Essential reading–“From the heart”

I’ve been busy today. So I didn’t have a chance to note two terrific posts over at the Incidental Economist (TIE).

In the first one, Austin Frakt gives a rather daunting assignment:

Listen to the Finding Emilie segment of the most recent Radiolab episode. It’s about a young woman’s near death and recovery after being hit by a truck. More than that, it’s about how her family participated in charting that recovery. How she was nearly left for dead, nearly sent to the nursing home for life, but, miraculously, is recovering. It’s an amazing story, the feeling of which can only be conveyed with the full audio-magic that the Radiolab team excels at.
After you listen, think about these questions:
o What would you do if the story was your own?
o Did Emilie receive too much health care? Not enough?
o Did her doctors work hard enough? Did they make the right decisions?
o If you were Emilie’s boyfriend or mother or doctor, would you have considered the cost of her care, how it was financed? If not, why not? If so, how would that have factored into your decision making?
o If, ultimately, decisions most of us make in health are from the heart, how do we navigate the system rationally? Should we?
o If you don’t think this is part of the crux of the health care cost issue, what is? Why do we love to spend so much? Are we thinking or feeling?

You should definitely read that, and then you should read Aaron Carroll’s response, drawing on a harrowing but all-too-typical experience many doctors have in their residencies. Here’s a snippet, but you should definitely read the whole thing:

Eventually, the ventilator stopped getting the job done, so we had to put the baby on an oscillator. Basically, instead of giving normal breaths, this machine shoves tiny amounts of air in and out really fast. It sometimes works when other things fail. It was loud, noisy, and made the baby shake. I don’t think he noticed.

Things slowly got worse. Nothing was working, and every vital sign was heading downwards. As instructed, I just kept adding stuff to keep him alive. But deep down inside, I started to think that what I was doing was wrong. Not incorrect — wrong….

I thought I would post a piece of Gawande’s article and talk about how we completely screw up end-of-life care. I thought I would make a comment about how we spend too much money or waste resources. I thought I would talk about tradeoffs and better choices. But I can’t. Partly because I can’t do his work justice, and partly because this is an issue where deep down inside I think we are doing a ton of harm. Full stop.

I would go further. We spend a lot of money on end-of-life care. Some of that money is surely wasted, beating the hell out of people when such heroic measures are no longer wise. Many health policy researchers, and others, note the high costs of end-of-life care and regard this as an arena we should engage to save money.

Let’s wait on that. Let’s first find out how to treat dying patients and their families honestly, humanely, and well. Once we’ve won people’s trust, we will have earned the right to start a second conversation, this one about lowering the costs of end-of-life care. Curbing health care costs is important, but so are other things, too. In this sensitive arena, it’s wise to be patient.

In the meanwhile, read Aaron and Austin today.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

5 thoughts on “Essential reading–“From the heart””

  1. Hear, hear. I'll take every opportunity like this to quote the marvellous dictum of Ambroise Paré, the court doctor to François I of France, on the duties of the physician: "Guérir parfois, soulager souvent, consoler toujours" (to cure sometimes, to relieve often, to console always). What's changed in 500 years is that "sometimes" is now "often" and "often" can be but isn't "always".

  2. Something tells me this thread will wind up like the abortion thread a week or two ago, and in the end, religious feeling will rule the day until it no longer can.

    There is nothing inherent about human dignity. There is no soul that survives the physical body. Ethics are necessarily situational. Human beings tend to be overly self-assured. So there.

  3. Steve, I am an emphatic nonbeliever. I am equally emphatic in disagreeing with your comment "There is nothing inherent about human dignity." What it means to treat people with dignity when their bodies have failed beyond repair is another question, entirely.

  4. The two cases considered at TIE are parallel but not directly comparable, at least I don't see them as directly comparable. In Emilie's case, the physicians (and her loved ones) were all doing the best they could under the circumstances. Fortunately, the story has a relatively happy ending. One of the reasons for the happy ending is that buried under the treatment, Emilie was still there and able to react to stimuli. That is to say, she was still capable of communicating. The physicians were wrong, but they were giving an honest assessment of the situation as they saw it.

    In the case of Aaron Carroll's NICU situation, the physicians were not honest with the parents about the prognosis. The consequences of that dishonesty echoed through that infant's brief life. Maybe they thought it was kinder to give the parents hope. The problem with that kindness is that it brings greater pain later, if things evolve along the likely course.

    I think Harold has called it correctly. Let's learn to handle end-of-life situations honestly, decently and compassionately. I understand that many physicians rail against death at least to the level of Dylan Thomas. That belief doesn't abrogate their responsibility to provide patients and their families with their best professional opinion.

    It's not good news to hear that your loved one is dying. Holding out false hope is worse, in my opinion.

  5. Harold, what is it that you disagree with in the rejection of inherence as an attribute of human dignity? To reject such inherence implies nothing about the way you treat people. You treat people properly, with respect, probably because you are a good person, probably because you are characterized at least partly by your intact human dignity.

    Are the people responsible for this in possession of their human dignity? I say they forfeited their human dignity long ago. By extension, this means human dignity is not inherent.


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