Death: Right or Duty?

DEATH: RIGHT OR DUTY?
By Richard D. Lamm

Too often, the limits of our language are the limits of our thinking. “If thought corrupts language, language can also corrupt thought,” warned George Orwell. How we label something too often controls how we think about it. We get particular concepts in our head and they are hard to change. They govern how we think and how we act. “Disease” and “death” used to be considered as “God’s will,” and it took hundreds of years and no small number of martyrs to get that corrected. It was very hard to develop modern medicine when so many factors were thought of as outside of human control. Similarly, the number of children a woman had was thought to be “God’s will,” and that has made the development of contraception controversial to this day. Human control over any part of human destiny is usually opposed vigorously. Change comes slowly. Humankind has the tendency to confuse the familiar with the necessary.

Science finally overcame (many) such outmoded concepts, however sincerely held. Medicine has developed ever more inventive and expensive things we can do to the body as it ages and approaches death. Now, language limits us in a different way. Today, we have so changed the concept of death that we talk about the “right to die” as if death were an option. “Right to die” is a useful term in some contexts, but it implies death is a matter within our individual control. Too many Americans think themselves “entitled” to all health care technically possible no matter how marginal, and will spend unlimited insurance or government money on long-shot attempts to delay death. We have gone from superstition to hubris.

This has its own trap. Death is not an option. Shakespeare said it so well, “We all owe God a death.” Humanity has a hard time putting death in perspective. Over the history of humankind, we are alternatively paralyzed or dismissive. Both concepts of death are wrong and cause substantial harm. We are not helpless in the face of death — there are a myriad of things we can do to postpone death. Likewise, death is not an option. Thinking of death as a “right” to be exercised misallocates tens of billions of dollars a year. America spends 27 percent of its health dollar on the sickest one percent of the population, 55 percent on the sickest 5 percent. This “concentration of expenditures” is far above spending patterns in all other developed countries. Insulated against the costs and petrified by the results, our culture, which considers death the enemy, spends more and more on less and less.

We do not have a “right to die.” Humans are mortal. Death is neither a right nor an option. Yet, there is a public policy tragedy in our misconception. Money desperately needed elsewhere in society is being spent on marginal and low benefit medicine throughout the system, but particularly on the dying process. No other society would take a 90-year-old with a terminal disease or terminal cancer out of a nursing home and put them into an intensive care unit. My wife and I were recently at the bedside of a 93-year-old man with three fatal diseases (metastatic cancer of the prostrate, end-stage kidney failure, and he had just been brought into the intensive care unit with a serious stroke). Massive resources were being poured into this gentleman, while blocks away people were going without primary care and kids were going without vaccinations.

Ten percent of U.S. hospital beds are ICU beds, while the rest of the developed world uses three percent of their hospital beds as ICU beds. What do we get for our extra intensive care beds? Mostly we get expensive deaths. There is no evidence we save more critically ill people than other societies. We have failed to develop policies that rationally limit the use of intensive care beds to those who truly benefit. An ICU bed was designed for a realistic salvage attempt, not end-stage care.

I would suggest the sum total of all “ethical” medicine, as now defined and practiced, is unethical health policy. The hubris in thinking that medicine can deliver to an aging society all the “beneficial” medicine its inventiveness has developed is misplaced.

Proust observed, “The real voyage of discovery lies not in seeking new lands, but in seeing with new eyes.” So, also, we must see with new eyes. Everything we do in health care prevents us from doing something else. We live in a new world of trade- offs, but without either the ethical standards or yardsticks to decide those tradeoffs.

It is imperative we question this concept. My generation’s bodies are developing ailments and chronic conditions faster than our economy can fund the treatments. We are spending too much money on the last generation at the expense of the next. We have run into the “law of diminishing returns.” Modern medicine has presented us with a Faustian bargain: Our aging bodies can bankrupt our children and grandchildren. Health care is important, but it cannot trump every other societal need. We must begin a dialogue by thinking clearly about death and its costs.