Medical rationing and indirect euthanasia as an idea whose time has come
How old is too old for lifesaving surgery? blares the headline.
Yup. Daniel Callahan is at it again with his "let's not treat grandmom and the retarded" philosophy of medical rationing.
For years, Callahan has been pushing the idea that we need to legally mandate withholding care for people (mainly the elderly but also the disabled) according to a sliding scale.
If you are a little senile, you can get your gallbladder out, but no Cardiac bypass surgery. If you are moderately senile, no gall bladder surgery, but you can get antibiotics for pneumonia. If you are Terry Schiavo, no antibiotics and no feeding tube...
IF government takes over medicine, it is only a matter of time until this type of thinking slips in. After all, in the UK, one "ethicist" named Baroness Warnock, said that the demented have a duty to die, because they are wasting the time and energy of their families who could be doing more meaningful things with their time if they weren't burdened with Grandmom, not to mention wasting the money of the National Health Services.
Ironically, the old and the handicapped don't always benefit from our high tech medical care. Some of them don't benefit from treatment, or have so many medical problems that the benefit of the treatment has to be balance by the risk of dying of complications.
For example, one of my retarded patients could not tolerate potentially lifesaving chemotherapy for her Hodgkin's disease; the chemotherapy almost killed her, so we stopped it, not because she was retarded but because her body couldn't tolerate the treatment.
Similarly, often the elderly have multiple health problems. You operate and they end up dying from a heart attack, a stroke, pneumonia or renal failure.
The Catholic church mandates all ordinary medical care, but you are allowed to refuse extraordinary care, especially if the risk is high for death, major complications, or a major financial burden to the family.
This last one is rare in the US, but here in the Philippines, it is a major problem: people die for not being able to afford simple pills for blood pressure, or from lack of prenatal care because the clinic for getting prenatal care was too far away.
Ironically, most people today in the US have either living wills or have told their families: No machines, etc.
The problem is that many minority patients just don't trust their doctors.
When I worked in the US, my Native American patients often required a lot of discussion,and even then they wouldn't sign a living will. Doctors in inner cities have noted a similar reluctance in their Black and Hispanic patients.
Paranoid? Maybe...but you never know....every once in awhile I've run into doctors who suggested this patient or that patient should have been refused treatment because they were old or retarded or had a stroke...no, racial prejudice had nothing to do with their judgement...I think...
So what do you do?
I usually recommend a Health care Proxy. They can judge if a treatment is needed and what the risks versus benefits are. A lot of time, it's not black and white, since often there is a middle way to treat people (patient spoon feeding of thickened liquids instead of a feeding tube...angioplasty for angina or medical treatment instead of cardiac bypass...home health care visits by nurses and respite care so people can be cared for at home instead of nursing homes.
Actually, I shouldn't bash the NYTimes, who is running a good series on the problems of growing old LINK LINK LINK.
In the past the elderly were cared for by a daughter, either married or who stayed single, or sometimes by the daughter in law, who stayed home to do the caretaking. I am not romanticizing this: my aunt lost the chance for children because she was the daughter who cared for her aging mother (and back then, "aging" was 60 years).
But now women work, and old is not what it used to be.
There are many private, church run or public organizations that help friends and family to keep the elderly comfortable at home, but still it means sacrifice by one's family.
Government programs can help by tax breaks, paying for home health care, or even granting stipends to family members who give up their income and time to help their elderly.
The bad news is that as boomers age, there are many without children, and many who were brought up with the idea that they should never be a burden. There is a worrisome under reported phenomenon of people, mainly the affluent, just deciding to kill themselves rather than "be a burden". No, I haven't seen it, mainly because I worked with the poor (who commit suicide for other reasons).
But it only a matter of time for the propaganda machine to roll up to persuade people that suicide is a justifiable and moral solution to being a burden on others.
Ah, but we've been here before: we now have a society where women/girls assume abortion is the answer to an inconvenient pregnancy (and all too often the pregnancy was inconvenient to the boyfriends or parents, who urged them to abort, so the claim it was "the woman's choice" ignores reality).
Similarly, we will slowly see euthanasia sold to the public as a "compassionate choice"...
Labels: medical ethics