Ambiance

Romantic Medicine vs. Utilitarian Healthcare: A Dialog [UPDATED]

December 29, 2009 at 5:15 pm (By Amba) (health care, medicine)

UPDATE: Highly pertinent to this post is Wendell Berry’s 2002 essay “Two Minds.” While it was ironically published in The Progressive, Berry is what you’d have to call a green conservative.  He talks about “Rational Mind” vs. “Sympathetic Mind” in very allied terms.

I recommend this beautiful post by James P. Pinkerton at his blog Serious Medicine.  I don’t have time right now to excerpt it in a serious, bloggy way, so I’ll quickly post the brief tastes I “tweeted” from it:

The argument for heroic surgery is like that 4 sending people to the Moon.

Talmudic teaching, who saves one life saves the entire world, vs. the health-policy, quantitative way of looking at it

‘Serious Medicine’ … “is qualitative, not quantitative. The quality of mercy is hard, if not impossible, to quantify.”

“the overall romance & mystique of medicine is inherently qualitative…that’s why civilization has so revered medicine…a romantic aspect”

While not unaware of the real problem of how all this is going to be paid for, Pinkerton makes a stirring argument — human, religious, and Romantic — for saving single lives even at horrendous cost, whether at their precarious beginning (look at Charlie Miller now!!) or near their end (the example of the advanced-cancer patient in the post).

I had recently been thinking about these issues as a result of hearing about an 80-year-old with fairly advanced Lewy Body dementia (what J has) who fell, broke his hip, and is now getting hip replacement surgery.  Because of the impairments that caused him to fall, it’s going to be very hard for him to rehab to the point of being back on his feet.  Does it make sense to replace the hip of someone who will probably never stand again?  Or is the surgery the only way of keeping him from being in intractable pain?  In the old days and the old world (I saw this in Romania), someone who broke a hip was usually bedridden for the rest of his or her life, yet could last a couple more years well-tended to by exhausted family members.  This man is now going into a nursing home to stay; he wife was reaching the breaking point anyway coping with his irrationality and paranoia (the latter being what J, thankfully, mostly HASN’T got).  She was terrified of trying to explain to him why he had to go into a facility, and was actually relieved that he fell and broke his hip.

All this led to another exchange between me and my sistah the doctah:

A[mba]: I found this an absolutely beautiful post, if problematic.  Even if you disagree with its “never give up” ethos being taken to absurd extremes, it will still make you feel good about being a doctor.

S[istah]: I confess to not being able to wade through the entire post…when I hit the religious stuff my brain shut down. even though he writes beautifully and says some perceptive things.

I read the NYT article about the surgeon and the surgery and confess that my first thought was Wow how incredible, my 2nd was what a cowboy (about the surgeon. not a fair response but an extrapolation from my own dealings with transplant surgeons who have egos as big as the great outdoors and motives that aren’t always altruistic but cravenly human), my 3rd what a waste. of time, money, resources. But how potentially amazing for both the patient and his family (i refuse to get involved with the god part).

The economization of medicine maybe does separate us all too much from the glorious ability [of] medicine to save and improve lives.  But we’ve gotten way out of hand here. I can’t help thinking of what the hundreds of thousands spent on that guys surgery could have done for old people who can’t afford their basic meds and all the other medical inequities that exist. It’s obviously not a quid pro quo, I know. And you can certainly make a point that in this particular situation the surgeon was trying out techniques that may be useful in more hopeful situations. But one of the problems I see is that people (Americans specifically) have absurd expectations about health and healthcare. we’re all going to fucking die some day. we need to focus on doing the most good for the most people…not do outrageous things for the few. or we can do those things as long as the many are getting the basics.

I REALLY feel it’s all about the capitalization of health care…so much $$ is being made by drug co’s, hospitals, insurance cos, and…yes…some doctors. Until we do something about that care will continue to be insanely polar. whew. a rant.

A: I think the conservatives’ argument would be that people on the whole are not motivated to do great things simply by the fact that it’s good and compassionate and sensible to do so.  They are most motivated by rewards — money, power, and fame.  So if you restrict the rewards, you restrict the greatness of what will be done.  Decapitalize “serious medicine” (or any other field of activity) you demotivate it.  And of course you will still have greed and corruption, the monopolization of wealth by the powerful and power by the wealthy, fraud, black marketeering, etc. etc., with less ability to regulate/correct them.  They would argue (despite their religion thing) that virtue and common sense are weak rewards, to which most people have to be prodded by fear (hell) and shame, or perhaps luxuries — the ultimate rewards for people who’ve already had all the other rewards, like Bill Gates and Pastor Rick Warren (of The Purpose Driven Life, who now gives away 90% of his income, so he says).

Do I agree, i.e. am I a conservative?  No; just not a liberal anymore either.  I’ll sadly entertain their argument (“entertain” rather than “hold” is what I do with most beliefs these days), but not being very motivated by material rewards myself (obviously, or I’d have some), I don’t get it viscerally at all.  I can just see that it may be true of others.  The Darwinian conservatives would just say this proves that a) I am simply not the fittest, not vigorously self-interested, not surviving, not reproducing, being eliminated from the gene pool, and b) proof that when greed dies out it is either the ultimate luxury or a symptom of vitiation or decadence.  It’s the brawling “getting yours” stage that they most admire, the force that propels deprived but enterprising people out of poverty and doesn’t stop there, but goes on to build empires, empires which do great good as well as harm.  I find it amusing that they can be so Darwinian and so pro-Christianity at the same time…until you observe that maybe Christianity serves its holders’ survival, optimism, will to power, and reproduction.

Possibly to be continued/updated between us; in the meantime, I hope you will jump in.

P.S.  In the interests of full disclosure (lest I make myself sound like a noble failure), while not very motivated by material rewards, I’m certainly motivated by attention, recognition, admiration.  Just not any good at getting them on a scale beyond the happy few.