Friday, May 1, 2009

President Obama's Grandmother and the Ethics of Health Care Reform

I've written a number of posts about the need for presidential leadership for our country to come to grips with the issue of health care costs in a meaningful way. (See here, here, and here.) An interview published on line by the New York Times suggests that President Obama is starting to provide the kind of leadership that will be required:

When my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

...I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

The President has done two key things here. First, he has started to discuss resource allocation and rationing in down-to-earth, personal terms. The question of whether to do a hip replacement is a truly challenging clinical as well as ethical decision. This wasn't a situation of "flogging" his grandmother with a chemotherapy that offered a small chance of minor extension of life but at the cost of major side effects and high expenditures.If the President's grandmother had nine months of life in store and the hip replacement went well, the operation could have contributed to a significant improvement in quality of life for many months, but her heart condition and the cancer made the procedure riskier. What to do was a tough question.

A successful hip replacement might have let the President's grandmother go to her beloved grandson's inauguration. Insurance in a nation as wealthy as the U.S. should cover the procedure.

But an ethically guided health care system should consider costs, and every doctor and nurse who has dealt with end of life care knows that many of the interventions we make are, in balance, harmful and should not be done, and that others could, at best, provide tiny benefits at enormous cost, and should be questioned. These are among the issues we need to understand better and deliberate about.

The final paragraph in the quote suggests that the President and his advisers have thought about a public process designed to foster more informed political dialogue and to head off the kind of posturing and demagoguery we saw at the end of Terry Schiavo's life.

The interview touches on other important issues for health care reform - I'll probably write about these next week. But the President's words point in a promising direction!


Jared Thomas, D.C. said...

Interesting situation our President described. To me the most pertinent part of the story is that he said he would pay out of pocket. The question is will the government still allow people to pay out of pocket and doctors to receive such payment for health care they think is important. And, if this is the case, how long before doctors opt for private pay only and/or patient get tired of more restrictions?

Jim Sabin said...

Hi Jared -

Thanks for raising these important questions!

I can't imagine the U.S. accepting any system that forbids out of pocket purchase of medical care. For me the significance of the President's comments about his grandmother was that he (a) implicitly accepted the concept of limits, (b) showed that he as an individual would purchase the care with his own funds and (c) didn't rail against limits as a moral outrage. I can't see any ethical justification for outlawing individual purchase of care that insurance doesn't cover.

I would guess, however, that doctors would have to be in an insurance program or out of it. That is - they wouldn't be allowed to take insurance from some and bill others who have the same insurance but could pay more for the same procedures. To me this seems like a fair and reasonable regulation.

There's no doubt that patients and the public will be unhappy about restrictions. Currently we dole out restrictions by leaving 46 million uninsured and paying primary care physicians so poorly that they have to race through their day to make a modest living. No one likes limits - but if handled correctly we can understand that a limit is disappointing but fair.

I appreciate your raising these issues and look forward to hearing more thoughts from you in the future!



Anonymous said...

My mother was hit by a car, while she was walking across the road to her mailbox in a little town in Iowa, when she was 87 years old. She was covered by Medicare and Medicaid. First of all there were incredible heroics in life saving and transporting her by ambulance, to a small hospital in a little bigger town, then a helicopter took her to a hospital in DesMoines. She suffered head trauma, broken bones and a tear in her stomach. She was hospitalized for five months and received extraordinary care. The insurance carried by the people who were driving the car that hit her picked up the tab for everything. She came to my home and had a reasonably decent quality of life for six more years, where all her medical bills were covered by Medicare and Medicaid. She moved to a nursing home where everything was covered by Medicaid and Medicare. She passed away at the age of 93. What in the world is wrong with this medical coverage that was in place before the genius decided it needed improving?

Jim Sabin said...

Dear Anonymous -

I'm sorry about the delay in posting your comment. The blog software didn't alert me that it had come in.

Your mother's experience exemplifies US medical care at its technological best. (It also must reflect your mother's remarkable resilience, and probably also her relationship with you.) The health care reform process was motivated by the fact that so many millions of Americans do not have access to the kind of care your mother received.