I haven’t read the book, but I thought the review in the Journal of the American Medical Association by Michael Bevins, MD, Ph.D., brought up some important points for pondering. In Defiance of Death: Exposing the Real Costs of End-of-Life Care illustrates the growing utilitarian emphasis in medicine and apparently pushes futile care theory as a way of supposedly saving big bucks. From the book review (no link):
Who decides when care is inappropriate is an even more difficult question. The crux of this book’s argument is its proposal of a system of “appropriate-care committees” made up of experienced physicians who would review each questionable case on an individual basis. These local, state, and national committees would be organized into a hierarchical structure, with local committees answerable to state committees and so on. Committee members would be paid a stipend,thereby avoiding financial conflicts of interest, and they would have the authority to withhold payment for care deemed inappropriate.Right. I’d sure trust that system (he said sarcastically)! The idea appears to be to empower faceless bureaucrats to second guess care decisions by deciding after the fact whether hospitals should be paid for services rendered. That would put the economic benefit of doubt into refusing wanted care, not to mention making it a federal policy to impose futile care on unwilling families.
The ironic thing is that futile care theory will not save all that much money. When I was researching Culture of Death, end of life care took up about 10% of the nation’s entire health care budget. Most people don’t want expensive interventions until the bitter end. Thus, even if medical futility were imposed on all dying patients, the savings would be minimal, a point noted in the review:
Fisher admits it remains an open question whether hospice care actually saves money. While he valiantly tries to defend the claim that shifting from more aggressive, “inappropriate” care to more compassionate, palliative care would save oodles of money, this is a hard assertion to prove. Furthermore, saving money is not the most important reason for making some treatment decisions. In some cases, not doing certain things (eg, intubation, cardiopulmonary resuscitation, chemotherapy, surgery,feeding tubes) in favor of doing other things (eg, aggressive symptom control, spiritual support, bereavement support) is the right choice simply because it is the right thing to do, regardless of the cost.I totally agree. But the method by which that shift should be accomplished is not the bludgeon of coercion, but education, compassionate counseling, and honest discussion. In the end, if people want their lives maintained, that should be permitted because keeping people alive when that is what they want is the quintessential purpose of medicine.
Moreover, going in the opposite direction poses a great risk to the sanctity and equality of human life, adherence to which is essential to a moral medical system. I once asked a futilitarian (as I call them), what would be withheld from patients next once the principle of withholding wanted treatment was established. He told me “marginally beneficial care.” When I asked for an example, he said, “An 80-year-old woman who wants a mammogram.”And so we see the terrible potential for medical discrimination masking as benign cost control.
We have to be very careful that in our reasonable desire to control costs and do right by suffering patients, that we don’t institute a brutal regimen of medical discrimination in which our consciences are assuaged by self deception and euphemisms.