Map of life expectancy at birth from Global Education Project.

Thursday, October 08, 2009

Half right is still wrong

I don't know how many of you managed to keep your eyeballs deglazed long enough for all of Olbermann's "special comment" last night -- the best I could do was check in from time to time between innings. But I got the gist. Keith thinks the way most people do about health and health care. He think they are synonymous, and he thinks that justice and compassion demand that we do everything possible, every time, for everybody, even if it means just giving them one more day of life because life is infinitely precious.

That is indeed the basis on which many people rest their demand for universal health care insurance, but as I have pointed out here many times, if we really believed that, there would be no way to provide universal health care. It's totally paradoxical. I've discussed this many times, you can go here if you want a refresher. But the discussion on yesterday's post got me to thinking that one important way in which our cultural biases are clearly manifested is on death certificates. Yes, I've also gone there before, but it's worth revisiting in this context.

The so-called Leading Causes of Death are familiar. In the U.S. they are, in order with the number of deaths attributed to the cause in 2006:

Diseases of heart -- 631,636
Malignant neoplasms -- 559,888
Cerebrovascular diseases -- 137,119
Chronic lower respiratory diseases -- 124,583
Accidents (unintentional injuries) -- 121,599
Diabetes mellitus -- 72,449
Alzheimer’s disease -- 72,432
Influenza and pneumonia -- 56,326
Nephritis, nephrotic syndrome and nephrosis -- 45,344
Septicemia -- 34,234
Intentional self-harm (suicide) -- 33,300
Chronic liver disease and cirrhosis -- 27,555
Essential hypertension and hypertensive renal disease -- 23,855
Parkinson’s disease -- 19,566
Assault (homicide)-- 18,573
All other causes (residual) -- 447,805

Now, there is a lot wrong with this picture. All but three of the listed causes are disease labels, and Keith rightly thinks that heroic doctors can do something to keep people who have these diseases alive longer, even if they can't cure them. Even in the case of the "non-disease" causes, if you will -- unintentional injury, suicide and homicide -- some people who suffer violent trauma can be saved.

But let's step back for a moment. What is the point of generating this list? What guidance does it offer for policy, or for institutional or individual action? The answer is almost none that I can see.

In the first place, since none of us can possibly avoid death, the best we can do is choose among causes. If one doesn't get us, another will, so if we reduce or eliminate any of these causes, it will just cause another to increase. It's a zero sum game. What we really need to be asking is not whether people die of heart disease or pneumonia or cancer. The only sensible questions are what people's dying is like for them and those around them, how well they lived before that, and whether they had enough time to do what they wanted to do, given that they aren't going to have forever. If you live to be 85, in excellent health, productive and fulfilled the whole while, and on your 100th birthday drop dead of a heart attack, your death certificate will say "diseases of the heart." It will not be a tragedy.

On the other hand, if you spend the years from age 50 to age 100 in chronic pain, demented, and socially isolated in a nursing home, and then your death certificate ends up saying "influenza," it will be a tragedy alright, but the tragedy will not be your death and influenza will not be the enemy.

In the second place, are these "causes" of death at all? Why do people have heart disease? Why do people have lower respiratory disease, or cancer, or diabetes? (Diabetes is actually two completely different diseases that have nothing to do with each other except for some overlap in the treatment, which makes the list all the more absurd.) Why do people kill themselves, or each other? Once we start asking these questions, health care stops looking very important after all. People are killed by tobacco, bad nutrition, alcoholism, sadness and anger, poverty -- and these causes of death tend to go along with happening too early, being ugly and painful and sad, and being just the final paragraph in a long story of disease or pain or despair.

And if we spend all our money on doctors and high tech scanners and proton beams and gamma knives and organ transplants, we won't be able to do anything about any of that stuff. In fact, we'll just make it worse.


kathy a. said...

i had the impression that keith's approach was emotionally influenced by his dad's illness the past couple of months.

i wasn't impressed with framing the problem as battling death, which will always be a losing proposition in the end; but his other point, alleviating suffering, that is something worthwhile -- i think that even you are behind that.

toward the end, he did say that people need to be able to consult with doctors, that all-out measures to extend life may not be at all what they want, that they or their representatives need the information to make good choices. the example he used here was his mother's death some months ago; she was diagnosed 2 weeks before she died with a metastatic cancer, and they chose comfort care.

one of his big points was how many people die each year because they lack the means to see a doctor -- which really is horrifying, particularly when such huge wads of insurance money are going to paying executives well, lobbying, denying claims to see if they can get away with it, etc.

Bix said...

I can't believe you said this. My thoughts exactly. I can't really comment though since I only saw a snippet. But the snippet I saw he was talking about dying. I didn't identify. (Kathy noted that he talked about alleviating suffering; maybe I should have hung around.)

To me, a priority should be improving quality of life, not preventing death. Everyone dies. You can't change that, but you can change a person's life experience, you can reduce suffering. Improving quality of life may have as a side effect forestalling death. (Exceptions may be accidents, infant mortality, others where preventing death is the primary objective.)

We need to step back and investigate determinates of health. Social, political, economic, environmental forces that impact quality of life. Scans and scopes near the end of someone's arduous existence should not be the goal. Food, clean water, security (freedom from violence), tolerance, sound infrastructure, universal education, freedom to pursue personal or corporate industry, these are goals worth pursuing. These are determinates of health. (Universal health care, as it's being discussed, is, should be, one aspect of health, in that it "promotes the general welfare." But there is so much more.)