It is well understood that
America’s health care system is in crisis. Access to care is an issue. The amount of
uninsured Americans has reached 47 million,
and this number continues to grow. Some people pay for health care
services out-of-pocket. In “The
Moral-Hazard Myth,” Malcolm Gladwell wrote that the uninsured spends an
average of $934 annually on minimal health care. Others cannot even afford this “luxury” and go without
medical care of any kind.
Additionally, U.S. health care is growing more rapidly than we can keep
up with. It is the size of Italy’s
entire economy. As of 2008,
health care cost the U.S. $2.3
trillion. If this growth
continues, health care will cause America to go bankrupt. And the icing on the cake? As a result of all of this spending,
Americans aren’t getting any healthier.
We have failed at addressing these problems, and instead we have "opted for a
makeshift system of increasing complexity and dysfunction." Such “solutions” have been plenty, and
we still remain in this health care
crisis.
Something has to change,
but what is it? I like to ask, where do we start? Before
talking about health care further, it is important to discuss culture. In
his book, A Return to
Healing: Radical Health Care Reform and the Future of Medicine, Len Saputo wrote that the U.S. health care crisis
emerges from “our dysfunctional cultural values,” such as “separatism,
mechanism, isolationism, and fierce competition.” Culture modulates the
expression of health care, and if the foundations are weak, it will eventually
impact the system negatively. I think that our cultural taboos (which
relate to our cultural values) also affect the health care system. A
large taboo that our culture particularly shares is our deep fear of
death. There are, of course, various ways that the fear of death can show
up. It can be fear of the unknown or suffering surrounding death.
It can be fear of having not lived to one’s expectations or leaving loved ones
behind. Either way, death is typically feared. Another related
cultural taboo includes aging. In a society that predominantly values the
young, aging is rarely seen as a "respectable,” “beautiful,” or “natural”
process. Aging, dying, and death are, in fact, consciously and
unconsciously ignored in our culture.
Serving as examples, this
article is about a woman who wants to be cryogenically frozen, and this paper describes
the “future of death” and cryonics.
These examples are extremes,
but they are intended to reflect our culture’s intense fear of death.
Although it is true that the fear of death
naturally diffuses throughout our everyday culture, it is impossible to ignore
death when looking directly at health care and medicine. According to Thomas Naylor,
the late Professor Emeritus of Economics at Duke University, American health
care “rests perilously on two principles: fear of death and
greed.” In his article,
palliative care physician Brad Stuart wrote that the health care crisis itself
is causing us to “confront the limitations of life.” One way this can be
seen is by exploring technology. Medical technology has advanced so
rapidly, and it has made us more aware of an alternate ‘zone’ of life. The more
widespread usage of ventilators, for example, has allowed individuals to
biologically survive despite not being able to breathe on their own.
Ventilators are useful for some patients.
On the other hand, these technologies have also created a new
"zone" that is between life and death. In her book, “And a Time to
Die: How American Hospitals Shape the End of Life,” Sharon
Kaufman described this zone, “it is the gray zone between health, awareness,
function, and viable life on the one hand, and “no longer a person,” “death in life,” or death
on the
other hand. This gray zone has become exquisitely complex during the past
thirty years and has spread—into new kinds of hospitals, into more patients’
lives and families’ worlds, to more medical conditions and corporeal
states.” What happens in this
zone? Doctors inform family members that the patient has a very little
chance of surviving, but a very small chance still exists. Families
struggle with the news and hold onto any ounce of hope, thus deciding that any
medical service and procedure should be utilized so that the patient may miraculously recover.
To ‘let’ someone die would be inhumane when a chance still exists, right?
Meanwhile, doctors, health professionals, and hospital systems have a
conflicting need, as Sharon Kaufman put
it, “to move things along.” The health care system is based upon efficiency—when a
patient is admitted into the hospital, it is a goal to discharge that patient
as quickly as possible after receiving proper care. However, doctors also
try to do everything to save lives, which serves as the ‘heroic foundation’
needed for a medical miracle to take place. In the documentary, “Money and Medicine,” a doctor
had patient in “gray zone”. He
stated we must stop giving false hope to families, thus making it seem we can
ward away death indefinitely.
Someone else commented that he is paid more for doing more even if it
is not beneficial (and he strives to preserve life). Many conflicting values
occur in this zone—where we modulate (or time) death itself—amongst health
professionals, patients, and family members because we fail as a culture to
discuss death.
There are several complications this “gray
zone” is bringing attention to.
Among these topics, a big factor is money. Len
Saputo discussed that half of health care costs go toward terminally ill patients who are
in their last year of life.
Although these patients may or may not have experienced the
hospital-maintained “gray zone,” a percentage of them probably did. Regarding the cost of dying, Sharon
Kaufman explained that some economists and policy makers complain that it
costs too much to die in America—the process of dying also goes on for too
long. In another article,
Richard Lamm pointed out that many of us would do anything to save our own
mother’s life. For her, we would welcome all types of medical
technologies and give her everything we can. In response to this logic,
he wrote, “you cannot build a health care system, or any public system, a
mother at a time. This is an unfair and unrealistic standard to hold
public policy to.” Thomas
Naylor stated, “When human greed exploits the fear of death, there is no
limit as to how high healthcare prices can rise. For those who are fortunate
enough to have good health insurance, the message is, ‘You
deserve the best medical care money can buy, because you are entitled to live
forever.’” Adding to the topic of
economics, in “End-of-life Spending: Can We Rationalise Costs?,” Amber
Barnato discussed the concept of quality-adjusted life-years (QALY). In her article,
she explained, "a year in perfect health (utility of 1.0) is weighted
equally to two years in 'half' perfect health (utility of 0.5)." Healthy individuals took the
surveys and determined the quality of life they would experience if they had certain
conditions. Certain diseases had a
‘better’ QALY whereas some health issues had a ‘worse’ QALY. This article made me think about how
much economists are really thinking about death and dying. As a country, do we want economists to make these decisions
based upon poor surveying? Do we
want hospitals and insurance companies to decide when to ‘pull the plug’ (i.e.
“death panels”) on our family members?
I propose ‘no’ to both questions.
There are solutions that directly deal with our fear of
death and dying. It is probably
the most uncomfortable solution, although it probably has the most useful and
long-term advantages. We need to address
our fear
of death. We need to start talking
about death on a very real level.
“We” includes doctors, nurses, patients, policy makers... and especially
you and me. Talking with family
members is a great place to start. It may also be helpful to ‘relay’ current
decisions to a primary care physician. Wills, health education on end-of-life,
and a ‘more general’ cultural conversation around death will allow people to
deal with emotions surrounding death.
Once we get talking about it, more clear solutions will appear. It is quite well known that most
people, when surveyed, do not want to experience a medicalized death. They want to die at home. What are the ‘gifts’ the “gray zone”
makes us aware of in our health care system? Are we now experiencing the point at which
materialistic-based science will show us that addressing spiritual needs of
patients, family members, and relatives are necessary to good health?
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