Monday, June 2, 2008

Technology Running Amok

My colleague and friend Muriel Gillick’s important article - “The Technological Imperative and the Battle for the Hearts of America” – ends as follows:

Instead of waiting until the rate of [Medicare] expenditures becomes intolerable and then instituting draconian cutbacks in covered services, we have the opportunity to start now to shape the development and diffusion of medical technology, the principal determinant of the growth in costs. The story of the LVAD [Left Ventricular Assist Device] gives us a model of when and how to intervene.

How right she was!

A case study in the January/February issue of the Hastings Center Report tells the story of Mr. P, a 62 year old man with severe congestive heart failure. Eight months earlier he had an LVAD implanted as a “destination therapy,” told by his doctors that the device would improve his capacity for self-care and allow him to lead a more active life. This didn’t happen. Instead, things went from bad to worse. For five months after surgery Mr. P was in the intensive care unit, with one complication after another. Now, after three months at home, he no longer wants to live in the state he is in, and has asked to be readmitted to the hospital to have the LVAD turned off. He knows that he will probably die within a few hours after the device is silenced.

The case asks – “should Mr. P’s physicians accede to his request and disable his LVAD?”

In the Hastings Center format, two ethicists comment on the case. One saw the situation as reflecting the right of a competent person to decline treatment – here the implanted LVAD. The other reached this remarkable conclusion:

Once the patient leaves the hospital, the LVAD ceases to be a medical treatment and becomes effectively part of the patient himself, much like a transplanted organ or even a native one…We would not remove a patient’s biological heart, transplanted or native, simply because the patient was suffering greatly from heart failure and did not want to go on; nor should we disable his LVAD.

The logic of this argument is coherent and elegant, but the position brings to mind Schopenhauer's comment about a view that he felt called for a cure, not a refutation!

Not only has Medicare run amok in its approach to approving new technologies with no attention to the opportunity costs entailed, but now we can envision the device itself clamped onto the recipient in perpetuity. We are in the process of letting Medicare devour the common good. Before long we we will let the new technologies devour their recipients.

What next!