Reflections on health care
Authors: Laurie H. Glimcher
Journal: Journal of Clinical Investigation (2009)

What do we need? Not what we have: a health care system whose costs are spiraling out of control, that fails to provide care for almost 50 million Americans, and that ranks far from the top in terms of infant mortality and adequate health care for our adult population. Ideally, we need a single-payer, universal health care structure. To paraphrase Ted Kennedy, why shouldn’t all Americans have access to the kind of health care that is offered to our congressmen and senators? Failing that, health insurance companies should go away or agree to compete on an equal footing with government-sponsored health care in a truly free market economy. 

Built into that system, though, must be the recognition that we cannot afford to spend such a large proportion of our health care dollars on the final few months of life. It is agonizing to watch hundreds of thousands of dollars being spent on ICU care for an elderly, desperately ill patient who, if he/she could voice an opinion, would ask, in contrast to Dylan Thomas’s poem, to be allowed to “go gentle into that good night.” It is a form of abuse to insist on intervention when it is not wanted and not justified. Those dollars need to go into preventive medicine, drug benefits, and social programs that teach healthy living skills to avoid chronic, preventable diseases like obesity, diabetes, and smoking-related lung cancer, not into respirator care for a 96-year-old man with aspiration-induced pneumonia who has begged to be allowed to die in peace. What happened to the old saying that pneumonia is an old man’s best friend? The availability of sophisticated technologies doesn’t mandate their use. Hard choices do need to be made — is an expensive biological therapeutic that may at best extend a life for six to eight weeks warranted for any patient when those dollars could instead be spent on well-baby clinic visits? The answer may be yes when the patient involved is a 40-year-old mother of three with breast cancer, but no when it is an 84-year-old man with metastatic prostate cancer. Who should make those decisions? The doctors, the patient, the family, and, if necessary, an institutional review board. Common sense should not be underrated. These issues do not translate into “death panels”; they speak to reality and to fair play — and to dignity at the end of life. 

The public perception of medicine and doctors as white knights who are not allowed to fail must also be taken out of the closet, shaken down, dusted off, and revised. Since when did we believe that life is without risk? The reality is that any procedure, any drug is always a risk/benefit proposition. Those risks should be made utterly transparent and abundantly clear. And the inevitable disappointments that ensue when a drug has unfortunate side effects or a procedure doesn’t go as hoped for should not translate into medical malpractice suits. That way leads to unnecessary tests and procedures that lead to spiraling medical care costs. My elder son, a surgical resident at Massachusetts General Hospital, sees the waste every day. Talk to any doctor and they will tell you they are forced to order expensive tests solely to protect themselves against malpractice suits.

For goodness’ sakes, let’s give President Obama’s plans a chance. Are they perfect? No. Are they visionary and courageous? Yes. Get on board, Republicans and Blue Dog Democrats, because we are headed for disaster with the status quo.