you - it's time to go to heaven." On that other hand, my mom thinks it's pretty stupid that at the age of 87 they're still doing mammograms on her. Does that help, Agnieszka? I can't believe we're having this conversation.
Posted by: alison at July 22, 2008
It does help, Alison. I was not proposing--and neither was Rob Moll, if I read this piece right--that we have such crudely utilitarian conversations with our dying loved ones. That's cruelty. I was just talking about the philosophy guiding our decisions and the need for it to take note of the very unpleasant, but nonetheless clarifying, financial reality. It does seem that the humility and realism Rob Moll is advocating for is already at work in your Mom.
Posted by: Agnieszka at July 22, 2008
These decisions are private and can only be made on a case by case basis at the time they are diagnosed. It is most likely that you pay for insurance that you may never receive the benefit from, Thank God! However buy it anyway, it only takes one illness to financially ruin a family. If you can't afford insurance then study every Government program tha you can before the emergencies happen. During a crisis the decisions come at you fast and there is not much guidance out there to help you navigate the medical maze. The insurance rules change literally every year so prepare yourself the best that you can, that is really all that you can do.
Posted by: TIMOTHY at July 22, 2008
This poll is not the best because it doesn't factor in the variables of who precisely is the family member, or what the medical condition is. I put the sky's the limit in the case of my children, however, should it be another family member then it would depend upon their opinions as well. Of course, this is all subject to the possibilities of new medications, or surgical techniques. Should there be nothing available at all, then that adds to the decision making process. The bottom line is that poll is overly simplified for all of the underlying complexities of the situation.
Posted by: Jenn B. at July 22, 2008
I had to re-read the website title and the article title to make sure I was on the right website. Still I must ask, Is this really a Christian discussion? Did not Christ say "consider the lillies"? When did we as "Followers of Christ" begin to care SO much about money? When did we become so CONFOMRED to the image of the world? We no longer look like Christ. This discussion is for philosophy or policial science. Not for us.
When Paul wrote "let no one cheat you through philosphy or empty deceit or through the basic principles of the world" he was writing about this. Use your childlike wisdom on the issue. Its HIS money, HIS resources, HIS cattle on a thousand hills. Why discuss how to spend the money when its not even ours?
Posted by: Mark Eaton at July 23, 2008
I agree that the poll is two simplified for such a complex issue. My 36 year old brother had a massive stroke this past spring. It was inoperable. He was paralyzed, comatose and possibly blind. My younger brother and I would have given our own lives to save him, but at what cost to our brother? Had he lived, he would have been on a feeding tube, paralyzed on diapers, severely brain damaged, etc. We based our decisions not on $$, but on his medical condition, what was best for him and finally, we put ourselves in his shoes. We authorized comfort measures only and God took him home a week later. In dire situations, ask questions of everyone. We found certain doctors and nurses to be very helpful and quite supportive us as we worked our way through the painful decisions we had to make. Hospitals also have ethic committees which can assist in such decisions.
Posted by: Madeline at July 23, 2008
Amen, Fred! We need a new ars moriendi.
Posted by: Rob at July 23, 2008
What bothers me about this debate is that people seem rather quick to judge someone elses decision based on how much it will cost. Obviously that is one of many factors. I just don't believe it should come down to, "That guy is too old to spend more than X dollars on him because he won't live that much longer." Or saying, "It's such a waste to spend all this money on some old American when there are so many poor kids going without vaccines."
Nor would I ever want to say that it is someone else's Christian duty to go ahead and die because he or she is going to heaven anyway and keeping that person alive for a few more months just costs too much money. It's one thing to die well, it's another to suggest to a loved one it's time to do it.
Posted by: Chris at July 23, 2008
One would think that as Christians our main goal in this life would be to move onto the next life....eternal life, when we are called, not when we think it is time.
I appreciate that the Lord wishes me to spend time here preparing for the life eternal, but I don't believe my goal should be to stay here as long as 'I' can make it possible.
As Westerners we have managed to make death sterile and something unknown and unacceptable. Do we not want to celebrate our true homecoming as believers? Or do we not really believe?
Posted by: rcmc at July 23, 2008
Anyone who thinks that the government would do a better job in determining who should get health care and who shouldn't, who is too old and who is too sick, should read Joe Bayly's "Winterflight." It's a chilling reminder of what happens when we try to take these decisions and sterilize them, applying one paradigm to all! If you have a loved one, have them make decisions regarding their own care, and put it in a healthcare power of attorney. Write it down! Ultimately, though, and actually firstly, we that love the Lord need to trust in his unfailing love for us, knowing that whatever happens to our body, our life is safe, hidden in him.
Posted by: Claudia at July 24, 2008
I'm spent the past 2 years wondering about this very subject. I think it's ironic that all my life I heard in church that heaven is our goal and now my elderly family members and community members do all and at any cost to keep from going there! The elderly dont make it clear to the family caretakers what exactly they expect to happen with their care. The family members and care takers want to pretend death will never happen to their parents and grand parents. It all seems so 'un-Christ like' to me. Do we or do we not believe heaven is our goal, and are we or are we not responsible for making sure we have a plan for the transition?
Just wondering.
Posted by: donna guzman at July 25, 2008
Health care is an excellent topic for public discussion by Christians. It was a key part of Jesus mission on earth. An excellent book I recommend reading is "The Best Care Anywhere" by Phillip Longman. It provides real answers and surprising findings.
Posted by: Peter at July 27, 2008
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