I lost my sister to cancer 9 years ago when she was in her early 20s and I was in my teens. Her experience with the medical system was humiliating, futile, and expensive. My parents have never fully recovered emotionally. It has taken me years to integrate the experience, and I still have ghastly memories of the pains she endured recovering from unnecessary surgeries. When I read something like this i feel how much I would like to see a change. It's only partly a techological change--it is also imporant for us as a people to let go when nothing can be done, not to make things worse out of a need to be seen doing something. Unfortunately when a panicked parent is demanding that something be done to save their child, someone will be willing to do something even if the first person knows that nothing can be done.
When it is my time to die I intend to fully engage with the experience of dying, and not to numb the experience with knife wounds, drugs, and over-stimulating hospitals. Until then I intend every day to live fully, with great sensitivity, and to remember that each day I live is one my sister did not have. There is no entitlement to health or longevity; some things cannot be predicted nor controlled.
>...it is also imporant for us as a people to let go when nothing can be done, not to make things worse out of a need to be seen doing something.
The problem is you don't know for sure when nothing can be done. A coworker's sister was diagnosed with lung cancer and told the prognosis was grim. Three months, maybe. She considered a palliative treatment only approach, but in the end decided a tiny chance was better than no chance.
The cancer responded well to chemotherapy. Before it relapsed a drug was approved for this particular type of cancer (based on a DNA test). After six years she's still alive and in apparent good health.
Sometimes you get lucky, and the medical interventions do help. Now, the case in the article may be different in the sense that it was clear there was no hope from the very beginning. But that's not normal with cancer.
Yes, there are cases like this. But consider: what are the odds of misdiagnosis? Is that higher or lower than spontaneous remission? Is that higher or lower than a response to chemotherapy?
I have a sneaking suspicion that the "miracle" recoveries from cancer are simply misdiagnoses. Cancer is often a diagnosis of elimination. This is very easy to get wrong. Lesions are the tell-tale, but it is only inference that links them together. Millions of people have benign lesions that have naught to do with cancer.
And these stories are dangerous to the vast majority of (accurately diagnosed) cancer patients who have metastasized and are looking for miracles. This "slim ray of hope" takes away from them whatever slim shred of hope they had to make peace with death. And making peace with death is a huge quality of life issue for both the patient and their family, an issue which has been almost entirely ignored.
>Yes, there are cases like this. But consider: what are the odds of misdiagnosis?
In this case? Zero. She had surgery in which they removed a tumor and some lymph nodes, which were tested and found to be malignant. And, as I pointed out, they had to do DNA testing on the cancer to know if she would benefit from the drug she's taking.
>And these stories are dangerous to the vast majority of (accurately diagnosed) cancer patients who have metastasized and are looking for miracles.
So what are you advocating? That we shouldn't treat people that would potentially benefit from treatment? Five year survival rate for people diagnosed with metastatic lung cancer is a little less than 10%. Those aren't great odds, but on the other hand I wouldn't classify survival as a miracle, either.
The above is not a "miracle" recovery. She was treated medically, and responded well. Don't confuse that with people who go into remission without treatment.
I agree with you that there is a point at which individuals and families have to consider the balance between invasive treatment with small chance of success against accepting death and having a better quality of life during those months. But for most people, as long as those chances are even in the single digits, they're going to try for the treatment.
> Her experience with the medical system was humiliating, futile, and expensive.
My girlfriend, her father, my sister, and various friends of mine have had such experiences. (Not to say all of the above have died. Just have had Kafka-esque experiences with the US medical system.) There is something about our system that elicits cold authoritarianism in the manner of caregivers. Our system does not incent caregivers to look out for the patient's best interests and the uncanny facsimile of the patient's best interests which is their target (avoiding lawsuits, maximizing profits, shutting down and ensuring obedience of relatives) leaves much to be desired.
> "it is also imporant for us as a people to let go when nothing can be done, not to make things worse out of a need to be seen doing something"
In the case of cancer, universal care unfortunately seems like running in the opposite direction. Sometimes admitting that nothing can be done is the right thing.
Look at the case description - I wouldn't be surprised if the total bill was at least between 100k and 200k - for 20 days of useless care which ultimately resulted in the patient death.
There are some good economical analysis showing yearly cost that'll make you cry, especially if you consider the alternative uses of that money and how many lives could be saved - say in other countries.
With our current technology, universal healthcare for fighting cancer seems like trying to stop a fire with gasoline.
Universal care is not running in the opposite direction.
I live in a country with universal healthcare.
I have several relatives who were diagnosed with terminal cancer. In this case, the hospital simply told them, the cancer is terminal and they've been given doses of morphine until they passed away. In USA, hospitals are facing conflict of interest. On one hand, they shouldn't be providing unnecessary expensive care but then they wouldn't be making as much money. No hospital should be ever put in this position.
Honestly, I'm shocked at how many people in US are against universal health care.
> I have several relatives who were diagnosed with terminal cancer. In this case,
> the hospital simply told them, the cancer is terminal and they've been given
> doses of morphine until they passed away.
Go with this?
> Honestly, I'm shocked at how many people in US are against universal health care.
You can ask for palliative care from US doctors any time you like. You tell them you don't want to be treated and they'll send you home to die. Morphine prescriptions at that point aren't tough to obtain.
The shocking thing to me is that anyone would want universal health care that leaves them with palliative care as their only option.
If I'm diagnosed with cancer that may be terminal, I might choose to go out in a blaze of money desperately looking for a cure... or I might choose to give up and die quietly. It should be my choice, though.
When you look beyond the political demagoguery for obvious power grab reasons, you see that the US healthcare system produces just about the best results in the world:
If you are lucky to be rich, nothing is stopping you getting better health care and trying to add 1 or 2 years of life at extraordinary cost.
It just won't be covered by your insurance. To me, universal healthcare is a tradeoff. Everybody will get at least some care and nobody will go bankrupt because of medical bills.
Rich people will be still able to get whatever care money can buy. I don't understand how this is a question of freedom. Nobody is giving up freedom.
What if you work hard to be rich, and then you choose to use your money to pay for expensive treatments for you or your children? What if spending a bunch more money buys you a great deal more than a couple of years? What if the discoveries made at your great expense helps others who aren't so rich?
> Nobody is giving up freedom.
That's the justification of every little bit of thrown-away freedom we've made over the last hundred years in America. Ah, the smell of boiling frogs!
By being forced to put taxes into a least-common denominator system out of your control, you can't help but to give up freedom.
> then you choose to use your money to pay for expensive treatments for you or your children?
That's fine in any country with universal healthcare.
> What if spending a bunch more money buys you a great deal more than a couple of years?
It's possible, of course, but generally you'll have the best health outcomes with decent (cheap!) preventative health measures. The current insurance-based care system in the US doesn't gain anything from preventative care. Universal healthcare systems have a strong incentive to take this cheap route to a healthy population, fortunately.
> What if the discoveries made at your great expense helps others who aren't so rich?
Um; you can be proud of that, then? Of course, you can be a rich person who pays for treatments to be developed which you can then deny to poor people; that's called "the pharma industry".
> Ah, the smell of boiling frogs!
That's a myth; look it up. The frogs jump out when it gets uncomfortable. The same thing applies to most slippery slope arguments -- you have to prove each step would force the next. Most systems actually have forces pushing as well in the opposite direction.
Personally, I see how getting reasonable universal healthcare working in the US will be a difficult course, but I'm also convinced we have to fight our way through the problems (mainly: the corporations currently earning enormous profits from the current system...) and get it working. I grew up in the US, sometimes without medical insurance; I've also spent much of my life with a sometimes-expensive "preexisting condition".
Obviously, it's not "fair" if I'm bankrupted simply because I had the bad luck to have this condition -- hey, not everything in life is fair -- but I'm pretty sure that on balance, I'd be a more profitable economic unit/taxpayer to the US if I simply didn't have to worry about that.
How many people don't launch startups because they can't risk it?
Uh, yeah, I know that it's not biologically true. It's a metaphor. It doesn't matter that it's not biologically true just like it wouldn't matter if I used the allegory of the Frog and the Scorpion or the Ant and the Grasshopper.
> How many people don't launch startups because they can't risk it?
How many people don't launch startups because they don't have the disposable income needed to take risks?
You could compare US startup rates per capita with other countries featuring Universal Healthcare systems. Wanna guess what that graph would look like?
> Uh, yeah, I know that it's not biologically true.
You're skipping over my actual point; "slippery slope" is a logical fallacy by itself.
>How many people don't launch startups because they don't have the disposable income needed to take risks?
That's my point. You need to have much more disposable income if you're going to pay for medical insurance while you're hacking away in a garage. If you're keen on cutting down your life expenses, you can get then down really very low, even for a family... but expensive medical insurance doesn't play along.
> Wanna guess what that graph would look like?
Hard to say -- how would you make it apples to apples? Obviously "has universal healthcare" isn't the most significant variable in a straight comparison.
> "slippery slope" is a logical fallacy by itself.
Not necessarily. I wasn't making a fallacious slippery slope argument of the form A leads to B leads to C : B, therefore C.
I was simply pointing out that we are CURRENTLY in a state of greatly reduced Liberty and we got here slowly, step by step. I wasn't positing an inevitable terminal stage which would indicate a slippery slope argument. The stage we're in regarding Liberty sucks plenty enough as it is.
> Hard to say -- how would you make it apples to apples? Obviously "has universal healthcare" isn't the most significant variable in a straight comparison.
Right you are. Since I'm not looking for a PhD in the area, I'll go with my impression that the US has a great deal more entrepreneurial opportunities than any other country on earth, especially when you put it against reasonably comparable countries with universal healthcare. Add to that impression my experience in starting up companies here in the US (in the Bay Area) where I had plenty of disposable income because I wasn't paying high taxes to go to large socialist programs for healthcare, housing, food, etc.
I'm not sure what you find funny about "we'll suspend you, but only for six months." "Basic plan" typically means "cheapest plan with a certain minimum quality of care", which is the only kind of plan that has a chance at full or partial subsidization; whether that's head-only or not depends on what the market costs for the procedure would look like if people started taking death seriously.
> universal healthcare for fighting cancer seems like trying to stop a fire with gasoline
Tell that to the unemployed dad whom, twenty minutes ago, I directed to take his son to the ENT. He has had a swollen left tonsil for 5 years (last time he saw his pediatrician). Now he presents with 1 day of left ear pain. There's a mass hanging off his ear drum. Cholesteatoma? Unlikely. Maybe bullous myringitis. But at this point this kid's whole left pharynx is suspect and 5 years of infection starts one thinking about scary things.
And how will people understand that some cancers should be convered while others shouldn't? (especially if they have the "other" cancers)
Add to the mix a difference of incidence based on ethnicity and people will want universal converage of all cancers regardless how useful or useless treatment may be.
> And how will people understand that some cancers should be convered while others shouldn't?
I don't understand the question. All cancers are covered. If a cancer is treatable then it is treated. If there's no hope than palliative care is provided. If it's in the quite wide margin then the patient and the doctor talk about current best practice, and decide based on what the patient wants.
If you're asking about how the people paying the bills decide what treatments can be funded and what treatments should not be funded, well, you develop a measure. That measure is something like "years of quality life" - Quality of Life Years is used in bit of English planning.
You have an independent body assessing evidence of effectiveness, vs cost. If something provides X QoLYs it gets permission for funding; if it doesn't the patient can fund it themselves.[1]
They then publish their documentation, and it gets reviewed every few years.
That's a transparent process, allowing people to review and challenge the choices made.
This can lead to some odd decisions. Treatment for some forms of age-related macular degeneration used to be limited to one eye, because being blinded is bad, but being blinded in one eye is not as bad. That decision was later changed.
Alongside that you tell people to stop smoking, and you offer them free smoking cessation services; you have strong H&S COSHH laws, and you enforce them; you educate about the dangers of too much sun[2]; etc etc.
[1] The UK had an unfortunate situation where drug companies were creating cancer treatment drugs that would provide maybe 30 days of extra life at a cost of tens of thousand of pounds. They then set up and funded patient advocacy groups who would call for the drugs to be funded on the NHS. Providing information to those groups was an effective way to bypass the strict laws against marketing to the public. The weird choice the government at the time made was to change a law so that if someone wanted to "top up" their treatment with one of these expensive but useless meds that person would have to fund all their treatment, not just the cost of those extra meds.
[2] Vitamin D is very important, and helps avoid some cancers. You only need a bit of bright sunshine (or better diet) to get it - sun bathing for hours everyday with no sun-screen is too much.
I can't comment of the UK system, I haven't had any experience with it (theoretical experience is not the same as the actual experience)
QALYs and DALYs have a potential - they are interesting tools to separate covered cancer from uncovered cancers, but I would fear political abuse and biased measurements - just like your [1] example.
The PBS (an independent government organization, which is walled off from political lobbying) will subsidize drugs, but only ones which are worth it (as decided by expert panels). They act as a monopoly buyer, forcing monopoly sellers (the drug companies) to offer a more reasonable deal. If the drug is too expensive, the PBS won't subsidize it, and the drug company can lower the price (to get PBS subsidies) or face drastically lower sales.
I don't get what is being discussed here. How is universal healthcare like fuel to a fire where cancer is concerned?
I live in a country with universal care, so my perceptions will obviously differ to others, but I'm totally not getting what is being discussed.
In the USA, universal care is seen as a silver bullet by many who have never dealt with the reality of what it would bring. To a lot of people who support it, it's a vague undefined concept onto which they are projecting a lot of things out of their own imaginations, hopes, and fears.
Depending on the implementation, "universal health care" could make some things better than they are under the present system. Some things would be worse. People will still get sick. People will still die. People will still avoid seeking treatment until their condition is untreatable, because people avoid doctors and hospitals for a lot of reasons besides monetary cost.
A big part of the problem in the original article is that of TOO MUCH CARE being provided regardless of cost without much consideration for whether the care is worth providing. One plausible concern about adopting "universal care" in the US is that it will make a bad situation worse, even further insulating patients from the cost of the care provided to them and thus making it more likely that we waste effort on extremely expensive procedures that don't do any good.
Now, certainly one might IMAGINE putting rules in place such that this didn't happen, but that doesn't mean such rules will get put in place or will actually work as intended given our generally messed-up political process.
> Now, certainly one might IMAGINE putting rules in
> place such that this didn't happen, but that doesn't
> mean such rules will get put in place or will
> actually work as intended given our generally
> messed-up political process.
Isn't the assumption that universal health care will have no rules just as based in speculation as the idea that it will?
'Universal health care' is a pretty broad term. Most discussions that aren't about particular implementations are meaningless.
>Isn't the assumption that universal health care will have no rules just as based in speculation as the idea that it will?
The problem is what's acceptable in terms of denying care is very dependent on culture. In the UK people accept that the NHS doesn't pay for a heart transplant when the patient is 80 years old. In the US people expect every intervention to be provided (if the patient wishes) up to the moment that person dies. Universal care isn't going to change that attitude, at least not for a generation or two.
The most likely outcome of universal care in the US is a two-tiered system, where the national system pays for some subset of the things that can be done, and people buy private insurance to cover what they're used to getting now.
That's what the UK has - there is the NHS for everyone, free at the point of delivery, and there is a smaller private health care sector where you can get anything you can pay for.
No, I'm sure it'll have rules intended to control costs and reduce unneeded care, but our regulatory history suggests the rules won't work as advertised. And that doesn't seem speculative at all - it's a dead certainty. Because the problem we have is NOT that individuals pay for health care, it's that health care is ludicrously expensive and ineffective and over-regulated and not subject to significant market competition on price or quality. Merely changing who writes the checks won't fix the other stuff which is the core of the problem.
In every other field, new technology makes production of goods cheaper. Even in medicine, if you look at the parts where people pay without insurance - LASIK, plastic surgery, dentistry, veterinary medicine - costs get cheaper over time. The parts of medicine that tend to get ever more expensive are the parts that involve third-party payment.
The book _Priceless_ has some decent suggestions for mechanisms that might help improve matters even given the existing (terrible) constraints we face.
> The parts of medicine that tend to get ever more expensive are the parts that involve third-party payment.
Medicine has a problem with third party payments that are invisible to consumers, coupled with insurance premiums invisibly negotiated by employers, coupled with ridiculous regulations that have created an enormous amount of dislocation of the economic incentives that would tend to drive prices down. In short, government got involved. What's our national solution? More government involvement.
See any similarities between health insurance, retirement planning (Social Security), "free" healthcare (Medicare & Medicaid), student loan programs and the cost of college education, or maybe in the home loans that caused the housing disaster?
Disaster after disaster is caused by applying heavy-handed Federal Government "solutions" to problems better solved by individuals, free markets, or at worst local and state governments.
Since there's already Medicaid for the poor and no hospitals deny care now... your statement would appear to be incorrect.
I don't mind funding a worst-case-scenario safety net for the most vulnerable in the society. I don't mind some serious legislation aimed at fixing the real problems with healthcare in this country. The law passed by the Democrats in 2009 was a useless counterproductive disaster.
I work at an urgent care. We routinely turn away people who are uninsured or have Medi-Cal (California medicaid) AND are unwilling to an upfront fee for the evaluation. So we see the uninsured but only if they pay. I see no difference in the chief complaints, but the uninsured generally wait quite a bit longer, and therefore often need not 5 times as much care, but 100 times as much.
The topic of universal health care is actively debated in the US. Some people have adopted a position that universal health care is less ideal than our current fee-for-service model. As they explore the merits of their position, they try adopting various arguments. He tried adopting the argument that universal healthcare leads to more access to care, which leads to more interventions between diagnosis and death for people with cancer. However, and perhaps our responses help persuade him of this, that argument ignores the vast middle ground of people who survive several years or even are effectively cured for life. It also, as my prior comment pointed out, ignores the value of routine screening, especially at the extremes of age.
This is less of a problem when he patient has been paying into the system his/her entire life, the premiums of which are not subject to profit margins or administrative inefficiencies (as much), and medical care costs less than half of what it does in the USA.
End of life care is surprisingly affordable when the above conditions are met.
> This is less of a problem when he patient has been paying into the system his/her entire life,
That argument ignores the opportunity cost of doing other things with the citizen's money, obfuscates the actual lifetime cost of healthcare, and is just an inherently Liberty-reducing due to a lack of opt-out.
> the premiums of which are not subject to profit margins or administrative inefficiencies
Which large long-term government programs can we refer to that are efficient? I'd be really surprised if you could name even one of significance.
... with significantly reduced treatment options for patients and an ever-dwindling number of doctors who will work with Medicare-insured patients.
It's fine for what it is, but I don't want it to be the only game in town. Given that the whole "If you like the insurance you have now, you can keep it." turned out to be a lie, healthcare reform in the US needs some rollback and rework.
Look at the case description - I wouldn't be surprised if the total bill was at least between 100k and 200k - for 20 days of useless care which ultimately resulted in the patient death.
This is exactly why universal health care is a good idea. For each person gaining little from expensive care, there are many who can be saved or get a better quality of life from cheap and relatively minor medical services they otherwise may not feel able or comfortable to pay for.
If you put all of those experiences into one huge melting pot and manage it properly, you get a positive net outcome, as demonstrated by numerous countries.
The fact that something might work in "numerous other countries" is of limited utility in determining whether it would work in the US.
Consider: If your kid is a bad student, pointing out that the neighbor's kids down the street are excellent students doesn't really help your kid pass math. Telling Microsoft or GM it should just "be more like Apple" doesn't mean they could succeed following Apple's strategies.
The US system has been very different from these other counties for quite a long time. We have different values, different skills, a different history, a different political process. It's quite possible that you simply can't get there from here. The transplant surgery necessary to put a european welfare system into an otherwise-American sociopolitical system could kill the patient. America is just NOT LIKE a tiny european country, and the ways IN WHICH they are different are relevant to what is politically and practically possible.
I think the country most similar to the US is probably Canada. Canada has both significantly cheaper medical care (US$4360/person/year vs. $7960/person/year) and significantly higher life expectancy (80.7 vs. 78.2) than the US.
Another candidate would be Australia. Life expectancy 81.81 years, medical cost $3445/person/year.
Or maybe the UK. Life expectancy 80.05 years, medical cost $3487/person/year.
I think we can get there from here. We've had Medicare for over 40 years. It's just a matter of slowly lowering the eligibility age until everyone is covered. Of course it's not politically easy -- the healthcare industry makes a ton of money and owns a lot of politicians -- but it's possible.
Those are good countries to compare US to for public policy. I go nuts when people draw in Scandanavian examples for diverse anglo nations.
But that doesn't mean that the alternative of universal health as it's practiced in those other countries is a good alternative, just the obvious one.
The current US system is stupid: tying your healthcare to employment. It's no surprise that creating distance from the people who pay and the people who consume significantly increases costs.
In Australia you can opt for private health insurance, and get a rebate. Nothing like that in the UK. People in London who can afford it often pay for private service to avoid dealing with the state facilities. I'd be interested to know whether that was factored into the books for the figures you cite - I'd expect not.
The big issue is aged care. If the official system is so awful that you find ways to keep your parents at home longer - how does that get reflected in the numbers. Also quality of life issues - whether people in state aged care in country A are having a good time at greater expense, whereas those in country B are being dosed up with drugs to keep them quiet. What choice does the person and relatives have in that care? With universality - very little.
I can't see how universal care could deliver good outcomes for aged care. It has all the makings of a numbers game, an exercise in muddying the waters about who is responsible so they can ship a cheap one-size-fits-all model.
The US system already have 'universal health care'-ish systems. Medicaid and the VA health system. Both different models (government as insurer and government as hospital owner).
This is what more specifically would happen in the US: providers of drugs, medical equipment, etc. would lobby for government mandates and other support, essentially sucking unlimited amounts of public funding to cronies. This is more or less how defense procurement works.
> useless care which ultimately resulted in the patient death.
Don't state it as if the hospital care caused the death, it was the cancer. This was a worst case scenario. In many cases that care could have bought the patient months or years to live, which most would agree is worth $100k to $200k when facing death.
I remember about an Australian medical economics study from approx 2 years ago which specifically removed "easy" to treat cancer (skin cancer + some leukemias) then tried to compute the average cost and average survival compared to abstention for all remaining cancers.
IIRC, it was about $1 million per person for at best 1 year saved on average.
Is $1 million when facing death still worth it, for less than 1 more year?
If it's your money and you've got plenty - or if it's someone else money, I am sure it is.
These are separate studies about specific cancers, and interesting.
But the biggest point in the study I remember reading was that it mixed up all the "not easy to treat [1]" cancers together, pondering each cost and survival time with the cancer incidence. It gave a better picture of the "less known" cancers - which is addressing the real question with universal healthcare.
I mean, if overall the expansive cancer or deadly cancers are rare they we can afford them - but they weren't, and overall outside specific case, even if one tried the best healthcare, it was not a very efficient outcome.
I'll love to find it back - that or a study sharing the methodology. IIRC it was in USD.
[1] : by easy to treat I mean cancer which is very unlikely to reoccur if properly treated, for which one or more therapies are known to be effective, with costs and morbidity well known - like skin cancer.
The Australian Dollar is roughly at parity with the US at the moment (Currently $1 AUD = $1.03 USD) and has been for sometime... so if the observations from the study still hold today, the amount would be about equal in either currency.
A lot of the discussion in this thread seems to be along the lines of “if universal care is instituted in the US, then it will be ruinously expensive, because doctors will authorize every kind of treatment and the taxpayers will pick up the bill” vs. “no, because when this is done in other countries, the agency that finances health care sets standards for what procedures and drugs they will cover under what circumstances”.
I would like to point out that whether or not universal health care is brought to the US (it’s scheduled to kick in under Obamacare, but if the Republicans win they can effectively kill it), the fee-for-service model of paying doctors will have to go away, because right now that model is one of the things running up the cost of private health insurance here. The insurance companies, faced with rising costs, can either impose more restrictive rules about what they will or will not cover, or they can hike their premiums.
In the former case, they’re doing the same thing that a government agency would do, except that people generally change insurers when they change jobs... meaning that any care that costs money up front but would prevent problems five or ten years down the line is not worth spending money on, because some other insurance company would be picking up the savings.
In the latter case, middle- and upper-class families see more of their paycheck going to insurance, while people who can’t afford the premiums but aren’t poor enough for Medicaid just go without insurance, depend on the emergency room if they really really need something, and risk getting bankrupted by medical bills if a serious condition does appear.
(Which is why Obamacare was passed in the first place.)
In a best case scenario, with educated and understanding people, no political interference, even with our limited technology, it would be a good thing and I'd favor it - especially for diseases which are cheap and easy to treat if caught early.
In the real world we live it, it will be bringing our economies on their knees. It's a bad idea.
Real world data show the opposite of what you're saying. The US spends more on health care than other developed countries with universal healthcare. You must know that, so what point are you trying to make here?
It's actually worse than that: US government spending on healthcare per-capita actually exceeds per-capita government spending on healthcare in countries like Canada or the United Kingdom that have universal healthcare [1], let alone total spending per-capita across both the private & government sectors.
Far from universal healthcare bringing an economy "to its knees", it seems to me that the US system has a far greater chance of doing so.
In the US, a market economy applied to healthcare limits the demand. Yet a lot of money gets spent uselessly in healthcare- and this happens even in government run programs.
People want more of everything, but there are physical limits about what is possible.
Even if each person get less per dollar than in other countries, for some reason I don't fully understand there is a high demand of healthcare, and also more distrust of an expert run system (like QALY evaluation in the UK)
It's not just an inelastic demand - it is more like a weird moral hazard scenario, or as if healthcare had increasing marginal returns for people utility function.
In this situation, replacing the market system by a government program might cost less in the short run - I fully agree - but much much more in the long run if demand is liberated.
That's because healthcare is not just like any usual good where you have reducing marginal returns, and it will be made worse especially after it has been "shown" that the endless money supply of the government can provide healthcare to anyone! ("shown" not as a valid proof, but as "noticed" by people who can cast a vote)
In the long run, I believe it will end up costing much more by this self perpetrating demand, up to the point it actually damages the economy.
A dollar spent on healthcare is not "productive" - healthcare is an investment with a negative interest rate. You can only put more money to try to keep your capital - but in the end you still die (maybe that's the reason for the increasing marginal returns - you need more and more of it).
It's bad enough when a country make debts not for investment but for consumption, yet it's much worse to make debts to "invest" in something like healthcare - with a negative interest rate
European countries are in for a bad day when they won't be able to patch the system anymore. In France IIRC the social deficit was around 100 billions in 2008 - much more than the government budget - with a 10 billions deficit just for healthcare. Now it's 160 billions in 2012 - http://online.wsj.com/article/BT-CO-20121001-707300.html]
Almost doubling in 5 years - let's round that to 60 billions per 4 years for a country of 60 millions persons.
Let's make some quick calculations.
Do you have any reason to think than, in a country with 5 times more people, and spending 16% of its GDP on healthcare instead of 9% in France (not sure about the precise %, but it's around 33% more), all others things being equal it won't create at least a 6051.33 ~ 400 billions deficit in 4 years?
(and that's a baseline scenario with an identical efficiency - with the highest cost of healthcare in the US, which can't be slashed in a day, I'd expect something at least like a 1000 trillion/5 years - and that won't be a stimulus, except for increasing demand)
I disagree strongly with pretty much all of your points.
You acknowledge that the vast majority of the evidence points towards universal healthcare systems being more economically efficient in your first sentence. You then proceed to make an argument that basically asserts the US is a special case and that a universal care system wouldn't "behave" as it does everywhere else and reduce costs, but instead increase them. I see no basis for this assumption and I want to challenge you to demonstrate why you should be granted it.
I also want to challenge you on your implied definition of "useful" or "efficient". You say you would favor a universal system if you were to see convincing evidence that it would reduce costs. In your argument, I at least, read an implicit assumption that cost ought to be the deciding factor. I find that point of view detestable. For corporations, whose sole purpose is profits, it makes sense to think of efficiency that way. You and I, however, are people, and shouldn't have values that put resource acquisition higher than human well-being. You're free to disagree, but doing so would convince me that we have very little common basis for dialog.
In the last part of your comment you give France as an example of a country that will suffer dire economic repercussions for having run an unsustainable universal healthcare system. I haven't double-checked your references, but I'm happy to grant you, for the sake of argument, that the data is on your side. You've chosen to ignore the vast majority of strong economies with universal healthcare. You've also failed to mention that whatever problems France may have in the future, they pale in comparison to the budgetary problems the US is facing due to the privatized healthcare system it is currently running. References forthcoming should you ask...
> the budgetary problems the US is facing due to the privatized healthcare system
Wait, the what?
Did you really just try to pin the blame of US budgetary stupidity on the PRIVATE healthcare system?
So, wars, enormous unfunded liabilities of Social Security, Medicare, Medicaid (both public healthcare systems), and the general welfare state don't dominate the "budgetary problems the US is facing"?
I'm sorry if I seem to be making a special case of the US - what I wanted to say is universal healthcare is not a good idea in general, and even more in the US which is like a worst case for trying to implement it.
Universal healthcare reduce individual costs, ie is "more efficient", but raise the demand. Even if it makes each act 50% less expansive, if the demand is 4x more, that'll still be 2x as much in total - it is less efficient on society as a whole, because it's not a productive use for money.
My point is not that resource acquisition is the highest goal of human beings, it is just that money spend of such thing can not be put to a better use. It's good to spend money on feeling good (healthcare), as long as the other way the money is spend provide growth.
I would favor universal system if I saw convincing evidence that people would not overclaim (ie seek treatment for minor ailments), and if they were respectful of the regulation system which has to exist if they can't self regulate with their own money. I see just the opposite, except maybe for the UK, but I don't have any experience with their system, and I don't know if they run a deficit. Anyway, if there is a special case, it certainly is the UK.
Even worse - I've noticed a troubling trend. Apparently "generosity" or "social spending" is correlated with group identification - i.e. people who self categorize as different groups (based on religion, ethnicity - anything) are less likely to favor social spending, maybe because it could favor the other group. I don't have evidence for this - it's just something I noticed when people are debating about social systems.
It is troubling, because most of the countries implementing universal healthcare are also running active immigration programs, which helps balance the cost of their social system. But if the trend is real, this countries will voluntary reduce their social spending after the initial period where immigrants footed the bill - leaving them resentful.
My hypothesis is that countries where diversity increases (such as countries in the western EU) will reduce their social systems, while countries where diversity plunge (don't know if there is any at the moment - but the province of Quebec in the 1970 is the closest example) will increase their social spending.
Please give some references for the US, but from quick calculations adding a trillion of deficit every 5 years looks like a bad idea (and I'm only talking about public healthcare in France- many people pay on top of that private insurance since the public system doesn't fully cover all the costs - money spent to purchase service from such for profit companies should certainly be added if you want to compare healthcare systems)
NOTE: This is meant as a reply to guylhem's response below.
It is true that the percentage of GDP the US is spending and will be spending in the future is not sustainable, but you're making an argument for universal healthcare. The reason costs are skyrocketing is that you have a privatized system that's (oddly) subsidized by the government. Patent laws give pharmaceutical companies monopolies on different types of drugs, while on the other hand the government is forbidden to negotiate with those companies on the price.
You also have huge overhead (31%) due to the inherent inefficiencies of running this kind of system through the private sector. For example, you need at least two doctors for each transaction - one to diagnose you and prescribe treatment and one working for the insurance company making sure that you actually need that treatment.
As for the argument about demand reduction, I agree that if you had much more demand, even reduced costs may make it unsustainable. However, in the real world that is demonstrably not happening. It simply isn't the case that universal healthcare is more expensive if we consider the evidence.
[temporary monopolies exist to preserve innovation - but let's leave that issue aside]
It might be possible that the overhead will vanish if universal healthcare is implemented. It seems unlikely to me, but a good part of the argument for universal healthcare depends on that.
Yet people just don't vanish or "lie down and die". Those who are making a living from the overheads will certainly want to go on doing that. Universal healthcare will just give them leverage and moral support (think of the patient!) to do it on a scale that will dwarf the gravy train of other government procurement contracts - at the taxpayer expense.
Such as increasing our level of technology so that the next generation will be better off, which is what every generation did until we got the idea that putting a bigger and bigger chuck of the GDP on healthcare each year was a bright idea. Over 10% it is not sustainable. It has to stop growing.
If it was used to develop life changing technologies for the whole human species such as whole brain emulation, space colonization etc- why not. At the moment is it just about making us more comfortable.
A temporary high quality of life indeed, at the expense of the future. Not a bright idea.
You aren't consistent in the point you are trying to make, which lends me to believe you believe in your side beyond reason. People have stated that universal health care has and does work in other countries.
Check out Australia's economy, and it's healthcare system. Admittedly it's scale is tiny in comparison to a U.S and there is a valid discussion of how universal health care scales (i.e is it linear, etc). But evidence already shows it works, so I don't see any point in further trying to convince you.
I don't believe in anything. Maybe universal healthcare will be possible some day, and even a good thing. Presently, in the US, it's a really bad idea.
Australia is the token example of what I said above- the bill for its social system is footed by immigrants, to which some bright bulbs think removing coverage would be another bright idea.
The best solution to reduce costs? Remove all the legal cruft - including medical boards which create monopolies in labor. Leave maybe only the FDA to evaluate drugs. Let the market sort out the rest - ie deregulate.
Australia is the token example of what I said above- the bill for its social system is footed by immigrants, to which some bright bulbs think removing coverage would be another bright idea.
Um... what? I'm Australian and have a pretty good idea of the funding of our healthcare system. Can you please explain in better detail how it mooches off our immigration?
Also, can you please cite some references showing folks that want to remove coverage from immigrants being sensible economists rather than fringe racists?
It seems to me that you're just inventing things out of whole cloth at this point.
I'm not australian so I can't say for sure what's happening down there, but the situation seems very much like France.
In Europe, and especially in France, many people share the belief that immigration is causing problems to the healthcare system. Whether they are economists or fringe racists does not matter if they manage to get enough votes.
I don't know how frequent racism is in Australia when compared to France - after reading about the riots in the press, along with this recent article which featured a poll, showing 83% thought racism was prevalent I thought it was "very much alive". http://www.heraldsun.com.au/news/victoria/racism-very-much-a...
Maybe the press and the polls are inventing things, and my comparison with France is not valid- but since we were talking about Australia, it seemed quite apropos.
EDIT: Volpe, please reread the parent comment. The problem is that western countries with diversity and immigration programs are also the ones with universal healthcare, and that there's a trend of resentment against other groups in these countries (quite related !!) that apparently conflict with the basic idea of social spending, and thus universal healthcare.
I've made my prediction - that countries with low (or no) growth will either reduce (or maintain low) their diversity and increase social spending, or increase diversity while decreasing social spending.
I'll be watching the situation in Europe and North America to see if these predictions happen - using universal healthcare as a proxy to see how social spending evolves.
Australia and Canada could give interesting example since they run active immigration programs and enjoy a decent growth - while still harbouring this kind of resentment. I'd be curious to know if growth can be helpful against this trend, or if the trend is stronger than the benefits of growth and will keep developing.
The article you posted highlights a peculiarity of the Australian racism debate - most of it is countering the idea that there is no racism in Australia, which is nonsense. There is racism here, just as there is racism everywhere. And it's got nothing to do with social spending - the US harbours quite a lot of racism (much more openly than in Aus) and it hates social spending. Australians are so sensitive about the race issue that most will either say there is no racism or that we're the worst in the world, but the truth is that we have problems, but aren't that bad if you actually start comparing to other countries. We certainly have nothing like France's actual laws on books that single out muslims.
But back to the meat of the question, you said this: Australia is the token example of what I said above- the bill for its social system is footed by immigrants. How are the immigrants footing the bill? From what you've said above, they're draining the system, not funding it ('causing problems')
Also, on the while still harbouring this kind of resentment bit -
There is not a country in the world that doesn't have a racism problem nor a population segment that resents foreigners.
France is having some problems that (i think) support my case, and I saw that Australia has some unrelated racism issue, so I concluded that France's healthcare system and Australia's healthcare system are the same.
Do you recall my earlier point about you being 'beyond reason' you are just making wild guesses at things, and cherry picking data to support your factually incorrect stance.
If you truly believe the market is the best way to sort it out, why not let the government compete? Have a single-payer system and let people opt-in. Also, repeal the laws that currently prohibit the government from negotiating drug prices. In a free market, if I'm a major client, I have some leverage to get preferential rates. Then, I'd be all for the market sorting it out. Would you support something like that? My guess is not, which means you aren't really arguing for deregulation, but for a different kind of regulation.
Seriously? You feel confident enough to evaluate the qualifications of the 'doctor' you've just gone to see about the potentially life-threatening bulge on the side of your neck, which he dismisses as just "an enlarged lymph node, no way its Non-Hodgkins lymphoma", which if caught early enough is totally treatable but if you wait too long is fatal? You really feel qualified to do that?
Skipping over the difficulties of implementing universal health care for the moment -- the thing I like best about it is that it drastically simplifies an entire category of "stuff I hate that keeps me up at night".
If "but what happens if I get sick" is no longer a large factor in questions like "should I start this business", people are freer to throw themselves into developing the kind of technology you're talking about.
I've literally spent months of my life dealing with the details of arranging and paying for healthcare for myself and my family -- including time worrying about "but if X happens, how will I pay for it?" It's one of the main stresses in my life, and it very obviously costs me in productivity.
You are quite coherent and this is IMHO the only case where healthcare could be considered an investment - so that it doesn't prevent people from starting a business.
Not sure it is enough by itself to support a universal healthcare ideal, but this a very valid reason - along with easy to treat diseases when they are caught early on.
Right, preventative care, and not just starting businesses -- it stops people from doing all kinds of good things.
Creating art or writing novels, going back to school, moving across the country, working for startups (not just starting them), having kids (or adopting, or taking a leave of absence to help raise kids)... there are lots more things that could go on that list.
Not all of those things equal "more money to the government". Some are "quality of life" sort of things; some add cultural value; etc.. But having a safety net for health issues fixes a lot of problems even for people who won't ever really need it (but can't know that for sure...), and is a sort of economic equalizing factor that I like more than taking more money from rich people and giving it to poor people.
I was trying to figure out what was bugging me about the line I quoted of yours and figured it out - you call a healthcare visit a 'claim' rather than a 'visit' or 'consult' or whatever. I worked in a hospital for four years and never heard of any malingerer referred to as an 'overclaimer'.
>I would favor universal system if I saw convincing evidence that people would not overclaim (ie seek treatment for minor ailments)
The saying "an ounce of prevention is worth a pound of cure" comes from medicine. Many problems are much easier to treat earlier on; by discouraging people from seeking treatment you end up spending more and getting worse results - as happens in the US.
>Anyway, if there is a special case, it certainly is the UK.
Hardly; look at Canada or Australia or France or Germany or Italy or.... The US is a clear outlier among countries with a similar GDP per capita; it's the only one without socialized healthcare, spends far more per capita on healthcare and has a noticeably worse life expectancy. I don't think this is coincidence.
A dollar spent on healthcare is not "productive".
What do you base this statement on?
Well run public healthcare programmmes are exceptionally cost effective. Cancer screening, childhood immunisations, dental, eye and hearing screening for children, free doctors visits for children. These are all things people around me use on a routine basis. They have a real and measurable effect on productivity for us all and do save money.
All these healthcare programmes and many, many more, aren't run for the sake of smiles and happiness. They save dollars, lives and increase productivity.
When it is my time to die I intend to fully engage with the experience of dying, and not to numb the experience with knife wounds, drugs, and over-stimulating hospitals.
This strikes me as fairly useless talk. You'll find out how you'll handle the dying process whenever you're actually faced with it.
It's certainly true that "I intend to" (in the GP comment) can't be the same as "I will".
I strongly disagree that it's useless talk, though.
If you haven't put any thought into the possible ways to respond to life and death decisions, when you find yourself facing them -- quite possible in pain, short on sleep, and flooded with anxiety and emotion -- it's not a good bet you'll be able to make the best choices then.
That's fair, more or less. My argument is that it's very difficult to predict how you'll act when you're "in pain, short on sleep, and flooded with anxiety and emotion." Even if you've thought a lot about what you intend to do in advance.
I've had two personal experiences of making stressful life/death decisions after several physically taxing days with no sleep.
Not end of life decisions -- and my own life wasn't on the line -- so it's not the same thing, but my personal experience was that the earlier research and prep I had done was like a ray of clear light in my otherwise clouded mind.
I realize this is less persuasive given the lack of detail, but these are not really my stories to tell.
We're in the realm of anecdotes now, so let me just add that I wouldn't want my last fully conscious decision -- asking for the morphine drip that might make the final few days of my life tolerable -- marred by the feeling that my resolve had suddenly failed. I think I want to remain open to the idea of a pain-reduced death at least until I know for sure how intense that pain is going to be.
(And this just focuses on the pain aspect. Similar arguments could be made against limiting last-minute surgical options, as well.)
Quite right on the anecdote comment; but I'm suddenly wondering what kinds of end-of-life plans you worry you could make that would require deep resolve.
The kind of thinking I'm talking about isn't about choosing one option, regardless -- "no matter what, I will only die at home with my family, with no drugs whatsoever" is one of those things that might sound nice for a moment but is a horrible option for some situations.
Instead, I think it's important to research the main philosophical approaches to end-of-life, to find out what the major decisions are (and what people tend to do, and what people tend to regret doing...), and just know what the options likely will be.
Simply asking the practical question "what will my life probably be like, and for how long, if we attempt this treatment, vs if we don't?" is something you need to know how to ask.
Another big one that you do need to decide in advance to avoid all kinds of potential problems: what guidelines should my loved ones follow when making decisions for me, if I'm comatose, seriously brain-damaged, etc.? Some people end up being kept alive for years in a hospital bed, even brain-dead with no chance of recovery, at huge expense, because they never thought to tell their loved ones "I wouldn't want that", and without that no one feels morally freed to pull the plug.
If they can't say "it's what s/he explicitly instructed us to do", they may well feel morally trapped into doing anything medically possible to keep you alive (even with no hope of recovery), because otherwise it looks like they're doing what's easiest/cheapest for them.
This hits close to home. I came within a hair's breadth of losing my infant daughter to cancer just over a year ago, and a few things come up in my thoughts:
- Not all medical systems are the disaster described here. We elected to move back from the US to our native Canada to undergo treatment, and our experience in ward (pre and post-op as well as on the oncology floor) was a dream (at least given the circumstances). We experienced nothing but exemplary inter-disciplinary cooperation, compassion for the patient (and family) experience, and a professionalism driven by clinical need rather than liti-mitigation. These qualities were exhibited even more strongly during the initial phases of treatment post-discovery, which unfolded along a timeline similar to the one discussed here.
- Academic hospitals are exhausting. My spouse ended up being the real hero in this story (she was still breastfeeding at the time, and only one parent was allowed to overnight in the room). My job was to make sure she and our daughter had recovered enough each day to make it through a night of vitals, endless beeping, and the occasional overnight chemo administration (don't even get me started about that).
- The need for patients and their families to drive the narrative of their hospital experience and be their own champion is critical. I had worked in healthcare for many years before this nightmare began (my old office was at the hospital across the street from her room) and knew the system very, very well. We divided up responsibilities so 'I looked outward, and [my spouse] looked inward', meaning that I spent my time making sure that the relevant referrals happened, that medications were administered on time and on dose, and so on. My wife looked inwards towards our daughter, making sure she was fed, entertained, and comfortable. This setup worked very well for us, and was a likely contributor to our level of care.
- The power of parents to be strong in the face of terrible (often inevitable) odds is truly inspiring. We were lucky enough to know with reasonable certainty fairly early on that we would one day be leaving the hospital and resuming a normal life. Many, many families we met were not so lucky. To see a parent express joy and love in the face of such long and terrible odds is a truly unique experience. I myself am a measurably better parent for having witnessed it.
Great thoughts. Very happy for your family that you came through this successfully. Lots to be thankful for there.
So, I've seen a couple of your comments on HN in the past, and just wanted to mention it would be helpful if you had some contact information (e.g. Twitter, URL, etc.) in your HN profile so people can follow-up one-on-one when it makes sense to do so. Unless, of course, you're trying to avoid people. :-)
Heh, I never actually noticed there wasn't anything there (I don't think I've been back to my profile page since I filled it out 866 days ago). Updated; feel free to follow-up as desired :)
I was struck by the amount of care that was seemingly influenced by fear of litigation. An ambulance driver diverted to a closer e/r despite having a physician onboard. A nurse wouldn't sanction ice chips without the admitting physician's chop. Exhausting and time-consuming tests needlessly repeated.
I once asked a veterinarian acquaintance of mine why he hadn't become a physician. "Wouldn't you rather drive something fancier than that pickup truck?" I needled, gesturing out the window at his old F150. "Yeah" he replied, "but those guys spend most of their time doing paperwork. I get to practice medicine."
The nurse's action in this situation is more a case of not violating his/her scope of practice. "Ice chips" is actually a specific diet order in the hospital. If a patient gets admitted with a diet order of "NPO", the the patient is not allowed to get anything by mouth ("nil per os") which includes ice chips and oral medications.
For the father to expect that the nurse should get his daughter ice chips when she probably had an NPO order is more a sign of his emotional distress during the situation. "I tell her I am the doctor, and I want the patient to have ice chips. I am told I am not the admitting physician and cannot give orders. She ignores my request to show me the location of the ice machine."
Though we all can identify with him in this situation, why would we have any expectation that the nurse would violated his/her scope of practice in this situation? The practice of nursing doesn't allow for writing a patient's orders.
His story is an example of the problem with the process of dying. All of us are dying. The question is when do you stop trying to extend life? Even a senior gastroenterologist could not help make that decision earlier for his daughter. No one - physician, father, family member - wants to bear that responsibility/guilt. We put that decision upon the person who is close to death, but they never really know how close they are. So what is the medical system supposed to do if a decision is never made? Continue will medical care, which is the most expensive at the end of life.
I've had several conversations with my vet about how his practice is so much smoother because he doesn't have to deal with an insurance industry (both from the sides of patients and a huge malpractice insurance cost) that essentially is just there to screw up everything. Few people attempt multimillion dollar lawsuits against vets because fluffy died from something that was unpreventable, but that's what happens daily in the US.
As a patient individually, health insurance is great. But as a system is so horridly broken that it slows stuff down.
Also, for anyone reading, getting into Vet school doesn't mean that you're not competitive enough for standard med school; quite the opposite. Getting into vet school is damn hard.
> Also, for anyone reading, getting into Vet school doesn't mean that you're not competitive enough for standard med school; quite the opposite. Getting into vet school is damn hard.
We were always taught in school that becoming an animal doctor requires better qualifications/grades and is harder than becoming a human doctor - presumably as there is more than 2 anatomies one must become an expert of.
Over here in South Africa, you actually go to med school for a year, and then apply for veterinary medicine. So you have to be the best of the med school applicants to get a place. Hardest course to get admission to of any.
My great uncle (who is pushing 90) was a vet here in the States, but for the last 50 years has been going to Nepal for six or so months each year to be a regular doctor.
>I once asked a veterinarian acquaintance of mine why he hadn't become a physician. "Wouldn't you rather drive something fancier than that pickup truck?" I needled, gesturing out the window at his old F150. "Yeah" he replied, "but those guys spend most of their time doing paperwork. I get to practice medicine."
That is an amazing (albeit gravely unfortunate) quote. I'm going to share it with some friends who are studying to become vets themselves (I hope that's alright with you).
Not all do. There are a few who have opted out of the insurance-based system. They run cash practices, and from what I've heard are able to spend more time with patients and charge them less because of the breathtaking amount of overhead they've eliminated.
Was the Doc in the ambulance? I thought he was in phone contact?
But your point remains. Another unfortunate effect of this is that the rest of the world follows the US. The system here in New Zealand, socializes the costs associated with medical mistakes, paying for costs and lost earning for patients. Our system isn't perfect, far from it. But it gets eroded somewhat by the extremely defensive medicine that is practiced in the US that is trickling in here, leading to higher costs and worse practice. Blood test, scan, rescan, more expensive scan. Oh wait, it's just a cough. More tests doesn't equal better care. Each carries its own risks and has a monetary cost.
I think it has more to do with bureaucracy than with fear of litigation. In an ecosystem as complicated as medical care, lots of policies and procedures accumulate over time and there's nobody with the authority to cut through the bullshit and redesign the system.
I imagine that these policies come about not from lawyers' memos, but from the physicians themselves.
A part of it is probably the litigation-happy culture in the US itself, the other one is laws that don't seem to include palliative care as an essential and non-negotiable responsibility of any medical profession. Would this be the case, the ambulance driver would be liable for driving a moribund patient to an ER instead of a hospice against a doctor's order.
>The purpose of this brief chronicle is not to criticize the practice of medicine.
Perhaps that wasn't his purpose, but that was the result. And it is a scathing, justified criticism, especially coming from an experienced doctor.
My father died of lung cancer, and we went through similar experiences with the health care system.
Before claiming that something is not a criticism, we have to ask whether or not we can imagine a better outcome, ask what is getting in the way of that outcome, and then make a change. This could be something small, like moving patients around less, and with less resistance. (The purely informational resistance in medical care is appalling, and this story shows it's real human cost. Electronic patient records is not about assuaging "people who can't be bothered to fill out forms".) Or it could be something huge, like revolutionizing what late-stage cancer patients, and their families, expect, and how they will be treated.
If you get late-stage cancer, the health insurance company should hand you $100,000 in cash, a large supply of morphine that can be easily self-administered, and a ticket to Hawaii. Huge bag of weed optional. The message is clear: you're going to die soon, so make your peace with it. Talk to your family.
My father fought until he fell unconscious, his personality ravaged by whole-brain radiation and chemo, in complete denial. He never got a change to face his sentence with courage, and he never really talked to me before he died.
So yes, the practice of medicine needs to be criticized.
I don't want to de-rail the conversation too much but this line brought home to me one of the most sickening injustices of the civilised world - “When the chemotherapy does not work, you will have to finish the job.”
No one should have to plead with their father to end their life early, this should be a choice that anyone can make without fear of consequence to their loved ones. This should be a well established and regulated part of terminal illness.
In the thankfully few times I've had to endure hospitals, I've always been struck by how unbelievable primitive what they're doing actually is. Sure there are some genuine technical miracles (dialasys, pacemakers, etc) but I always get the distinct impression that most of it is window dressing; a kind of theatre to make it seem like they're more in control and much less helpless than they really are.
And that's just off the top of my head. I think modern medicine has advanced a lot more than we give it credit for. I know a lot of hackers tend to compare other industries to the tech field, and expect everything to advance at a rate like Moore's law, but that just isn't feasible in most fields.
He described her as a "previously healthy 50 year-old daughter" and then she went from feeling weird to death in a month? I had no idea cancer could be so aggressive, is it 1 in a million that it can be this aggressive (from showing symptoms to death) or is this something common? This would explain why early diagnosis is so emphasised, I still didn't understand how much it could matter.
Cancer can absolutely be that aggressive, and many of your internal organs don't have the sorts of pain and proprioception sensors we think of from our experience interacting with the world through our skin.
It's possible to have twenty small tumors throughout your body, causing no real issue, and then shortly thereafter they continue growing enough to impinge nerves, blood vessels, airways... And you're suddenly diagnosed with stage IV cancer.
> He described her as a "previously healthy 50 year-old daughter" and then she went from feeling weird to death in a month? I had no idea cancer could be so aggressive, is it 1 in a million that it can be this aggressive (from showing symptoms to death) or is this something common?
Up til just a decade ago, certain kinds of pancreatic cancer could kill you in as little as 2 weeks after diagnosis. I wouldn't be surprised if this was still the case. Also, my understanding is that sudden early death from cancer is fairly rare, but yes, it can happen.
I lost a friend (55) to a brain tumour. From initial diagnosis to funeral: 17 days. His last words to me were 'I'm going to fight this thing'. He never stood a chance.
This really can happen. A friend from work went from a small cough that wouldn't go away (treating it with antibiotics) to dead in about two months. Throat cancer, spread everywhere. He was in his mid 40s, vegetarian for years, major math nerd. Just unlucky.
Stage four cancer? These are things I've learned from almost twenty years as a "hospice spouse."
It's probably time to call hospice, not the "We can beat this oncologist." It's probably time to write a living will and a sign the DNR. It's probably time to decide how and where you want to die.
It's most assuredly time to decide how you want to live the rest of your life.
Not always. I know a guy who has been living with stage four colon cancer for four years who, recently, has seen his tumors contracting for the first time ever.
So while I agree that you need to identify a point where you say, "Let me die in peace", I don't think that point is always the day you've been told you have stage 4 cancer. I'm not sure that the 20 days reference in the article is really time to come to terms with that.
This is truly the problem with evidence based medicine. You can say how a given treatment will impact a population (i.e. 1 out of 100 patients with stage 4 colon cancer will survive past 6 months) and say it's not worth it, but when you're talking to a single patient, you don't know what the outcome will be. Maybe the treatment will be in vain or maybe he or she will be the one patient that goes into complete remission.
Not to be insensitive (I've had a few encounters with cancer myself, from both the p.o.v. of a healthcare professional and from that of a relative/friend of a patient), but WHY is this on the front page of HN?! The story is (unfortunately) very typical and repeats time and time again in all parts of the world... but this type of description really brings no new information to "the anti-cancer game"... I know it touches everybody's emotions and stuff, but is this really the place to have these conversations?
Your point number one occurred in New Zealand too. And the US is pressuring the NZ government to abandon its very successful drug purchasing agency as part of a free trade agreement. Having one agency purchase drugs for 4 million people creates a fair bit of bargaining power, which US companies do not like.
is a medical doctor and academic researcher in medicine at the University of Minnesota. I used to file his grant applications into the office file drawers as a duty of my part-time job while pursuing my undergraduate degree. Michael Levitt is perhaps the world's leading authority on intestinal gas and still has an active research program in diseases of the human bowel. He indeed has seen many patients at a research hospital over the years, the same hospital where my mother worked as a nurse for most of her career.
Dr. Levitt writes in the submitted article, "Overnight admission to the hospital is recommended for 'observation' and rest prior to the trip home. Fifty years of experience have taught me that admission to an academic hospital is not restful. I have stopped counting the patients who want to be discharged to get some rest." I have an immediate family member who was given excellent care at the same academic hospital Dr. Levitt knows so well. My relative is in excellent health now decades after that treatment. But indeed, even with best care, the patient experience at a research hospital is not restful, as world experts on the patient's case vie with medical students and a variety of other health science trainees and practitioners to learn from the patient. When a case is puzzling, as was the case of my relative, research-oriented practitioners are curious about how to understand the case, trying to find established, verified practice to help the patient, and otherwise working "empirically" (an ominous word--to me--used by my relative's main doctor to describe a procedure he attempted when he wasn't sure what to do next) to do whatever they can to help.
As the father of a daughter, I can hardly imagine a rougher kind of news to hear. Another immediate relative lost a fiancee to cancer years ago, and that relative's memories of that time are full of frustration. The various kinds of cancer are still so varied--as mentioned in the article--that there is essentially NIL prospect of ever having a general treatment that will be an effective first-line treatment for most forms of cancer. Instead, there will continue to be surgical treatment for come cancers, a growing variety of chemotherapies for a variety of cancers, in the best luck genome-matched to vulnerable cancer cell strains, and radiation treatment for other cancers.
Ultimately, though, we will all have to learn to die better,
because we will all eventually die of something. Meanwhile, if you are a parent, this submission is a reminder to cherish your children while they are here, and if you are a medical researcher, as Michael Levitt is, this is a reminder to continue to strive for better understanding of health and disease, while remembering the patient experience as new tests and treatments are devised.
My father spent much of his last year of life in hospitals. It was a frustrating experience as well.
As far as the expenses went, he had Medicare in addition to supplemental insurance as a retired Marine. So he paid nothing out of pocket. I can definitely understand how this would add to the frustration of the experience.
A huge problem is that no one is actually in charge of a patient's treatment. The individual doctors were quite good, with maybe one or two exceptions, but there was never enough evidence of actual coordination between them for me to feel very confident. I saw him on a daily basis, but much of my time was spent staying on top of what half a dozen doctors and nurses were doing or planning to do at any given time and keeping everything coordinated. I worry about people who end up in the hospital without anyone else around to watch over them.
Hospitalization can be a very frustrating and disorienting experience, especially for older patients. The thing about hospitalization is that it's essentially a form of captivity. You could write a good psychological horror story that took place in a hospital, and it wouldn't be too far from reality.
I hate to say it, but hospitals need medical project managers.
My wife had some minor complications after a C-Section. We must have recited our name, address, insurance provider, drug allergies, first pet's name, etc about 250 times during the 8 day stay.
The older nurses rocked. The attending physician was someone we know well and rocked.
Everyone else, from resident down to tech were not to be trusted. An incompetent tech burned my wife's arm by putting a blood pressure cuff wet with bleach. A resident waited until I went to grab breakfast to try to pressure her into a procedure that she didn't want.
> I hate to say it, but hospitals need medical project managers.
They are called GPs, or internal physicians. Dr Cox (Scrubs) is an example. The new name is Hospitalist, I think (actually, there's a push to have this as a distinct specialty, so experienced non-specialists have a better development path). If you didn't have a doctor competently managing your case, it wasn't because no-one was responsible, but the doctor who should have been managing the case wasn't.
Physicians are always at arm's length. Nurses rule the roost in the hospital -- within each unit, there is a senior RN who is really the person managing your care.
The problem is, nowadays you often move from unit to unit -- the MRI machine or w/e is an enterprise resource. So when you move from Labor & Delivery to Post-Partum, or from the ER to Imaging, etc, there needs to be some sort of liason/hand-off process between two qualified individuals. Right now that's done via clipboard and a $9/hr orderly.
Not a good idea. Unproven as a technique, very expensive, very low resolution when whole body imaging is performed, will miss important stuff, and generate unnecessary biopsy procedures.
Population screening is a vastly complicated area - for example, what would a whole body MRI be looking for. Name the process(s) and there will be a better way, even if its a scan of a smaller body site, the results will be vastly superior. Dedicated coils, established imaging protocols etc.
This is one of those things that seems like it would be a good idea but doesn't really work in practice. There are outfits where I live that will do a full body MRI for you for a few thousand bucks. So people think "Hey, what's more valuable than my health? Maybe I'll catch a tumor before it metastasizes and live an extra 20 years."
The problem is people have benign tumors and cists and other oddities that show up on the MRI, most of which will never cause a problem. And every time you have something done at the hospital, even something generally thought to be totally safe like a biopsy or a minor excision, there's some (hopefully very small) risk the doctor will make a mistake, or you'll react badly to anesthesia, or you'll pick up MRSA, or something else bad will happen unrelated to the reason you're there.
People have cranked the numbers on this, and what they found is you're more likely to die from an unnecessary medical procedure as a result of one of these scans than you are to be saved by early detection of a problem.
Exactly. And as I mentioned elsewhere in discussion, its hard to emphasize enough how low resolution full body imaging is compared to local area imaging. It's really bad. Slices of 7mm or so in thickness versus 3ish mm. Like all sorts of things, in imaging there is a relationship between the quality of the question and the quality of the answer. Have I got something wrong with me? Versus Have I got a HCC of the liver? One is more easily answered than the other.
Image fusion software exists that does this, allowing you to mere images and emphasis areas of difference (usually used for allowing comparison of different imaging modalities such as CT and PET, rather than same modality over time. The trouble is, people are never, ever in the same position (different breath hold, mobile organs move, people lie in different positions, get taller, shorter, more bent etc) , and, more importantly, are the changes seen problematic or normal?
In the case were a big mass has appeared, its easy. But that is easy to spot without software help. If a software technique is to emphasis small malignant changes early on, it's going to have to be very clever and be better than (or help improve the abilities of) some very clever people.
Edit: sorry, I do realize that this doesn't quite address what you said. Your suggestion would be very hard to implement I suspect, but is better than what I discussed.
Whole-body MRI? Several thousand dollars just for the scan. The radiologist's interpretation typically costs as much. We haven't even begun to talk about resultant interventions. Eat less and exercise more is a lot cheaper and more effective.
Where I work, about $700 US. It's not a great test, despite excellent radiologists and brand new equipment as whole body imaging is far lower resolution than localized imaging (its about 1500 pixels by 250 in resolution versus 512x512 when just your knee is done using an educated guess).
Based on the aggressiveness of the cancer in this story, my (non-medical) guess is that you wouldn't have seen the cancer any earlier unless you scanned every two months. This thing came out of nowhere and came fast.
Even if you did see it... what would you do? Surgery, chemotherapy, radiotherapy... these things don't stop a metastatic cancer this aggressive.
Without a cancer treatment that can stop the progression of an aggressive metastatic cancer within a week or two we are powerless to stop this type of death.
Affordable routine scans will result in massive overloading of the health system with unnecessary procedures, and the complications arising from those procedures will kill more people than would have died otherwise from whatever shows up on those scans.
There is no such thing as an intervention without risk, and that starts with the risks associated with general anaesthesia.
Scanning is one thing, interpreting a scan and deciding when and where to intervene is something that does not scale well at our current level of technology. Basically it needs a human to sit down and spend time analysing the scan to make sure that what is there warrants intervention. So even if the scan costs would drop to 0 you'd still have the component of the interpretation to deal with.
The end result of overloading the system like this is that those with symptoms that need care are less likely to receive it or receive it timely, and that those that didn't need the care will suffer from complications.
Knowing when to scan and when not to scan is a crucial ingredient in giving good care.
What if I get scanned every month and no one looks at them until I start showing symptoms?
My aunt got breast cancer recently. She got mammograms every year but the doctors never saw anything. Finally there was a mass discovered, and a when they went back to look at the old images, they could see it growing.
Better than what I said. And your last point flows into socializes versus privatized care quite quickly, where fear of litigation drives further testing, which creates a positive feedback loop.
The more you test for the more you need to test for.
In an exceptionally cynical view of private healthcare by S. Sheem, House of God, he says Rule 10: If you you don't take a temperature you can't find a fever.
There are quite a few gems in there for those with a dark sense of humour.
No. Many, many people have small, non-malignant cancers growing within us right now. Some people carrying such growths will develop life-threatening cancers, whilst the rest (probably the vast majority) of the population will die of something else at a ripe old age before the growths in question ever become malignant.
Once you start screening everyone, suddenly you have this huge population of growths that you have to biopsy in order to determine whether or not they're malignant or not. Your false-positive rate means that you start giving extremely harmful treatments (chemotherapy is itself mutagenic & can cause cancer!) to individuals who if they'd never have been scanned would have remained blissfully unaware of the harmless growth within them & would have had productive, happy lives.
Routine scans are not cost free: They put a huge diagnostic burden on the system & they inevitably mean that you deliver invasive, potentially harmful treatments to people that don't need them.
No, not now, maybe in the future (with regards to MRI). Even with breast imaging where MRI provides great results, routine screening is only shown to be helpful in those genetically predisposed to disease. Generating masses of biopsy procedures, untold stress, misdiagnoses, botched procedures etc. The false positive rate for MRI is currently too high in breast imaging for it to be a routine tool, let alone whole body imaging with the pitfalls in the technique.
I'm surprised there are three responses to this comment, all starting with the word "no". I'm not arguing for scanning irrespective of the cost. I'm saying that if the cost were 0 then you should always scan.
More information should always lead to better decisions and better outcomes. If it's the case that more information leads to worse decisions then it's indicative of a problem in your rule set, not a problem with your information.
Imagine if taking someone's blood pressure was a multi-thousand dollar test that required specialized expertise to interpret, and could easily lead to misdiagnoses of heart problems. Now imagine that we just got the technology to do it cheaply and easily. It wouldn't make anyway sense to be afraid of testing blood pressure- it's just more information that can lead to a more complete picture of a patient's condition. But that's exactly what my sibling comments are arguing for now with MRI scans.
The parent post wasn't some theoretical awesome scan with no false-positives; it was specifically whole-body MRI. Even if you could do a whole-body MRI scan for say a nickel, and have automated software mark all new tumors, more people would die sooner than if you hadn't done this.
Once you find a tumor you need to biopsy it before you can treat it. There is a small, but non-zero, chance of death from a biopsy. The number of tumors that won't kill you right away is so much greater than the number of tumors that will kill you right away, that this small chance of death multiplied by the large number of people with non-threatening tumors is a larger number than the small number of people with highly malignant tumors.
So then it's a problem with the rule set- you shouldn't automatically biopsy every tumor. It's doesn't make sense that there's a rule in place (you must biopsy every tumor) such that people are afraid of getting more information because it will lead them to make worse decisions. More information should always lead to better decisions and better outcomes. Why are we forced to biopsy every tumor, even in the case where you agree it's suboptimal?
Imagine if every time someone had really high blood pressure, we had a rule to perform bypass surgery. People would then avoid taking blood pressure because it might lead to surgery. That doesn't make sense- knowing someone's blood pressure isn't the problem, the problem is our suboptimal rule.
Ah, so now we uncover the real problem- our legal system. I have to admit that that's a real shame.
I hope cheap diagnostics become common place over the next twenty years so at least some countries can start taking advantage of more information to improve patient outcomes.
It's not a problem with the legal system, it's a problem with human nature. It is easier to blame someone for doing nothing, then to blame someone who does something and fails.
An awesome book titled "The lives of a cell" by "Thomas Lewis" delved into the problems of Medicine (among other things) in the later 70s. He was amazingly prescient about the problems that Medicine faces today. He also offered some wonderful solutions for fixing Medicine.
"The Lives of a Cell" by Lewis Thomas is a tremendous book, pulling back the curtain on biology. Clear, concise and well written, very similar to Feynman with physics.
Very sad and heart-breaking. While reading the story, I couldn't stop imagining myself in his daughter's shoes and wondering "what would I do if I was in her place?"
Would I struggle and suffer in the hopes of living a few months longer or accept the fate and go in peace sooner. This reminded me of discussion with my wife during will preparation about how long should I be kept alive before plug is pulled.
We are all working on the wrong things. How can society not be spending far greater percentages of GDP on health care research? Yet the medical establishment, supported by Congress, operates as a guild that keeps people/innovation out, and the system wastes billions of dollars a year on futile treatments in the last year late in life, instead of finding cures.
Great read and for myself, someone who is not part of the medical community though who is a father of a daughter, I can imagine the professional and personal frustration that must have been felt. Thanks for the write up - could not have been easy (even clinically) to put together.
FWIW, my Indian friend says there's a medicine for cancer in South India with Siddha. When I searched http://en.wikipedia.org/wiki/Siddha_medicine some editors seem to have removed references to cancer from the article.
We know how cancers work to a pretty good level of detail. This means that it can be fairly straightforward to classify many treatments as ineffective.
The other point is that cancer research is incredibly well funded by non-partisan, non-commerical organisations (charities like Cancer Research UK don't have an active stake in one approach over another). The notion that these alternative remedies are being wilfully ignored doesn't stand up to any remotely rigorous evaluation.
> We know how cancers work to a pretty good level of detail.
IIRC, Steve Jobs was survived with alternative medicine for sometime than surgery. So, I'm more interested to know any research conducted on alternative medicines (to prove that they're wrong and ineffective). As it seems to work for Indians this can better be tried like yoga
This reminds me of the story of Dr. Ben Carson, a famous neurosurgeon who also teaches oncology at John Hopkins. In 2002, he was diagnosed with prostate cancer and successfully underwent traditional treatment.
However, Dr. Carson has stated publicly, both at conferences and on radio interviews, that he believes he was largely cured by a controversial holistic treatment called glyconutrients.
However, due to legal liabilities on the company's part, they banned all testimonials and would threaten lawsuits to anyone who publicized this information.
20/20 did a story on glyconutrients, disproving them based on glycobiologist Dr. Ronald Schnaar from John Hopkins School of Medicine. Dr. Schnaar said, "All of the sugar building blocks that we need in our body are made from the most common foods we eat."
Contrary to this, Dr. Carson says we do not get these simple sugars from our natural diet and said that his family, his employees and everyone he knows uses glyconutrients with great results.
He said he considered not having traditional surgery but he didn't want others mistakenly following his path to the detriment of their health.
Dr. Carson is not a glycobiologist. However, he is the Director of Pediatric Neurosurgery at John Hopkins and a colleague of Dr. Schanaar. He's been awarded the Presidential Medal of Freedom and had a film made about his life story starring Cuba Gooding Jr.
But none of this information about his alternative cancer treatment is widely known. Not one word on his Wikipedia page (http://en.wikipedia.org/wiki/Ben_Carson) nor on the page about glyconutrients.
It's disappointing there's no unbiased scientific research to explain what is factually true. And it's unbelievable that such a high profile cancer survivor could make these claims with virtually no one knowing.
1. Post hoc, ergo propter hoc - "he tried a controversial holistic treatment, therefore he was cured" - My father was cured of prostate cancer just after he quit smoking. Therefore I advocate quitting smoking as a cure for prostate cancer.
2. Fallacy of the single cause - "he believes he was largely cured by" - it's unlikely that any single cause is responsible for something as large as being successfully treated for cancer. Many prostate cancers are simply left untreated with no harm.
3. Hasty generalization - "his family, his employees, and everyone he knows" - We can know nothing about the effect on the general population from anecdotal evidence.
4. Red herring, subtype appeal to authority - "However, he is the Director of Pediatric Neurosurgery" - entirely irrelevant to prostate cancer treatment.
5. Ad populum, in reverse - "None of this information [...] is widely known" - whether it is widely known or not, it should stand up to scrutiny on it's own.
And of course, my post itself suffers from 'argument from fallacy' - something need not be false just because it is argued for in a fallacious manner.
That said, you can roll your quackery up and take it with you.
As far as I (IANAD) understand, there is no such thing as an universal cure for cancer. If and when we beat cancer, the solution will not present itself as a magic pill.
Therefore for any instance of magic pills (glyconutrients included) we can infer that it won't cure cancer with any reliability. You can have a narrow tool that strikes one kind of cancer and does nothing (or even harms a little) on all others, or we can have something that comforts you a bit but without much statistical outcome.
If you have malignant cells dividing inside you, they would not be easily stopped.
Trying to self-medicate a random cancer with a random magic pill will likely yield no result at all - or maybe only from Placebo effect.
Therefore if you're at earlier stage, your best bet is conventional treatment, and if you're at late stage, it might be better to spend the remaining time wisely.
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When it is my time to die I intend to fully engage with the experience of dying, and not to numb the experience with knife wounds, drugs, and over-stimulating hospitals. Until then I intend every day to live fully, with great sensitivity, and to remember that each day I live is one my sister did not have. There is no entitlement to health or longevity; some things cannot be predicted nor controlled.