What Is Good Health Care?

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This article in the NY Times yesterday finally gave expression to some thoughts I’ve had for a while.  In particular, I’ve found it interesting that a discussion of health care reform, which ostensibly is about helping more people live longer, healthier lives, devolved into a debate about euthanasia.  In part, this is because we do not have a consensus on the philosophical underpinnings of our health care system.   Here is an excerpt:

The third level [of the health care debate] . . . is an examination of the fundamental dimensions of health care. “How do we think about the ultimate goals of the health care system and even about health itself?” he said.

Existing medical care, he said, is “open-ended, progress-oriented and technology dependent.” Are we doomed, he wondered, to a relentless battle against death in which “nothing will ever count as success”? Won’t “aging societies, expensive technologies and rising expectations about the benefits of medicine” add up to “an impossible cost situation”?

“We don’t have a debate at that level — and we need to,” he said.

Six weeks ago, I had my second son, Reed, at home.  I chose home birth because I believe it was the safest place for Reed and for me to be during his birth.  One thing I have noticed in reading the words of and speaking with other home birthers is that our conception of risk is different from that of the average American.  Most people seem to think that life and death are the only things worth considering when it comes to health care — if you end up alive, that’s success, regardless of what else happens.  So the 99% of American women who give birth in hospitals are willing to subject themselves to a high likelihood of needless, preventable injury, infection, and major surgery in order to hedge against the infinitesmally low likelihood that being a few minutes away from a hospital will make a life or death difference for themselves or their babies.

And when something does go wrong in a hospital birth — which happens more than you would think — sometimes the doctor will be sued.  Because after all, if you’re in a hospital, you’re guaranteed a healthy baby and a healthy mother, right?  Home birthers accept the fact that there is no such thing as a risk-free birth, because we knowingly choose to take a very small risk of death (the same level of risk as exists in the hospital, by the way) in order to avoid the much larger risk of trauma, injury, and infection introduced by the hospital environment.  We know that more technology, more invasive testing, and more interventions do not correspond to better outcomes, as Atul Gawande recently pointed out in a celebrated New Yorker article.

But that’s not the conventional wisdom in the United States today, where the assumption is that more is, if not necessarily, then usually, better, when it comes to health care or almost anything else (and where, notably, doctors are paid based on that assumption).  We have a strained relationship with the idea of mortality and a deep distrust of the idea that sometimes, it might be better to take a hands-off, watch and see approach, and that medical intervention can sometimes create more problems than it solves.

I’m not arguing in favor of euthanasia or passing judgment on people who want to live as long as they can.  But the idea that a whole swath of our citizenry is up in arms because they think that a doctor telling a patient and her family that hospice (i.e., giving up and accepting death, to those who can’t imagine doing so) is an option reveals a deep-seated fear of and paranoia about death.  Perhaps that’s something we as a culture need to work on.

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9 Responses to “What Is Good Health Care?”

  1. urbino Says:

    Well said.

    It really does seem that part of our (Americans’) weird relationship to medical care is a consequence of our weird relationship to death.

  2. alsturgeon Says:

    Great thoughts, Sandi.

    Back in my pastor days, I remember reading (probably Eugene Peterson) that long ago it was said that a pastor’s role was to help people “die well.” I don’t have a point – and don’t remember his – but your post made me remember that, and I thought how this obviously wouldn’t go over well in today’s culture.

  3. jazzbumpa Says:

    Sandi –

    Congratulations on your son’s arrival. Hope all are healthy and happy.

    I’m not disagreeing, but I do have some other thoughts.

    People chose to have their babies in hospitals because that is the societal norm. Actually “chose” is the wrong operative verb, since that implies the use of some critical thought process. They just do what mom and most of their neighbors did. I really don’t think (perceived) risk avoidance is a big factor.

    The whole euthanasia/death panel controversy is a manufactured problem cooked up by right-wing liars.

    I have a conflicted relationship with the American way of medical practice. It seems to be largely about magic bullets and radical intervention. We’re very good at putting the pieces back together, but vary bad at preemption and prevention.

    But – here is a success story. My grandson Nate turned 7 last Friday. He was born with transposition of the great arteries: The pulmonary artery and aorta were hooked up to his heart in reverse. This required radical intervention as soon as he was born, and open heart surgery a few days later. the condition was spotted very early in my daughter’s pregnancy in an ultrasound. This borders on miraculous.

    Cheers!

  4. Sandi Says:

    “People chose to have their babies in hospitals because that is the societal norm. Actually “chose” is the wrong operative verb, since that implies the use of some critical thought process. They just do what mom and most of their neighbors did. I really don’t think (perceived) risk avoidance is a big factor.”

    I’m sure in many places that’s true. Among my demographic group, it’s not. There’s a high level of awareness about birth and choices surrounding it. As the topic gets even more publicity, that will trickle down.

    Obviously home birth is not for everyone — it’s not supposed to be, and there are those, like your grandson, who really need medical intervention. No one who home births is averse to packing up and heading to the hospital if there is a medical reason to do so. I didn’t mean to imply otherwise.

    There’s a huge, long, complex back story regarding the state of maternity care in this country that I couldn’t address in the post because of space concerns. The information is out there for anyone who’s interested, however; Ricki Lake’s documentary “The Business of Being Born” (available on Netflix) and the website pushedbirth.com are two good introductions to some of the main issues.

    But mainly I was just using birth as an example of how too much health care actually hurts rather than helps people (in addition to wasting colossal amounts of money). BTW, there are a couple of fantastic op-eds in the NY Times today addressing this issue — one of them is even called “Telling Grandma No.”

  5. Sandi Says:

    “The whole euthanasia/death panel controversy is a manufactured problem cooked up by right-wing liars.”

    It is, and it isn’t. The Telling Grandma No op-ed does a good job of addressing the concerns seniors have that their access to unlimited health care will be curtailed by health care reform.

  6. jazzbumpa Says:

    I’ll go check the article, but meanwhile,

    1) seniors access heathcare through medicare, and
    2) medicare isn’t changing.

    Or am I horribly wrong?

    JzB who will be on medicare in 30 months.

  7. jazzbumpa Says:

    Oh, good god, it’s Douthat.

    The controversy over “death panels” is just the most extreme manifestation of this debate. Obviously, the Democratic plans wouldn’t euthanize your grandmother. But they might limit the procedures that her Medicare will pay for. And conservative lawmakers are using this inconvenient truth to paint the Democrats as enemies of Grandma.

    Death panels as part of a debate?!?

    They MIGHT limit the procedures?!?

    Here are some thoughts on the use of the word “might.”

    http://www.ginandtacos.com/2009/08/17/a-letter-to-the-dean-of-the-university-of-wisconsin-law-school/

    Sorry. I’m about to start foaming at the mouth. Douthat is a god-damned right wing liar. There is a point where ad hominem becomes justified.

    Now I must go hug a squid.

    JzB the having-a-really-bad-day trombonist

  8. Sandi Says:

    I had no idea who he was . . . gathered he was a Republican from the op-ed . . . I’m clearly out of my league here . . . but the point being that one way to reduce the cost of health care is to start working on the way doctors are paid, and to reduce the number of unnecessary procedures and tests performed in this country, which is something Obama thinks is crucial to reform. To some people, that will seem like worse care, but it really isn’t . . .

    So yes, the death panel thing itself was invented by right-wing liars. And no one with half a brain believes that such a thing was ever proposed. But the underlying concern that those liars were trying to speak to is elderly Americans’ fear of death, and the related fear that they won’t be able to access, at little or no cost, every single pill, test, and surgical procedure a doctor suggests to them (in the vain hope that such things will make them immortal), whether they would do any good or not. Now, whether or not Medicare would start drawing such lines under the proposals now before Congress, I don’t know, as I haven’t read them. But Obama and a lot of other people believe there is waste in the system and that such waste should be curtailed. One person’s waste is what another person thinks of as good care because of the mistaken assumption that more is better.

    I’m not sure where I’m going with this . . . I guess I’m saying that if Medicare did start telling Grandma no, with the research to back up that the recommended test or procedure was unnecessary or harmful, then I think that’s a good and necessary thing if we want to reduce the cost of health care.

  9. jazzbumpa Says:

    OK, it is three days later, and having received numerous hugs from all 11 grandchildren (thus rendering the cephelopod irrelevant) I have calmed down some.

    The issue of necessary vs non-necessary procedures is a knotty one, and I will not claim to comprehend it. However, it must also be faced in Canada, England, Germany, and Switzerland, to name a few, so I’m confident that experts in the field can draw on these experiences to generate a suitable answer.

    However, I think the key to Health Care success lies not so much in controlling costs as it does in finding an effective method for universal access. Again, there are many good examples to be learned from.

    Sure, there is waste in the system. But I’m willing to bet that much of that is inherent in the way it is set up, and could be reduced in a workable universal plan. A huge cost driver is the profits taken in by insurance companies, pharma companies, hospitals, etc. Taking health care out of the free enterprise system will automatically reduce costs.

    I get to go on medicare in another 30 months. By all acconts, its the most effective and efficient plan in the country. So we also have a good model right in our hip pocket. I want something just as good for the rest of my cointrymen.

    Cheers!

    JzB the aging trombonist

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