Wednesday, November 4, 2009

Hope of "Defeating Death" defeats Health Care Reform

I wrote a diary last week,Why Health Care Reform is tearing our country apart , that attempted to explore why this issue has elicited such powerful emotions among so many people, in some ways even more than the dissension over our wars.

After the diary had run its course I was still thinking about it, still convinced that I was on to something even though it wasn't picked up by too many people.  And then I came across this segment of a White House Bioethics Report, that could have been the summary of that diary.  

Attitudes toward Death and Mortality: An individual committed to the scientific struggle against aging and decline may be the least prepared for death, and the least willing to acknowledge its inevitability. Therefore, given that these technologies would not in fact achieve immortality, but only lengthen life, they would in effect make death even less bearable, and make their beneficiaries even more terrified of it and, in a sense, obsessed with it.

Fear of death is ubiquitous, as is aversion to suffering in ourselves and those we love. Other species may mourn their dead relatives, wolves and elephants come to mind, but none anticipate their own fates. All societies from time immemorial have had ways to deal with this knowledge, from modern religion, shamanism to Utopian visions that transcend our mortal existence. All of these also happen to entail a degree of acceptance, so that death is reinterpreted into something meaningful, transcendent, and as such, acceptable.

Only in recent times has this been changed, so that death and debility is seen as preventable, or at least able to be postponed until the distant future. We no longer believe in magic. We don't believe that a trip to the shrine of Lourds will allow the paralyzed to walk, the blind to see or cancer riven to be cured. Yet, we have not given up on faith, but rather changed its focus. Whatever our religious perspective, we have added a new tenet, that a modern health system can save us.

But unlike worshiping at a church, or being part of an idealistic movement, this new faith is intertwined with the global high tech free market economy. The payoff for primary research in basic science comes when it all comes together to cure or enhance the lives of individuals. And this is now happening at an accelerating pace.

The mechanisms to extend life, to end suffering and to make life fuller, have grown faster than our nations wealth. This is because discoveries in biology, chemistry and physics are reaching a point where they can be brought to bear on human disease. We may blame the high cost of maintaining health on greed, waste and inefficiencies, and certainly they exist; but cost increase is primarily because of the success of research that now provides cures for what had been death sentences.

Most people my age, nearing 70, have some loss of short term memory. With each forgotten name there is the chilling fear that this could be the beginning of something dire; the dreaded Alzheimer's, a subset of what is now seen as "Senile Dementia"

Drug companies would make fortunes if they produced a medicine that actually forestalls memory loss, but that's not actually a requirement. One that even gives the hope of this, the merest glimmer of temporary improvement, has value. It will be snapped up, with the public demanding it, at great profit to the provider. Aricept, the minimally useless drug for Alzheimer's is a good example.

The belief in medical miracles morphs into an expectation of them, and finally a demand that is so powerful that no panel, either of a health insurer or a government is able to say, "No, we won't pay for it because it doesn't work." So not only does every private insurer in America pay for this drug, but so does Medicare, and even the British National Health System provides it, as that government was not about to deny, what is actually only a hope.

It has become our secular common faith that with enough "health care" we can live better, longer fuller lives. It is this broad belief that makes every product or treatment associated with this demanded by the public, even when the evidence of effectiveness is lacking. This irrational faith causes ever growing demand with no consideration of cost, until the bill actually arrives.

There are serious scholars who say in the lifetime of those now being born, death itself can be defeated. Sounds absurd? If someone had said in 1940 that this new born child would live to see hearts, livers and kidneys routinely transplanted, to see infertile parents able to have their gametes joined outside of the body, with the embryos implanted to begin a full pregnancy. And that a fetus could be examined by ultrasound, his DNA (his what?) could be evaluated and the health of the child predicted, they would have been considered nuts.

The routine miracles of every day medicine that have occurred in my lifetime makes dismissing any prediction of future possibilities not an especially good bet. How inadequate does the term "health care" become when we are approaching a time when this is the institution that will determine who shall live in good health for an unimaginable period and who shall be deprived of this long stretch of vitality.

If every other industrialized country has achieved universal health care then why not us? That's really my point; they have already done it. Whatever the faults of their systems, the defects have become part of their civic culture. We are attempting to reconcile two opposing central central philosophies, that of egalitarianism and that of free enterprise. It's a problem our society deals with every day, but never in such stark terms as this.

The present United States Health Care System is a Byzantine agglomeration of Public (Medicare, Medicaid, VA, Chips, Research Funding) and Private (Insurers, Hospitals, Doctors, Drug Companies) with varying Federal or State Jurisdictions. Every state has elaborate rules on every aspect of health insurance, from what must be provided to how the rules are to be enforced. It's fair to say that no individual can possible understand the complexity of this system. The inequities that exist are acceptable to most because they are mostly unknown and unrealized.

Because of this complexity, we focus on our own interests in either preserving what we have, or demanding that we have more of the benefits to come. Without a specific proposal to evaluate, we are forced into two camps. The first is those who not only trust Obama, but have confidence in his capability to make this work, that an imperfect law will be the first step to their goals. The others are the mirror image, not only distrusting him, but despising him for threatening something that is precious for us all, and assuming a vague bill will be a slippery slope to their worst nightmares.

While many criticize President Obama for his handling of this endeavor, and I am one of them, it is useful to understand just why this is such an enormously difficult task. So let me rephrase the opening quote from the White House group:

Modern medical advances make death and debility seem no longer inevitable, and as such, even less bearable. As we learn of both the reality and the myths of such advances, those who fear being denied them become terrified, and at times, enraged. The stakes are high, and getting higher as the previously mysterious causes of death and disease start to be understood, with the growing real prospect of intervention.

One of the verities of humanity, that we are born, mature, have a period of healthy adulthood, and then decline and die, is for the first time in our species' existence being altered. We have no model for dealing with this change. The current health care reform debate, while unspoken, is made infinitely more difficult by this new reality.

It could be that the inability to find consensus on this legislation is much more than any failure of the sponsor, but the profoundness of the changes in Medical Science, that we as a people have not even begun to deal with.

Monday, November 2, 2009

Under HCR iotragenic disease will increase

If you don't know the definition of iotragenic don't feel bad, most people don't. Here's the Merriam Websters definition:
induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures

The word incorporates the nasty side effects of medications, contracting resistant infections in a hospital, and of course incompetent practice of medicine. The term is neutral, as it's existence doesn't mean that a cost benefit analysis of a procedure, or a system, would find that such iatrogenic effect negates a net health gain.

Under HCR, with more people going to doctors, of course, iotragenic disease will increase, but other diseases will decrease.  My point is that the down side of increased doctoring has recieved little attention in the Heath Care Reform debate.

One of the major planks of this HCR is promoting preventive care, with the administration depicting this as an unmitigated good, such as more education, safer food and safer highways. Actually, it is more complex than that, much more so. Preventive care means more tests, such as Mammograms, PSA tests for Prostate Cancer and an array of others.

The argument that such testing saves money has been challenged by many studies, including the this one being a single example that makes the argument that in the very long run it will save money....but no where near what it's advocates claim.   

Actually, the annual doctor visit, if the current system is kept in place, which it fundamentally will, would vastly expand the cost of medical care due to false positives that would require extensive follow ups. And example of this trend is here:

The American Cancer Society (ACS) does not recommend routine prostate cancer screening for all men at this time.

And here's the worst part, from a N.Y. Times article that explains opposition to regular screenings such for PSA, Pap tests, and Mammograms. 

But Dr. Silvia C. Formenti, the chairwoman of radiation oncology at New York University Langone Medical Center, said: “I don’t think there is enough debate. Screening does not pay off the way we expected.”

Dr. Formenti said she was concerned about finding tumors in older people that would probably not kill them. But the diagnosis turns them into cancer patients and erodes their peace of mind forever.

“We take away the innocence of being healthy and not having to worry about cancer,” she said. “The psychological cost of becoming a cancer patient is underrated.”

Dr. Formenti said the emphasis on screening by groups like the cancer society might have misled the public into thinking that screening could prevent cancer. “It’s a giant misconception,” she said.

This HCR will be a victory for the worst strand of the Medical-Hospital-Pharmaceutical complex.  The real cost can not be measured in dollars, although if taken to its logical extreme, it will have dire fiscal consequences.   It is a victory of those who want to make medical care into a religion, a panacea to all that humans are heir to.

It is a false religion, which like every such faith based plan, will exact its toll on a society that it captures. And to make it worse, it will be imposed on every citizen of our country whatever his or her view of mortality.  We will not be forced to dutifully march to our doctors every year, but we will be forced to pay for those who chose to.

This has little to do with providing basic health care to every citizen, something that could be done for a small fraction of this HCR, that requires everyone become full members of the believers in salvation by doctor. 

Learn that word, "iatrogenic." We me have more use for it in the near future.


Comprehensive diary on defects of HCR.

Diary on the roots of the "faith based" Medical religion