health care

Dying and in Denial

A new book offers a powerful dissection of contemporary end-of-life care, yet misses the underlying problem.

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Being Mortal: Medicine and What Matters in the End, by Atul Gawande, Metropolitan Books, 304 pages, $26

The near-universality of a slow death is a triumph of modern medicine. Our success in managing what had been rapidly fatal diseases has essentially created a new phase of life—a period of physical and mental decline that can last for many years. But as Dr. Atul Gawande argues in his new book Being Mortal, rather than take advantage of the possibilities of these bonus years, we've allowed them to be defined by the ultimately futile struggle merely to survive. We've turned over the last years of our lives to the medical profession, which has, in Gawande's phrase, "almost no view at all…of what makes life significant."

Being Mortal traces Gawande's evolving realization that the default values of his profession conflict with the needs of his dying patients. At the core of this disconnect is mutual denial—both the patient's (or her loved ones') difficulty accepting that death is inevitable and the physician's difficulty accepting that his skills can't defeat this ultimate foe.

Mutual denial leads directly to excessive treatment, as physicians try anything to maintain the patient's—and their own—hope that they are effectively battling disease. Gawande describes end-of-life care as the equivalent of distributing very low-odds lottery tickets on survival at massive cost. "The waning days of our lives," he writes, "are given over to treatments that addle our brains and sap our bodies for a sliver's chance of benefit." Often, treatment fails even this low standard. For example, the widespread use of multiple prescription drugs by seniors substantially increases their risk of catastrophic falls.

Gawande contends that in our age of "informed consent" and "shared decision-making," a doctor can hide from true candor through accurate disclosure—by becoming "Dr. Informative." What is needed instead is an emotionally honest conversation with a dying patient about what she wants for her remaining time. Such conversations require physicians to see that medicine's purpose is broader well-being, not just physical health. This requires the emotional sensitivity to know when a patient and her family are ready to have that conversation, a skill peripheral at best to prevailing medical culture.

At the core of Being Mortal is the poignant story of the decline and death of the author's own father. A proud and accomplished man, Gawande's dad is determined that his cancer not interfere with his career, his charitable projects, his civic activities, or even his tennis game. As Atmaram Gawande's cancer slowly spreads, and as the associated incapacities and embarrassments grow, the author struggles to have the very discussion with his father that his book urges physicians to have with their dying patients. "We had trouble finding anywhere safe for conversation to take purchase."

Being Mortal: Medicine and What Matters in the End
Being Mortal

This is despite Gawande's father and mother both being practicing physicians. All three know exactly what is happening physically, but if anything, that makes candid discussion more awkward. Ultimately, Gawande senior's irrepressible energy drives the correct balance of treatment and capacity: He still has too much to do to settle for being merely kept alive.

This highly personal example best illustrates Gawande's central point. The approach of mortality isn't essentially a medical challenge. It's a highly personal one, centering on individual choice and priorities. The important lesson of Being Mortal is that patient well-being, not mere survival, is the proper object of care, and that "well-being is about the reasons one wishes to be alive."

My own father's death from a hospital-acquired infection inspired my initial interest in health care. It was a horrendous experience in every way: dehumanizing, opaque, and confusing. So how could I—or anyone who's dealt with our health care system—not find Gawande's call for a more humane, more sensitive, more personal approach to care appealing?

Yet that very universal appeal of Gawande's approach suggests its ultimate limits. Like much of his work, Being Mortal is fundamentally about the professional culture of doctors. This is his comfort zone—and ours. We all want to believe that our health issues can be addressed by wise, sensitive physicians with the time and inclination to attend to our personal needs and sensitivities. And perhaps some of us will be so lucky.

But though we hate to confront this reality, health care is no longer just a doctor's craft. In fact, it's our largest industry. There are roughly 18 million people employed in today's medical-industrial complex. Gawan­de himself is one of merely 900,000 practicing doctors. For each physician, the industry has roughly 19 other mouths to feed.

When I speak in public about the importance of economic incentives in health care, at least one audience member invariably comments that medicine "shouldn't be an industry," as if that somehow resolves the issue. If we want health care to offer the benefit of high-technology diagnostics, advanced pharmaceuticals, and genetic-based treatments to whole populations—and I think we do—then we'll have to understand it as an industry and hold it accountable the same way we do everything else. Our nostalgia for Marcus Welby has kept us from coming to grips with the reality of health care today: excess volumes of ineffective and often detrimental treatment, inconceivable volumes of medical harm and accidental death, primitive use of information technology (except in billing), and absurd expense.

Gawande sees hope that change can come to end-of-life care. He examines innovations in assisted living that emphasize the dignity and autonomy of the individual and he shows how such ideas have begun to infiltrate even traditional nursing homes, where frail seniors had been essentially infantilized to protect them from the slightest physical risk. He looks at the spread of hospice as an alternative to dying in a hospital and reviews research suggesting that palliative care may extend survival periods beyond what's possible with more aggressive treatment. And he describes how some of his patients used the imminence of death to define what made them fundamentally alive—often setting very individual goals relating to personal autonomy, time shared with loved ones, ability to perform daily tasks, even watching sports on television. It is helping patients achieve these personal priorities, Gawande discovers, that is the true mark of a good physician.

But pervasive change can only start with recognizing that today's incentives point away from more personalized, more sensitive, and more humane medicine. America's relentless medicalization of death would have proven impossible without our government's seemingly limitless willingness to pay for it. And death is merely one of many experiences our society has paid to medicalize. At 17 percent of GDP, the health care industry has the funds with which to medicalize the senior years generally, to medicalize what had been lifestyle choices, even to medicalize poverty.

It is hard not to notice that this book about courage in dealing with mortality is fully in denial about another m-word: Medicare. Throughout the developed world, health care is heavily subsidized by governments. But Medicare is unique. As an unbudgeted entitlement, Medicare is mandated to pay for all care that seniors "need." Providers have readily responded to this unlimited mandate by relentlessly expanding the definition of "need," even for those who are clearly dying. Without review, Medicare will reimburse for colonoscopies performed on people too old by its own guidelines, for spinal fusions even after its experts raise doubts about their effectiveness, for surgeries on secondary illnesses in terminal patients. In fact, one in three Medicare patients has surgery (reimbursed, of course) in the year of his death.

Medicare may be undisciplined, but that doesn't mean its impact on care is neutral. Gawande is right to view the decline in gerontology as a particular tragedy for seniors; these are the only physicians who explicitly deal with the problems of aging as interconnected issues. But why are we down to only about 7,000 gerontologists for 40 million seniors? It's not because of some inevitable medical progress. It's directly because of Medicare. The entitlement's rate-setting panels (dominated by specialists) have long preferred the concrete nature of treatment over the vague expenditure of a primary physician's time. Even though it spends $600 billion on seniors' care, Medicare's economic incentives have driven gerontologists out of business.

Gawande ignores Medicare, systemic causes, and economic incentives for the same reason most people do: The whole idea makes us squirm. It's too awful to imagine that the amount, type, and even quality of care are driven primarily by economic incentives. Yes, the desire to do good and to be compassionate are also important incentives; but if we are to understand an activity involving 18 million people, we have to focus on the economic incentives our policies have created.

It's far more comfortable to maintain what can be called the Prime Illusion of health care. Most traditional health experts believe that there is an objective, inflexible need for care determined by health and available treatment technology (sometimes mistakenly described as "inelastic" demand). Government's role under this illusion is straightforward: Merely help people pay for this needed care (and often set prices in the process). The illusion is that having the government subsidize health care (either directly, by paying for it, or indirectly, through regulated insurance) doesn't meaningfully alter the amount, type, or quality of care we receive.

Because it has an unlimited, unbudgeted call on resources, Medicare is essentially a massive test of this illusion. The results are both clear and difficult to look at. Medicare, as our surrogate, has unleashed a torrent of unnecessary care, accidental death, and inattention to the personal needs of the patient.

Bizarrely, Medicare's very incompetence only confirms its advocates' belief in its superior efficiency. The program spends roughly $3 on administration for each $100 of medical services it buys for its beneficiaries, compared to as much as $17 by private insurers. If you believe in the Prime Illusion, this appears to be far greater efficiency. But this supposedly superior ratio is only the mathematical result of Medicare's unwillingness to do any meaningful administration and its simultaneous willingness to pay for any treatment whatsoever, no matter how useless or destructive.

Some Americans look longingly at foreign single-payer systems and wonder why America can't use this seemingly simple and lower-cost alternative to pay for our care. But Medicare is a single-payer system, although one that has never had the political support to restrict demand that exists in other countries. Nor is it likely to. Instead, Medicare relies on the fiction that it can control spending by paying low prices even while leaving demand unchecked; the Affordable Care Act continues this wishful thinking. Sadly, low reimbursement rates drive valuable care (such as primary care) out of business while encouraging ever higher volumes of higher-priced, and often unnecessary, treatments. The low prices paid may look good to the voting public, but the reality of the economic incentives they unleash is ugly.

If Gawande had been willing to address the systemic causes of medicalized death, he could have had to face a difficult question: How can we reconcile his hope for personalized end-of-life care with the large, centralized institutions (Medicare and private insurers) that are the system's actual customers? Gawande's whole point is that objectively "needed" care has little meaning when it involves a person who is dying. The course of treatment must be based on personal preferences, on finding the correct balance of treatment and life's objectives that he so eloquently prescribes. But how can a centralized payer—in this case Medicare—ever drive the correct set of incentives for a world of personalized care?

It can't. And while we may not yet realize it, end-of-life care is not an outlier. It's only the most obvious segment of care for which the Prime Illusion is increasingly useless. Ever more of contemporary health care—for seniors and non-seniors alike—is essentially a trade-off between lifestyle issues and a variety of medical treatments. We may like our illusion that there is some fixed health care need, but patients every day choose between statins and dietary changes, between exercises and spinal fusion, between prostate surgery and "watchful waiting." Only the patient can choose. And the future of health care is almost certainly one of ever-more-personalized treatments, matching genetic characteristics to targeted interventions.

Government may be good at redistributing money. It may even be adequate at buying a standardized product or service on behalf of an entire population. But does anyone believe government—or any centralized institution, public or private—can successfully provide or even just pay for the tens of thousands of services that will comprise health care in an age of personalized medicine? How can centralized management of the health care system work once reality forces us to drop the Prime Illusion? Well, how is it working now for end-of-life care?

The concept of having centralized institutions—insurers or governments—buy our health care for us is relatively recent. One could argue it is an artifact of the first time in history widespread medical care could even claim to be effective. Like so many medical insiders, Gawande finds the idea of fundamentally changing this approach inconceivable, preferring to tinker around its edges as "reform." But things change. There's no more reason to assume 20th century–style centralized payers will work for the personalized care of the 21st than to believe they would have transformed the ineffective care of the 19th century. It really is OK that we don't use the U.S. Postal Service to deliver our email.

Is it surprising that the health care industry responds to the needs of a single-payer customer with de-personalized care? In the rest of the economy, we use markets and actual consumers to drive diversity of choice and service. If we want the benefits of personalized care—not just end-of-life care, but all care—we'll need to bring these same incentives into medicine.

That needn't mean abandoning a health safety net. The two most successful American safety-net programs are Social Security and the Earned Income Tax Credit. Both simply give people money to pay for things of their own choosing. We can do something similar to prepare for the future in health care.

Gawande finds it inconceivable that real health care consumers could ever exist, contrasting the anticipated problems of a consumer-oriented system to a nonexistent paternalistic ideal. His very brief discussion of a market-based alternative is almost a caricature; he argues that markets can't work in health care because consumers will place excessive value on low-likelihood chances of survival. He also notes that in developing countries, the emergence of a middle class is often associated with barely regulated physicians successfully marketing useless treatments to gullible and desperate patients. Did he not notice the irony of criticizing consumer-driven care for these prospective weaknesses in a book devoted to the tragedy of end-of-life care under our current system?

None of this is to deny the real successes of Being Mortal. Gawande's book is an excellent reminder of the true value of life at a time of excessive medicalization. It offers a vital perspective and guide to those dealing with the decline of a loved one. And most readers will wish their own doctor had Gawande's commitment and compassion.

But ultimately, systemic problems will require systemic solutions. The reality of modern health care is like death itself: Its very existence makes us uncomfortable. Yet if we hope to align the medical-industrial complex's imperatives with our priorities—and to take advantage of the endless potential of care in the future—we'll need to apply Gawan­de's own call for the "courage to confront reality…and the courage to act on the truth" to the health care system itself.

NEXT: The New Old Age: Reason's Special Issue on Aging, Pensions, and Immortality

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  1. In the most egalitarian/socialist of societies, the head tax collector will always have better access to healthcare than the worker bees.

    1. But bees can smell fear! Like dogs!

    2. Can you tell me which countries those would be with specific examples for each? I really want to know as I experienced the Japanese healthcare system not only first-hand where I was diagnosed with cancer but also second-hand with my daughter who had surgery, my wife who was hospitalized and of course, in-laws and friends and saw none of what you mention.

      1. I’m surprised Japan saw fit to apprise you of the medical history of it’s head tax collector.

        Silvio Berlusconi, Hussein bin Talal, and Hugo Chavez all provide convenient examples of heads of state with socialized medical care opting to go elsewhere for better treatment though.

        1. None of those countries you mentioned are noted for being reasonably priced, efficient healthcare systems.

          1. And where the fuck you pulled that criteria from is anyone’s guess, since the post to which you initially replied said:

            In the most egalitarian/socialist of societies, the head tax collector will always have better access to healthcare than the worker bees.

            There exists no socialist society with a centralized health care system where the politburo and the proletariat avail themselves of the same medical care (or anything else for that matter).

            1. I am still looking for specific examples and have been given none. Instead I get replies with words such as “statist” and “politburo” and “proletariat.”

              1. You were given three, and that’s right off the top of my head. You’re just equivocating and adding qualifiers that weren’t present in the original text. As trolls go you’re not even very good. And you’ve wasted enough of my time now.

                1. Mmm … oligarchs and dictators aren’t what I am looking for.

                  1. The Japanese often carry supplemental insurance. Pretty much everyone does, as a matter of fact. There is also a longstanding tradition of “gifts” to medical workers.

                    You know not of what you speak.

                    1. I had supplemental health insurance in Japan. I was diagnosed with cancer in Japan. My daughter was hospitalized for surgery in Japan.

                      I know what I am talking about.

                    2. Oh, and the “gifts” to medical workers is largely outdated. I lived and worked in Japan for 16 years. I much prefer the medical systems of Singapore, Taiwan and Switzerland to Japan.

                    3. Oh, and the “gifts” to medical workers is largely outdated.

                      lol.

                    4. I didn’t give one. I don’t know anyone in Japan who has given one and I asked if I should give one and I was told it was outdated. How is that “lol.”

                    5. Also, the largely outdated practice of giving gifts, whether cash or whiskey to physicians was part of a larger Japanese gift-giving culture. Employees that are transferred to another location are often given a monetary gift by the other employees. Teachers as well, but like physicians, this is being discouraged. Summer brings another round of gift-giving and winter brings another. Let’s not forget weddings. It all got rather tiresome …

                    6. There is also a co-pay in Japan. You didn’t mention that which casts doubt on your statements (google, of course). I paid a 5000 yen co-pay for an MRI in Japan. I thought that was really expensive until I returned to the States. For those who are self-employed in Japan the split is 70% – 30%, at least when I was there. Yet the costs are managed in such a way that the co-pays are affordable. Many self-employed get supplemental insurance. Corporate salary men may also get supplemental insurance, some of which actually pays you if you get cancer, money that goes into your pocket to spend as you want. One is free to purchase all the supplemental insurance one wants in Japan. I had a cheapy policy when I lived in Japan so didn’t get the cancer *bonus.*

                  2. Funny, the history of nations with National Health Care Systems indicated that Oligarchs and Dictators are what you are foing to be seeing most of.

          2. None of those countries you mentioned are noted for being reasonably priced, efficient healthcare systems.

            Of course not – they’re *socialized*.

            1. Another who can’t provide real-world examples of countries that provide reasonably priced healthcare to their citizens but instead throw around words like “socialized” instead. Would you rather have a catastrophic illness in Taiwan, Singapore, Israel, Switzerland or the USA? Hmmm? Would you rather be the American sucker who HAS insurance AND savings AND has to declare bankruptcy because he can’t afford the medical bills? Happens every fucking day in the States.

              1. has to declare bankruptcy because he can’t afford the medical bills

                In Obama speeches it does. Of course, he’s a fucking liar who only a fool would believe.

                Oh wait. Found the fool.

                1. Do you *really* believe that hardworking Americans, WITH insurance, WITH savings, don’t have to declare bankruptcy … everyday? With or without Obamacare, America has the most expensive, least efficient healthcare system in the world.

                  1. If you’re not willing to go into bankruptcy to save your fucking life, then you don’t really deserve to keep it.

                    Also, bankruptcy itself is already a handout from the government to protect you from your creditors.

                    All of the countries where it’s “cheaper” have social “welfare” as far larger elements of their budget, and generally much higher debt-to-GDP ratios as well. When all of that credit starts to fall apart, there will be no higher authority to grant anyone the privilege of bankruptcy.

                    1. If you’re not willing to go into bankruptcy to save your fucking life, then you don’t really deserve to keep it.

                      The “expensive American healthcare causes millions of middle class bankruptcies” claim is bullshit. It’s a trope the left has been trotting out for over 20 years and has been soundly disproven every single time. It ranks up there with the “1/5th of Americans struggle with hunger” claim in patent dishonesty.

                      All of the countries where it’s “cheaper” have social “welfare” as far larger elements of their budget, and generally much higher debt-to-GDP ratios as well.

                      They also have poorer healthcare outcomes.

                      About the only outcome that tracks poorly in the US versus “the world” is infant mortality rate, and that is the result of what amounts to accounting tricks.

      2. You don’t think that the Japanese Prime Minister gets better healthcare than the rank and file ?

        That is his point.

        1. Can you give me a specific example of how a Japanese prime minister got better healthcare than the rank and file? I am not saying it doesn’t happen. It happens in the USA every day – not everyone has access to the very best.

          1. I asked you if you think the japenesse Prime Minister gets the same healthcare as the rank and file.

            That was my question to you.

            Is it to destructive to your narrative for you to answer ? Is that why you attempt to send me on a errand to educate you about some ancedote?

            1. He certainly has a private physician. Does that answer your question? The Queen of England has one, several actually. I would guess every American president has one, or several as well. I can’t imagine any head of state not having one.

              1. See, after circling around the drain several times you finally found the answer to the first post you responded to from Chumby by trying to take it off on a tangent.

                That wasn’t so bad was it ?

                1. CEOs too have private physicians.

                2. You seem to have missed what Chumby was really getting at …

              2. I can imagine a head of state in a *socialist* country not having one.

                That’s sort of the *point* of socialism after all – from each according to his ability, to each according to his need.

      3. First, the comment was a tongue in cheek channeling of Animal Farm.

        Regarding your time in Japan, I’m glad you have no evidence of disease. If you were attempting to make a point, you provided 25% of what was needed. A to B is more extreme than C is to D. You provided part of A. I’m guessing you weren’t inferring that folks in the US don’t receive top cancer care. I think the only time that is true is when the FDA prohibits then from specific drug access. And you tell me, is the FDA more like or less like socialism?

        Regardless of who paid, your treatment (and the care your daughter is receiving) is being paid for by someone. Though there costs are cheaper since they don’t have 30 million people that aren’t legally there using the services. Also, their lifestyle is much different than in the US. Compare obesity, smoking, and driving (injuries and death). The US trumps Japan in all three (I believe all three are in the top ten causes of deaths in the US including the top two spots). My analogy is trying to compare a Subaru that is driven off-road regularly and in extreme weather versus a Kia that is babied. Just looking at the cars side by side and the repair bills you’d think Kia makes a better car and their parts and service is superior to Subaru.

        My state examples are Cuba and Japan. When Fukushima went up none of the Japanese politburo went there. When we had TMI meltdown, we demanded and received our President to get his ass there.

  2. I’m not sure whether there should be any government subsidization of medical care.

    But it seems more cost-effective and humane to re-focus our spending on end-of-life care instead of futile attempts at prolonging life.

    We spend billions of dollars on trying to save a life that will ultimately die anyway. We could spend just as much on humane end-of-life care with even greater success.

    1. Unfortunately, futile attempts at life-saving are much more lucrative. This informs health policymakers, which is the reason that Medicare policy is distorted towards futile life-saving measures. It’s important that economic incentive and so-called ethics are entangled factors.

      1. “important to remember”

        1. We basically understand infectious diseases, so we can prevent/treat those (with exceptions, of course).

          Our understanding of chronic diseases is not good. We kinda understand cancer and atherosclerotic vascular disease, but not to a level where we can stop them. Our understanding of neurodegenerative diseases like Alzheimer’s is zip.

          Which is why I drink Orphan Blood? — Your Source for Eternal Youth

      2. Unfortunately, futile attempts at life-saving are much more lucrative. This informs health policymakers, which is the reason that Medicare policy is distorted towards futile life-saving measures.

        I think you’re wrong about how this informs Medicare policy.

        I think the main reason Medicare focuses on life-extension medicine (even/especially when futile) is because no one wants to be told that ‘well, its not cost effective to keep you alive, but we’ll make your last days as comfortable as possible’.

        Remember the backlash against people who said PPACA would institute ‘death panels’ – its the exact same thing driving Medicare’s policy.

        Medicare would *love* to have the authority to say – too old, too fat, smoker, too white/not white enough, stop treatment. Doing that would be political suicide.

      3. Absolutely. Yet … if the government were to, for example, ensure that every American have healthy Vitamin D levels (which would cut chronic disease by at least a third) there would be a collective whine from Reason readers. So instead we are stuck with spending trillions on end- of-life care rather than pennies on life-care because Reason readers are stuck on their principles.

        1. spending trillions on end- of-life care rather than pennies on life-care because Reason readers are stuck on their principles.

          lol yes, the magazine of the party which has never held a Congressional seat, governor’s office, or the Presidency, who’s candidates have never taken over 10% of the vote in any election, those people are OBSTRUCTONISM!!!! preventing the glorious future.

          You’re a very bad troll.

          1. Mmm … I am interested in real world examples of what works, not an imaginary “glorious future.”

            1. lol you just blamed an utterly powerless minority (libertarians) for the problems with the American healthcare system.

              We have no control whatsoever over government policy. We have been opposed to every healthcare market interference from Truman to Obama.

              Every problem in the American health system is the result of governmental interference.

              1. No, I am interested in real-world examples of What-Is-Working, not what-ifs. In the 1990’s several countries created healthcare systems that are actually working for their citizens. Why haven’t we done the same?

                1. In the 1990’s several countries created healthcare systems that are actually working for their citizens.

                  Like where, exactly? It’s amazing also how you draw the cut-off line at the 1990s, since many countries have had socialized medicine for far longer than 20 years, and unsurprisingly all of those countries have shitty care that is ridiculously expensive.

                  But it’s all magic and ponies because those costs are “socialized” so instead of a couple of people being unable to afford to prolong their lives, the entire country is going to collapse.

        2. No, we are stuck spending trillions because people like *you* keep insisting that *government* do everything.

          The same government that got us into this healthcare mess in the first place.

          Don’t blame vitamin D deficiencies on something libertarians *haven’t even done yet*.

          1. Not at all. I am providing an example of a simple and inexpensive way of saving billions of dollars. You are intent on sticking to your principles even if it costs billions of dollars. Penny-wise and pound-foolish.

            1. Since no one listens to you, you’re not really saving anyone anything either.

              I mean, if it’s fun imagining the world left to the charge of DirkT, then I don’t see why it’s unfair for anyone else to do the same.

        3. DirkT:

          So instead we are stuck with spending trillions on end- of-life care rather than pennies on life-care because Reason readers are stuck on their principles.

          Those Reason readers sabotage everything. Damnit.

        4. Yet … if the government were to, for example, ensure that every American have healthy Vitamin D levels (which would cut chronic disease by at least a third) there would be a collective whine from Reason readers.

          How would the government do that and save billions? Magic?

          Having “healthy vitamin D levels” isn’t going to prevent old dying people from being old or dying. The vast sums of money spent on expensive end-of-life Hail Mary medical treatments aren’t being spent on 30-year-olds.

          So instead we are stuck with spending trillions on end- of-life care rather than pennies on life-care because Reason readers are stuck on their principles.

          So instead we would spend pennies on “life-care” and people still get old and sick and we still end up spending trillions on end-of-life care because people like you believe in magic.

    2. You would be sure of the wisdom of government subsidized medical care if you were diagnosed with cancer and were presented with a seven figure bill.

      1. In the absence of government subsidized medical care there probably wouldn’t be very many seven figure medical bills. Oddly, when unlimited “free” government money flows into an industry, the price seems to skyrocket. See also: college tuition and health insurance.

        1. @PM You are like the 40 year old virgin talking about sex.

          1. A response roughly commensurate with your demonstrated grade level. I guess it’s easier than trying to engage any further in a topic of which you are wholly and completely ignorant.

            1. So you know what it is like to be really sick or are you only living out of your head like most of the readers of Reason?

              1. Being sick is not a prerequisite to understanding basic fundamentals of economics. Your feelings aren’t data.

                But actually, yeah, I do. I’ve got more than one family member with chronic illness, including one that’s been involved with multiple, thus far unsuccessful clinical trials and has been on medications running nearly $100,000 per dose.

                1. It is sad to see that kind of money go to nothing isn’t it? Sad to see a loved one suffer. It generates compassion wouldn’t you say? Compassion is worth more than all the data in the world.

                  1. Pay for your next naturopathic seminar with compassionate then. Leave policy and economic discussions for the grownups.

                    1. Sorry, I know nothing of Naturopathy. Have never seen one. I have kept myself healthy over a decade of living with cancer however. And have never sucked at the public heathcare tit if that worries you any.

                  2. The money didn’t go to nothing. It went to an attempt to save a life.

                    Would your feelz be better if the money went to buy a house ?

                    You value a house more than a life ?

                    What a sad little troll you are.

                    1. not sure what you are blathering about …

                    2. “DirkT|2.21.15 @ 1:38PM|#

                      It is sad to see that kind of money go to nothing isn’t it?”

                      Need any more help ?

                    3. Have you considered what I meant by that statement or are you more interested in putting words into my mouth?

      2. I am not ignorant of the costs of medical care. But there’s the question of whether government subsidies are actually contributing to the costs.

        1. Tell me, where is the most expensive country to be treated for cancer? Israel, Taiwan, Singapore, Switzerland or the USA? All these countries created reasonably priced healthcare systems that work for their citizens in the 1990’s … except one.

          1. Do you understand the difference between price and cost? Especially when government distorts both with senseless regulations made in the very vacuum of inexperience that you decry in, for instance, PM, the 40 year old health car virgin?

            I doubt it.

            1. Do you understand what Israel, Taiwan, Singapore and Switzerland have done with their various healthcare systems?

              I doubt it.

              1. You repeat your assertion in the form of a question without answering my question.

                Continue, please.

          2. Wich one of those countrie’s system provided the incentive to develop most of the technologies that the rest use to provide such gleaming healthcare ?

            1. I don’t know. I do know that Americans are the biggest suckers in the world when it comes to healthcare because they stick to their principles instead of taking action like all these other countries did in the 1990’s.

              1. If only there were another country whose system develops most all of the cutting edge medical techology that we could then use to show everyone what a great healthcare system we have.

                1. Could you clarify that? Are you saying that the USA develops ALL cutting edge technology yet has has the most expensive and inefficient healthcare system in the world? If so, you may be mostly right: I can’t imagine that Americans develop ALL medical technology. Really, most people don’t need cutting edge technology. Most people simply need affordable front-line medical care for the minor things.

                  1. Really, most people don’t need cutting edge technology. Most people simply need affordable front-line medical care for the minor things.

                    “All anyone could ever need is a solid, well bred horse. This automobile nonsense is frivolous and unneccessary.”

                    Innovation is progress. The lowliest wretch in the streets gets better treatment than George Washington got in 1799.

                    You’re fantastically ignorant.

                    1. I am not arguing against innovation.

                      Most people simply need basic, affordable healthcare over their lives.

                    2. Reasearch and development are expensive and not often not profitable.

                      The quest for profit is what drives people to invest capital and take chances.

                      But you know that, you’re just being obtuse.

                    3. I understand all that. But, again, most people never need all that. Instead, they need basic, affordable healthcare.

                  2. “DirkT|2.21.15 @ 2:17PM|#

                    Could you clarify that? Are you saying that the USA develops ALL cutting edge technology yet”

                    Can you not read ? Of course you can you’re just being a twit. Here is what I wrote in case you can’t lift your eyes a few inches.

                    “If only there were another country whose system develops most all of the cutting edge medical techology that we could then use to show everyone what a great healthcare system we have.”

                    Do you understand the difference between “most all” and “ALL”

                    I suppose not since I had to point it out to you when it was so evident.

                    You’re a waste of time. Your willfull ignorance of what I have posted only a few inches above your obtuse questions is tiresome.

                    1. Israel, Taiwan, Singapore and Switzerland all have very different healthcare system but they all are efficient and reasonably priced. These are real world examples of what is working. Yet you offer … nothing.

                    2. Ah HA! Yes, reasonably priced. No mention of their cost.

                      You also prattle considerably about what “most” people need, not only as if you are the judge of that, but in opposition toy our love of government supplied and mandated health care.

                      You are a maze of contradictions.

                    3. And you provide not a single real-world example of what is working, presently, on this planet. I have.

                    4. If the pre-Obamacare American healthcare system was so lousy, why the fuck is there so much medical tourism? Why are there three huge hospitals in Buffalo catering to Canadian patients?

                    5. American healthcare, with or without Obamacare, is the most expensive, inefficient in the world.

                    6. American healthcare, with or without Obamacare, is the most expensive, inefficient in the world.

                      Prove it. Take a procedure, identify the sources of the cost, and then do an apples-to-apples comparison.

                      I’ll wait.

          3. Tell me, where is the most expensive country to be treated for cancer? Israel, Taiwan, Singapore, Switzerland or the USA?

            Tell me, which one of these has the highest cancer survival rates?

      3. What do you think “government subsidized” actually means? Does that money come out of thin air?

        It comes from taxpayers. It does nothing that insurance can’t do, except it relieves people of the opportunity to tune their coverage and premiums to their own individualized wants and needs. Government forbids that individualism.

        You, sir, are a collectivist redistributionist statist with no grasp of simple reality.

        1. Yes, I think I realized what “government subsidized” actually means some time in Junior High School. I also outgrew Ayn Rand some time after that.

          1. Continue, please. Explain how government can do a better, more efficient, more individualized job than insurance.

            1. I have already mentioned several countries that provide reasonably priced, efficient healthcare to their citizens. Can you point out countries that do a better job?

              1. You apparently are afraid to explain the difference between cost and price, or explain how forced redistributionist government can be more efficient and better tailored to individual needs than insurance.

                Can you point out anything other than party lines?

                1. No, I really want to know of other countries that do a better job than those mentioned. I am truly non-partisan.

                  1. Gotcha. You continue to dodge the question of how government is better than insurance.

                    1. Again. You have no real-world examples of what is working. You have only what would work only if …

                    2. There are real-world examples. There are doctors (and nurses, etc.) in every developed country who work hard and save lives every day. There is constant improvement, even in some of the shittiest countries. There is also a lot of malfeasance and weariness.

                      What the fuck do lines on a map have to do with healthcare? People who do the right things should be rewarded, people who do the wrong things should be punished. This system of incentives is built into market-based economics. It does not need to be legislated into existence, it only needs to be allowed to thrive.

                      There is no “real-world example” of a perfect country (aka a unicorn) because democracies and dictatorships alike favor central control. Yet there are plenty of examples, here and elsewhere, of people doing the right things and making progress. Yet you would substitute your own diseased conception of “what should be” in place of what people are deciding for themselves is best.

      4. DirkT:

        You would be sure of the wisdom of government subsidized medical care if you were diagnosed with cancer and were presented with a seven figure bill.

        Actually, this is where I disagree.

        When my time comes and I get cancer (anytime before the age of retirement, I would say), I plan on having the dignity to say “just let me die painlessly, and leave as much of my wealth behind to my family.” And in a free society, I would do that. And, probably lots of other people, since it’s the most rational thing to do.

        Instead, since every elderly person has guaranteed medical for everything (which is bizarre in and of itself: haven’t they lived long enough? We don’t even do that for children), old people say “Gee, I get all this medicine to save my life and no pay for it? Sure! Hook me up! Hey, there’s a chance it might work!”

        And they just let the taxpayers pay for the heroic attempt to save their lives.

        It’s called a “moral hazard”. And it’s all based on the premise that, for some reason, it’s just a tragedy if anyone pays for their own medicine. Why that became a tragedy and who decided it is beyond me. As far as I know, politicians started promising medicine, people assume it as a right, and just whine like children when they thing someone might not give it to them, or take it away.

  3. The near-universality of a slow death is a triumph of modern medicine.

    *Beautiful* lead sentence.

    why are we down to only about 7,000 gerontologists for 40 million seniors?

    I recently asked a gerontologist a similar question. His answer was that gerontology is essentially just consoling the family.

    1. In American medicine, you get paid to ?do?, not to ?think?.

      There’s a lot of thinkin’ and not a lot of doin’ in Geriatrics.

    2. I too was struck by that sentence. Modern medicine has largely failed in treating chronic illness.

    3. I too was struck by that sentence. Modern medicine has largely failed in treating chronic illness.

      1. So, on the one hand, you have no respect for the practice of medicine, and on the other hand you think everybody is entitled to it.

        Surely, you are the intellectual light of our times.

  4. I think “end of life care” means something like “getting you dead at the least possible cost”.

    1. I think “end of life care” means something like “getting you dead at the highest possible cost,” at least in the USA.

      1. As opposed to the “die quickly lest you be a burden” tradition most everywhere else.

      2. DirkT:

        I think “end of life care” means something like “getting you dead at the highest possible cost,” at least in the USA.

        Well, exactly which part of the compassionate desire to “guarantee everyone who needs everything medical all the latest, greatest, highest technology treatment that money can buy at someone else’s expense” did you expect to be cheap?

  5. There’s a presumption that extra days on this earth are and should be the overriding priority for everyone, yet so many of us lead lifestyles at odds with such a priority. If longevity was truly what was important, we’d not eat the way we do, live the sedentary lives we live, and in many cases take the risks we take.

    Instead, we eat, drink, smoke and engage in other behaviors that are likely to shorten our lives. Why? Because, perhaps, many of us embrace John Mortimer’s sentiment,

    “I refuse to spend my life worrying about what I eat. There is no pleasure worth forgoing just for an extra three years in the geriatric ward”

    It’s only at end of life, when, perhaps, we are less likely to be firm in our wants and more likely to act in ways that others want, that we chase extra days or weeks or months or years via heavy amounts of medical intervention.

    1. I discussed this with my health economics professor.

      The demand for extra years of life should be balanced with the concerns regarding the quality of life now versus the quality of life in the future.

      For example, I can imagine myself still being happy at age 90. However, by age 100, I can start to imagine that life may not be so grand.

      So, do I want to invest the time in living to 100, or should I just be satisfied with 90 and live accordingly?

      1. Why, it’s almost as though each person should weigh the risks and benefits for himself. And we mustn’t have that – what would our government minders think!

      2. College students such as yourself never think they will get sick and need healthcare.

        1. Either that or they’re interested in a health care system that won’t be completely bankrupt by the time they actually do need it. Ensuring that going forward requires an analysis more thorough than “GIMMEGIMMEGIMMEGIMME!”

          1. No, the young, at least those who have never experienced what it is like to be really sick, simply never consider that one day they will need healthcare.

            1. Well, there’s no possibility that your 5 year old “FREE CANDY” view of economics could be flawed, so you’re right, that has to be it. It’s just that them yung’ins ain’t thunk about it as deeply as you have.

        2. And the statists like yourself never think that anyone else has a valid opinion at any age. You have always been wiser at any age than everybody else at any age.

          1. I have often thought that people like you, if passengers on the Titanic, would have refused a life raft and called everyone who didn’t refuse a “statist” while you stuck to your principles and drowned.

            1. I have often thought

              Facts not in evidence.

            2. I have often thought that people like you, if passengers on the Titanic, would have refused a life raft and called everyone who didn’t refuse a “statist” while you stuck to your principles and drowned.

              Derp derp derp.

              Do you really think is a comparable example?

    2. Because, perhaps, many of us embrace John Mortimer’s sentiment

      I’d like to embrace John Mortimer’s daughter as she reads aloud all three Rumpole omnibuses.

      More claret please!

    3. Do you really believe that only the sedentary who eat crap and smoke get life-threatening diseases?

      1. Do you really think anyone else’s lifestyle and health decisions are any of your business?

        1. No, I don’t tell people what to eat. If I am asked I try to be of help.

          1. Compare and contrast that statement with all your other assertions that coercive government redistribution is better than individual insurance.

            1. I can’t find a single real world example of where the countries I have mentioned do a better job than “individual insurance.”

              1. Well, you have to (a) look, and (b) know what to look for. Statists are incapable of understanding even the concept of individual, so of course you will never find it.

                1. I am still waiting for you to show me where you would prefer to get sick: Israel, Switzerland, Taiwan, Singapore or the USA?

                  1. I am still waiting for you to show me where you would prefer to get sick: Israel, Switzerland, Taiwan, Singapore or the USA?

                    Considering that when I get sick, I won’t be able to teleport myself to the best hospital in the world, it would be nice if I could at least exercise some measure of control over the details of my treatment, and the people who are responsible for my care have an incentive to do it well.

                    You know, like how it works when I buy something in any other context.

  6. The fear of death follows from the fear of life. A man who lives fully is prepared to die at any time.

    Mark Twain

    Since every man is a rapist and pedophiles stalk our children in every neighborhood and those evil guns will kill us all, it seems many Americans are scared to death of life. We’ve become a nation of pants wetting pussies scared of our neighbors, scared of everything. No wonder people cling to every last possible second of our short and inconsequential lives. But then I ride motorcycles, and while I’d like to keep death away, I realize that doing the things I love means accepting risks. I’d rather die while living than linger on for years and years lost in dementia like my grandfather did.

    1. I want to die peacefully like my uncle and not like the screaming people in the back of his car as he drove over the cliff after having a heart attack. 🙂

  7. End of life medical care is all about squeezing the system for every last drop of money. It’s not limited to Medicare.

    Nursing homes and hospices are expert in keeping wealthy customers alive in catatonic states just so they can keep billing. They’ll pump them full of antibiotics every day like cattle.

    Estate lawyers will visit their comatose clients 5 times a week to get their billings in. Everyone is trying to take a slice of that financial pie before that will gets read.

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  9. We also have an unrealistic view of the limitations of science and medicine. Most people believe physicians have an arsenal of magical medications and surgical procedures that can irrevocably cure anything and everything. Doctors are trained to give hope, and humans have persevered throughout history with a resolute determination to live.
    Our human brains are not wired to accept defeat even when our bodies have long surrendered to the inevitable.

    What constitutes “Quality of life” should be a conversation all families should have, even if it seems an obvious conclusion to a very difficult decision. If my brain is sharp at 90 yrs old , I know I can emotionally contribute to the welfare of my family even if my body can’t run marathons anymore. If my body can still run marathons at 90 yrs old and my brain has moved to another dimension other than earth,
    I’d prefer to move my body to that place and be at peace as a whole.

    1. ” I can emotionally contribute to the welfare of my family…”

      Even if they might prefer I wouldn’t 🙂

      1. Physicians can be very bad at telling people that they should give up, and they fall victim to it themselves, perusing often-futile treatments for fatal diseases.

        Bad medical joke:

        “Why do they put nails in coffins?”

        “To keep Oncologists out.”

  10. While the cost savings of a quickly-terminated life may be actuarially, if morbidly, attractive, it’s been from novel approaches to “end of life” diseases that a lot of medical breakthroughs have taken place – and are currently taking place.

    If Leonard Thompson’s parents had shared Goldhill and Gawande’s fatalism they probably could have saved a bundle on hospital bills, and he and thousands of other children could have continued dying from the then-inevitable effects of diabetes. The next major breakthrough in Alzheimer’s treatment, at a development cost well into the billions, is probably going to be “wasted” on some half-senile old coot who will only get a few extra months or years of confused living out of it. But the multi-billion-dollar treatment after that might be the cure. Keeping people alive longer and developing a better understanding of their diseases is a major step along the road to actual cures.

    Of course, that becomes complicated in important ways by the third party payment system. But encouraging pops to take one for the team isn’t always the best course of action.

  11. 10 years ago I was diagnosed with an indolent yet malignant cancer and have been able through great effort keep it indolent. If treatment is ever on the horizon, rather than first go to an expensive and toxic mainstream treatment, I will go to a state where “Rick Simpson Oil” (a whole-plant cannabis extract with a high THC content) is legal. The real crime is that this oil isn’t available to everyone.

    1. The real crime is that you think your particular experience applies to everybody at all times, and that it imbued you with the wisdom to make choices for everybody else, regardless of how their experiences differ from yours.

      Fuck off, slaver.

      1. Cannabis oil with a high THC content is effective for many chronic conditions. Why is it a crime to suggest it should be made available for everyone?

        1. Ask your redistributionist State friends. You seem to think they have the answers to everything for everybody.

          1. I don’t have any friends like that. I do know of people that have paid for this cannabis oil out of their pocket however and saved their own lives.

    2. Lol. A naturopath too. Well, that explains the ignorance and arrogance. Give my regards to Steve Jobs.

      1. Sorry, I didn’t mention Naturopathy and know nothing about it. How does it relate to whole-plant cannabis extract with a high THC content? Steve Jobs? Don’t follow you …

        1. He was another know-it-all nanny. Apparently you know-it-all nannies compete with each other for stupidity. But since you obviously know more than he ever did, and he’s dead, you can pretend to not understand the analogy from your mountaintop summit of wisdom.

          1. I only know that I have kept myself healthy for a decade now without the help of a physician and without sucking on the public tit while living with cancer.

            1. without sucking on the public tit while living with cancer.

              And when that stops working, then what?

            2. I only know that I have kept myself healthy for a decade now without the help of a physician and without sucking on the public tit while living with cancer.

              This sentiment is quite frankly bizarre, considering that at the top of this thread told us of how both you and your child have received care at the Japanese public tit and your statements in the rest of the thread have been extolling the virtues of nations that have completely replaced self-reliance with the public tit.

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  14. It’s the government intervention, stupid. The payer and the regulation.

    Stop restricting competition among providers, and stop enabling endless demand for services with tax payer largess, and we don’t have to obsess over the limitations of the “culture” of the medical profession.

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  18. Just cremated an uncle who suffered for some years of dementia. Our culture and laws made sure that he hung on to that crappy life to the bitter end. Fortunately or unfortunately the family could afford the $17K /month in a really nice home plus a private caregiver to make sure he got breakfast and lunch each day. The $250K in long term care benefits were used up before going into the home with his in home care. Compassion for him? I truly believe we have treated several of our dogs more kindly at the end. If birth is a miracle of life then so is death. Bring it on. We are,all going to die.

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