This was first posted three years ago, but written about ten years ago. Still true.
When my roommate was preparing to marry a man who practiced medicine thirty years ago, she told me, with a great deal of discomfort, that her husband could expect to earn more than a million dollars in his productive years. She had entered a convent upon graduation from high school. Her expectations for her life were baseline poverty; she didn’t feel good about all this money. Her husband was a Quaker; he was not driven by money, so the question was what to do? How to responsibly steward the money he was going to earn?
Now, the expectation of a physician is quite clearly that he will earn substantially more than a million dollars, and a gathering of these more-than-a-million-dollars people made the decision that it was okay to spend $5.2 million dollars on one man. What if the decisions were being made on a pay-as-you-go basis? Take away Medicaid/Medicare, private insurance and teaching hospital money, and look at this situation.
We’re talking about $153,000 per day. On the third day in the ICU, somebody comes to the guy’s wife and says, “Tomorrow you have to move into an apartment; your house has to be sold.” The wife gets upset, cries, and says, “Okay.” The kids look grim and talk to each other. They say, “This isn’t right. Mom and Dad worked their whole lives to pay for that house. They meant to have it as long as they live.”
“Yeah, but it’s just a house. Mom would rather live in an apartment with Dad than a house without him.”
“I know—but what if she ends up in apartment without him?”
A week later, somebody comes to the guy’s kids and says, “Now we need your houses. And the funds for your kids’ college education.”
The kids look at each other and say, “Uh, no. Dad wouldn’t want us to do that. He and Mom worked and saved to get us through college. It really mattered to him that we go to college. He’d be sick if he knew we were giving up our kid’s future just to—maybe—give him a couple more years. You remember when his mother died? He just kept saying, ‘She had a good life; she had a good life.’ Well, Dad’s had a good life. It’s time we let him go.”
That is the nature of human reality. We weigh and balance our assets and liabilities. Income and outgo are budgeted and balanced. We, as individuals, make choices about what is valuable but we, as a society, have now divorced our income from our outgo: the balance has been destroyed. It is not about one man’s life versus his children’s houses and grandchildren’s education; it is about one man’s life versus the houses and education of strangers. But the $5.2 million man was quoted as having “told his doctors to spend the money on someone younger.”
Doctors and administrators who do not live in the real world are making the decisions. They live in enclaves of wealth. They live in three-bathroom houses, get new cars every year, and send their kids to private schools. Discretionary income is about a ski vacation in Aspen versus taking the Concorde to Paris. This is not the real world.
In the real world, according to the federal census, a family of four has an income of $60,000. How many people do you know who have a $60,000-a-year income? Who takes home a paycheck of a thousand dollars a week? Not the woman in the ICU who changes the oxygen tubing on the $5.2 million man. Not the guy who moves the linen cart or the woman who draws blood or the man who pushes the mop—and they are the people who should be participating in making the life or death decisions about how much is spent on one person’s care.
Duke University Hospital’s pharmacists “consulted colleagues . . . and scoured medical studies . . . ‘We found nothing that we could look to and say . . . here are the guidelines.’” Look to the real world. Don’t look at the medical studies: go sit in the cafeteria and listen to the workers who are talking about the cost of milk, sneakers and car mufflers.
We are a society, a single body. If one of the parts suffers, the whole suffers. It is time to put a cap on spending. Insurance, according to my friend, is like the lottery, only backwards. If you win (lose) then you win (lose) big, and nobody else wins/loses at all. A million taxpayers pay five dollars a year to keep one man alive. You pay for your insurance but don’t use it, so it’s all there to spend on somebody else—but let’s play Republican and return the money to the people paying it. Let’s let the individuals decide how they’ll spend their money. Let’s let individuals who are representative of the masses participate in making the decisions.
Let’s just look at the ICU and reconsider how money could be spent. Let’s do a survey of the outcome of the money that’s been spent. For every $100,000 bill from the ICU, follow up for five years at one-year intervals. Ask, “Where are they now?” The woman on whom we spent $250,000—is she at home in her kitchen baking cookies for somebody? Is she in elder care, reading to somebody’s grandchildren? Is she in a vegetative state in a nursing home? Is she in a cemetery? What about the man who got half a million dollars worth of care? Is he back teaching? Mowing the lawn? Worshipping God?
The woman upon whom society spent $86,751 in the ICU in 1999 is now writing you this message.
Put a cap on ICU spending. If somebody is so sick that it costs half a million dollars to keep them alive in the ICU, do they ever again have a good life? Do their grandchildren? In the real world, you cannot divorce the quality of one person’s life from the quality of other people’s lives. It is not about judging the quality of one person’s life—for who can do that? It is about judging the quality of one society’s life—or one world’s. Five-point-two million dollars for one American man, and how much for a hundred El Salvadorian children? The women of India, the miners in Africa, the sweatshop workers in Bolivia? You are a citizen of the world. Should your father live while a child in Yugoslavia dies? Think about it.
Age counts. We need the old people to be wise for us, but we also need the children. Besides, do we, as a society, listen to our old people? We put them in government subsidized warehouses where they are ignored. We neither seek nor reap benefits from the old people whom we save in the ICU. Old people die. The age of the person in the ICU should be factored into the decision about how much to spend to keep the person alive. Is this person, who is being treated so expensively, supposed to be dead? Does God have a plan for us? Is there a God? We should be asking the questions. Every important decision we make in our lives is determined by what we believe about death. If you are a doctor and believe death should be prevented at all cost then the cost will be very high. If you are a farmer and believe that death is a natural and inevitable event, the financial cost will be low.
The question is not “Should we let this person die?” because, ultimately, we have no control over whether the person will die. The question is “Should we let this person die now?”