Technology promises that once fatal medical conditions are now surmountable. Patients with once incurable conditions will live, and even when the condition is only manageable, through technology, therapy, and familial support, they can often live rich meaningful lives. The outcomes far exceed what we used to expect.
The article "In a Stroke Patient, Doctor Sees Power Of Brain to Recover", in yesterday's Wall Street Journal describes how some of these medical techniques are changing patient paradigms. Thomas Burton's article centers on a young doctor who suffered a series of strokes and sank into a coma. A couple of weeks into the patient's coma, his family moved him from one hospital, where they perceived he was destined to doom, to another.
"Dr. Mayer concedes that some of his techniques, including the use of sodium solution to relieve pressure, remain unproven. "We're in 'Deep Space Nine' here," he tells medical residents.
The article dramatically illustrates that this patient, summarily dismissed as a hopeless case by more than one doctor, was a breath away from not being alive today, from not being the *former* patient who now has resumed his career as a rehabilitative doctor. His recovery is phenomenal and because such cases have shown the potential of relatively untested life saving technologies, doctors are rethinking their patient care strategies:
"Doctors often make minimal efforts to save the lives of advanced stroke victims, especially those who are days or weeks into a coma. They often see the prospects of survival as low and question the value of saving a life that they expect, in the best case, to be severely constrained by mental and physical damage...Now proponents of neurointensive care are challenging these assumptions."
Said the doctor: "Doctors are telling people there's no hope when, in fact, there is." Technology is coming through for us, and not only for patients in comas. The New York Times reported in "A Doctor for the Future", a few weeks ago, that doctors can now manage genetic diseases that used to be common, fatal and debilitating in Amish and Mennonite communities with the aid of sophisticated genetic analysis technology. On all medical fronts; cardiac surgery, in vitro fertilization, embryonic stem cell cloning, prognoses of birth defects, technology gives and saves lives.
The article details some of the tensions around the technologies used to treat this patient and others like him. In clinical practice, some of the so called "experimental procedures" may work, or they may not. They're not all proven by large scale clinical trials, so some doctors refuse to use the techniques even if they offer patients their only chance at survival. As many issues around high tech medicine are discussed in the media, the costs of the newly emerging technologies are often glossed over. Technology is not available to all patients because not everyone can afford such expensive and intensive treatments.
It isn't that various aspects of health economics go undiscussed. We can certainly read economist Paul Krugman's astute discussions of national health care. We come across articles about families who are in debt because of their childrens' health care. But often the media keeps it a separate discussion, or we read about nominally priced technologies or those deemed optional, rather than "life-saving". The New York Times' recently published; "For Those Who Snore Heavily, Implants May Help", for instance, and we learned that the cost of the implant not covered by insurance might run $1500 - $3000. But that's peanuts in medicine, less than the cost of one day of low-tech in-patient care at a hospital.
We talk about stem cell technology as if it were the silver bullet to our most intractable medical problems, but how much does such technology cost? Certainly in other arenas we don't shy away from the discussion. People immediately marvel about cloning that it "may initially cost $200,000 per animal before dropping to $10,000 in several years", "See Spot Run, Or Is That Spot's Clone?; Owners Look to Science To Resurrect Family Pet" (New York Times, December 9, 2000). Of course this isn't human health, people aren't pets, nor will they be cloned. But in vitro fertilization costs $10,000 or more per treatment and some patients rack up $100,000, and don't get pregnant. Insurance companies most often don't pay for it. Many families can't afford IVF. As insurance companies decide what therapies to approve and how much to cover for what procedure, as your genetic profile will provide a tangible risk factor for procuring health care for your family, and as we increasingly depend on technology to save lives, we can't ignore questions hovering in the background about who will actually have access to what technology.
People tend to get squirmy thinking about medicine in these terms. As an experiment, ask your doctor how much your next treatment will cost. Amazingly, my experience is that they either don't know or feign ignorance, as though cost is not involved with care -- their care is priceless. When we talk about medical aid for developing countries -- retroviral drugs for AIDS patients in Africa for instance, arguments about logistics are abundant. While many logistics questions are valid they also conveniently disguise underlying economic questions. It turns out that its not an argument about logistics at all, it's an argument about who's going to pay for the medicine. Drug companies? Foreign governments? NGOs? Public donations? It's an argument about who is worth what treatment.
We can actively avoid these discussions all we want but then they will only leap out at us in cold harsh cruel relief once we are immersed in a private or public illness or tragedy. When families are compensated for death or injury, they are subjected to ruthlessly mathematical evaluations about the cost of a life or arm. When an earthquake hits in Sri Lanka, Pakistan, or New Orleans, we see, oh so clearly, who the math favors. Yesterday's WSJ article, to its credit, does not entirely avoid the topic:
"Aggressive treatment of stroke victims can have a serious downside. If a patient is kept alive for a few extra weeks in an intensive-care unit only to die at the end, the cost may be tens of thousands of dollars with no benefit. The American Stroke Association estimates that the annual U.S. cost of stroke care is $35 billion. [U. S. Stroke Facts]"
This three sentence discussion is more then many articles provide.
Why can't we speak about the cost of the technologies supposedly available to us while we breathlessly marvel about lives that will be saved? The costs of these medical treatments, even if they're known, are not juxtaposed against the hopes that these treatments inspire because that's uncouth. Politicians can rivet the country about moral obligations to keep people alive one way or another, and no one, politician or not, will risk marring the ecclesiastical discussion with questions like: how much will that cost? Who will be able to afford it? Who will pay?
The fact that medicine is not affordable to all isn't profound. It's tragic, yes, but not everyone can travel to the moon either. However when we start attaching morality to medical choices, when articles in the media dare the reader to question which medical choice is the "right" one, then we embark on a thorny, if not unwinnable public debate. Can everyone afford the "right" choice?
It's easier to steadfastly ignore difficult questions about who will actually have access to these treatments. But while we devour the optimism of technology, at what point does refusing to discuss who will be able to afford such treatments become perverse behavior? We should consider, as we publicly shirk such unsavory discussions, that policy makers, drug companies, and insurance companies are busy in their rooms tapping out formulas that determine who gets what treatment.
