Monday, May 21, 2012

When Does Life End?

Generally speaking, it’s bad to base public policy on anecdotes, even when the anecdotes are as poignant and sympathetic as Michael Wolff’s description of his mother’s last few years.

Wolff’s 86 year old mother suffers from dementia. She has suffered from a number of other serious medical conditions, from heart disease to seizures. She has rare moments of lucidity, but can no longer care for herself.

So, Wolff-- or the headline writers at New York Magazine-- says that he wishes she were dead.

Surely, this is hyperbole, but Wolff is correct to say that no one really wants to spend his last months or years living as his mother is living today.

At the same time, no one is going to pull the plug on Mom because her quality of life has deteriorated.

It’s unthinkable to allow people to degenerate in such awful conditions. And it is unthinkable to sign their death warrant.

Whatever their wishes, Wolff and his siblings are doing their best to keep their mother as comfortable and as alive as possible.

How does it happen that Wolff’s mother is living out her days in demented agony? We owe it, he responds, to the wonders of modern medicine, and to our deep pockets.

Since we as a culture believe that, when it comes to life and death matters, money should never enter into the equation, we happily pay whatever it takes to help the very elderly and infirm eke out a few extra months of life.

But then, there is the public policy issue. How much can we afford to spend on end-of-life care? Wolff attempts a solution:

I do not know how death panels ever got such a bad name. Perhaps they should have been called deliverance panels. What I would not do for a fair-minded body to whom I might plead for my mother’s end.

The alternative is nuts: to look forward to paying trillions and to bankrupting the nation as well as our souls as we endure the suffering of our parents and our inability to help them get where they’re going. The single greatest pressure on health care is the disproportionate resources devoted to the elderly, to not just the old, but to the old old, and yet no one says what all old children of old parents know: This is not just wrongheaded but steals the life from everyone involved.

And it seems all the more savage because there is such a simple fix: Give us the right to make provisions for when we want to go. Give families the ability to make a fair case of enough being enough, of the end’s, de facto, having come.

I think that the point is worth making and worth debating.

Wolff is attempting to solve a major ethical issue, namely, who is going to decide who is old and who is old old?

Most of us, when in doubt, stand on the side of life.

One might come away from Wolff’s article thinking that medical science, to say nothing of industrialization, has visited this horror on us.

In truth, an article in The Atlantic points out, industrialization and modern medicine have not only extended the normal lifespan by decades, but it has also greatly improved the quality of life.

Oxford professor Bennett Foddy says this about the topic of increased longevity:

When you're talking about medicines that help us live longer, it's important to realize how much we've already accomplished. In the last 150 years or so, we've doubled our life span from 40 to 80 years, and that's primarily through the use of things you can characterize as being medical science. In some cases it's clear that we're talking about medical enhancement---vaccines, for instance, or surgical hygiene and sterilization. And then more broadly there are other, non-medical things like the sanitation of the water supply and the pasteurization of milk and cheese. All of these things have saved an enormous amount of life. 

It used to be that people would die of an infectious disease; they'd be struck down when they were very young or when they were older and their immune system was weak. Now almost nobody in the first world dies of infectious disease; we've basically managed to completely eradicate infectious disease through medical science. If, at the outset of this process, you asked people if we should develop technologies that would make us live until we're 80 on average instead of until we're 40, people might have expressed these same kind of misgivings that you hear today. They might have said, "Oh no that would be way too long, that would be unnatural, let's not do that." 

As though to answer Wolff’s concerns, Foddy comments:

We think of aging as being a unitary thing, but it's made up of hundreds of different processes. So, one of the different things we think about, for example, is dementia, the state where your brain sort of wastes away. Now, if we discover a way of reversing that process, or slowing that process, that would be one dimension where we no longer age, where our minds will stay youthful for longer. It's also possible that we might be able to find a way of stopping people's muscles from wasting away as they get older. 

Such aspirations are not, Foddy affirms, the rule in modern medicine. They are where we ought to be going. Today, the scene looks as Michael Wolff described it:

Some of the biggest strains on our resources stem from the fact that populations are getting older as birthrate's go down, especially in the first world. Aging societies are spending more and more on nursing, and so I think that it makes sense to pursue a youth-extending medicine that would diminish the number of years that we have to spend in nursing homes. You could imagine us living more like the lobster, where we still live to be about 80-85, but we're alert and active until we drop dead. In that scenario we wouldn't have this giant burden where the state has to support and pay to nurse people that are unable to look after themselves anymore. 

Now, it has to be said that the story of medicine and medical progress in the past 50 years has not been heading that way. If anything, we're extending the number of years that we spend needing nursing. We've gotten good at keeping people alive once they're fairly decrepit. And that sort of guarantees that you have the maximum drain on resources, while also producing the kind of minimum amount of human benefit. You get to be 90 years old and your hip goes out, and we give you a massively expensive hip replacement, but we don't do things to prevent your body from wasting away and becoming corroded when you're 20, 30 or 40. 

All of it is worth pondering.


Dennis said...

Both my son-in-law and myself are disabled veterans. He spent 20 years in the Army as a Ranger, Pathfinder, paratrooper, et al. His job required jumping behind enemy lines and doing RECON. As a matter of course that entailed jumping with a lot of equipment and the force of every landing on his knees.
The battle that ensued with TRICARE to replace his knees is an example of why I am so much against government run health care. If they can give a disabled veteran who is still in the prime of his life as much grief as they gave my son-in-law, who served his country well and faithfully during wartime, what are they going to do to those that did not.
If veterans and their families are subjected to a panel of non doctors, who are far removed from the veteran and his family's medical needs , I shudder to think of the decision making done by people who are more interested in saving money on the backs of perfectly heathy seniors than providing the medical care that maintains one's health.
These costs would not, and would not have been had the government put itself in the job of regulating every aspect of health care, have been near the burden for everyone involved. These would be personal decisions made by those closest to the person involved.
What causes me worry is the fact that the more we accept the death sentence at the beginning of life, and now the end of life, the more we get inured to death as a solution to every thing that may cost money, is hard to do, et al. Where does it all stop? Do we get to a "Logan's Run" type of society/

Stuart Schneiderman said...

We don't even have to wonder about it. I just posted about the situation in Great Britain today.