Tags

, , , , , , ,

Romanticism seems to be making a comeback, in of all places, the health care industry, or more particularly, in debates over how the health care industry in the US should be structured.   When former Alaska governor and Vice-Presidential candidate Sarah Palin shrieked that government “death panels” would push granny off the cliff if Obamacare became law, she was making an argument heavily steeped in Romanticism.  When an infamous political commercial showed just that (granny being pushed off the cliff), connecting the dots in the mental imagery to explicitly show how such a thing would actually look if candidate “x” were elected (though if I recall correctly, the candidate being excoriated and Sarah Palin were on the same team), the appeal was to the emotional, not the reasonable.  And when an oncology nurse wrote a column in the New York Times recently, showing how different the health care market decision matrix is when the “skin” in the market is one’s actual, not simply metaphorical skin, and then described in great detail a patient whose skin actually sloughed off before he died, the strings she attempted to tug weren’t the ones attached to the head, but to the heart.

Romanticism, a train of thought arising in Europe in the eighteenth century, whose contours were originally and most capably enunciated by Rousseau, was a revolt against the primacy of reason.  By the time of Rousseau (1712-1778), starting with roughly Galileo and Newton and carrying through Bacon, Descartes, Spinoza, et al, Renaissance and Enlightenment thinkers had unintentionally but nonetheless systematically dismantled the edifice of beliefs and metaphysical understandings promulgated by the Catholic church, the reigning social institution in Europe at the time, and since the fall of the Roman Empire.  Romanticism didn’t necessarily seek a revival of discredited beliefs (the earth really does revolve around the sun), but sought to dispel the idea that only through reason could the world be understood and engaged.  With only a reactionary metaphysical view, Romanticism never rose to the level of a fully developed philosophical system, but did, with Rousseau as its champion, move the needle of epistemological influences a bit away from their being the exclusive province of the mind and a bit closer to the heart.   

In essence, the Romantic ideal is that emotions matter, to some extent, even more than reason, in engaging and understanding the world.  And for Romantics, the truth of an emotionally-held belief is determined by the depth with which the emotion is felt.   Truth is a very subjective inquiry.  Whatever is deeply felt is sanctified as true, and whatever action is taken as a response to this subjectively, emotionally discovered truth is thereby justified.  Thus, when Shelley’s Frankenstein felt rage and anger for having been designed in such a manner that no one could love him, the monster was justified in going on a murderous rampage which ultimately left its creator dead.   A bit later, during the American Civil War, there was, for example, a profoundly Romantic strain to rank and file Confederate thinking over the cause of preserving a system of Southern feudalism from which they profited very little, else the war would never have happened.   The rank and file Southerner had to profoundly believe their cause was just in order to engage the fight.   And in the Romantic ideal, they proved the validity of their belief by their willingness to commit suicide (e.g., Pickett’s charge) in the service of the cause. 

Barack Obama’s election had Romantic underpinnings.   It took belief surpassing all understanding for anyone, including him, to think that his election would be one day be recalled as the time “…when the oceans stopped rising, and the planet began healing…” as he claimed in his speech accepting the Democratic party’s nomination as its presidential candidate in 2008.

It is not surprising that emotionally derived truth dominates the health care industry debate; that political appeals are directed to emotion, not reason.   While understanding the myriad cause and effect relationships within the human body, and between the body and its environment, demands adherence to a rigidly rational and objective perspective, the enterprise of gaining understanding and affecting medical outcomes is often considered the product of miracles. How many times has the process and its outcomes been referred to as the “miracle of modern medicine”?   There is nothing miraculous about modern medicine; in fact, modern medicine is very nearly the complete antithesis of miraculous, yet the human heart so wistfully yearns for the continuation of life that it can’t help but attribute medical interventions that save lives to the realm of miracles.   Even the accumulated knowledge and wisdom of the ages can’t dissuade people who don’t, or can’t, understand cause and effect relationships in the body from attributing everything they don’t understand to the miraculous, even when they know that other humans around them fully well understand the causation mechanisms of which they are ignorant.  It is why doctors are so routinely considered to be something like demigods to their patients. 

In the health care debate, the Romantic ideal is expressed in the notion that costs don’t, or shouldn’t, matter in determining the appropriate level of care.  Both sides in the debate—those who believe government should be more involved in delivering, or at least paying, for health care, and those who believe it should be less involved—harbor this sentiment.   Thus Palin didn’t want any expense spared to extend granny’s life, not even if the cost was enormous, and the extension of life pitiable.  And for the oncology nurse, “…the man had good insurance, and he and his family used it freely to provide him with as much comfort and care as possible…” so no consideration was given to the cost of her patient’s ultimately futile care.  The idea that costs don’t matter arises from the emotional impulse to want to do anything that might possibly extend a loved one’s life.  It is a Romantic, i.e., emotionally-derived, belief that more life is always good, with the depth of that belief being proved by the willingness to spare no expense in providing it.  But there’s a catch.  The belief could not be expressible, in most cases, except that the expenses not spared to extend life come from the wealth of another, whether third-party private insurance, or from the government. 

But the capabilities of modern medicine makes the idea that more life is always better, and that no expense should be spared for its continuation, even more suspect than any such notion arrived at solely through emotion ordinarily would be.   Modern medicine can make monsters just as readily as it fosters apparently miraculous cures. 

The patient described by the oncology nurse in the New York Times article had leukemia.  When the standard chemotherapy regimen failed, he was given a bone marrow transplant.  His skin sloughed off because his new immune system (transplanted with the marrow) did not like its new home, and set about to destroy its surroundings.  He suffered from graft versus host disease (GVHD), and ultimately died a horrific death from it, so grotesquely malformed by the time of his passing that the nurse and the man’s wife wondered whether to even let the children in to see their dad before he died.   

Bone marrow transplants are hideously expensive, both in financial terms and in the pain and suffering endured.  They require intensive in-patient hospital care routinely lasting eight weeks or more, which is followed by months, and sometimes years, of out-patient care, with often lengthy and frequent readmissions along the way.   And that’s for the cases that are relatively successful.  Those which develop complications, like GVHD, are either fatal or relentlessly expensive in both realms.   

Yet, the idea that more life is always better, and no expense is to be spared in attaining it, will not allow factoring the costs into the calculus of such an undertaking.   It is not permissible to ask whether the guy would have done better without a transplant.  The potential tradeoff between a shorter, but less painful life and death, and a costly treatment with only a remote chance of success is not admitted (the typical five-year survival rate for allogeneic bone marrow transplants in leukemia cases is about 25%-50% when there has been no previous relapse, and the survival rate is inversely correlated to age–as age goes up, survival prospects decline).  But the cost of a bone marrow transplant, not just in cash paid by the insurance company, is enormous.  How can the costs of such an undertaking relative to its potential benefits not be practically the only calculus worth performing in deciding upon the course of care? 

The oncology nurse claims that Mitt Romney doesn’t understand medicine when he speaks of the patient needing “skin in the game” and offers this tragic tale of death by skin disintegration as anecdotal evidence in support of her claim.  She further asserts that medical decisions are not susceptible to market analysis, because there usually is only one option available.  She’s wrong on both scores.  In her example, had the patient’s family been footing the bill, they might have thought better about undertaking a most fraught and painful procedure.  Even surviving a bone marrow transplant does not mean that the life that survives it is worth living.  It might mean more or less complete debilitation.  Not surviving means mortgaging what few good days are left for a hollow promise that yields only a harrowing and painful death.   There are worse things than dying of leukemia.  Dying of a bone marrow transplant is one of them.   Perhaps the family and the deceased would have profited had they been forced to discount the treatment financially as well as otherwise. 

I will counter the nurse’s anecdotal point with one of my own.  When my mother was diagnosed with stage four pancreatic cancer a bit over a year ago, she would have ultimately been better off had her husband been forced to include the cost of her treatments in the calculus of whether to proceed with them.  She was covered by Medicare and a supplemental policy, so he didn’t have to pony up the hundred grand or so it cost to administer treatments that I knew, and he knew, (he’s a family physician), would be futile.  (My sisters were more or less oblivious, thinking she might get better).  He’s so tight with his money that he refused to hire a nurse to help him care for Mom, instead asking her adult children to quit their lives and come and care for her, so he could keep working at a job he could have retired from on the spot and never been missed (he ultimately did retire, a week after her death).  So had he been asked to pay for her treatment, I’m certain he would have balked, and told the family and her, the truth; that it was pointless to bother with anything but ameliorative care.  It would have saved her a great deal of pain and suffering, and the insurance companies and government a great deal of money. 

The notion that costs are irrelevant in making medical decisions is infantile, much as the Romanticism of Rousseau’s day was childish fantasy, making believe that simply by feeling something very strongly it can be made true.  The rejection of mysticism and emotion as information sources yielded, over the years, a remarkable, though still quite crude, understanding of the manner with which the human body operates.  It is no small irony that the very reason which made such advances possible is being rejected for a Romantic, emotionally-derived truth, in deciding how to apply them.

Advertisements