Infected Worldmind

2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor. Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence. We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.

3. A modest bundle of guaranteed coverage and services. I am very influenced by David Braybrooke’s book on meeting basic needs. Yet for me basic needs truly are basic and do not involve cable TV or small probability chances of delaying death from prostate cancer.

Everyone who looks at the high cost of health care worries about the expense at the end of life. But what about at the beginning? Turns out there’s one deceptively simple change in obstetric care that can save millions of dollars and lead to healthier babies and healthier moms: stopping women and their obstetricians from inducing births before 39 weeks without a pressing medical reason.

..

About one in 10 births in the United States is intentionally early, and some estimates are higher. It’s a matter of choice and convenience, and sometimes efficiency, for both women and their doctors. A baby born at 38 weeks — a common time for early induction — isn’t premature. It sounds safe. But mounting evidence shows that planned early births put babies at risk: more infants staying in neonatal intensive care units, more complications, more permanent damage and a higher death rate. Respiratory and digestive problems occur, and scientists are learning how early delivery can disrupt brain development.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.