« Georgia: a very, very Christian state
The Long, Hot (and Ridiculous) Summer Days of Presidential Politics »



Debating Kennedy’s Life-and-Death Decision

July 13th, 2008
By ROBERT STEIN

Print Print

His dramatic return this week to cast the deciding vote for a crucial Medicare bill brought tears and cheers in the US Senate, even as some medical ethicists question Ted Kennedy’s decision to undergo life-prolonging (and expensive) surgery, chemotherapy and radiation.

On the New York Times Freakonomics blog, an internist involved in public health issues suggests Sen. Kennedy might have issued this statement instead:

“Because I am not a young man, the cancer in my brain will progress rapidly and is likely to incapacitate me in the near future. I trust that my doctors will do everything they can to prevent further seizures and to keep me in comfort. I will not endure extraordinary excess pain and suffering, while hundreds of thousand of dollars will not be spent on surgical debulking, radiation, and chemotherapeutic regimens which do not work.

“Modern medicine cannot cure my cancer, but it can keep me comfortable and free of pain. I have already contacted the Massachusetts General Hospital Hospice program.”

If such a suggestion seems heartless, it nonetheless reflects a crucial debate that has started about end-of-life care, which accounts for a significant percentage of Medicare expenditures.

Read the rest of this entry.



This entry was posted on Sunday, July 13th, 2008 at 8:47 am and is filed under Death, Senate, Disease, Ted Kennedy, Leadership, Life, Medicine, Legislation, Society, Health, Health Care, Politics. You can leave a response, or trackback from your own site.

Viewing 13 Comments

    • ^
    • v
    From what I was reading about the current state of treating this cancer the internist isn't quite right, depending on the details of the individual case. Since the statement is based on generalities that they can't know about Kennedy's case I don't think I'd say that he should be "doing a Frist".
    • ^
    • v
    End of life, as well of beginning of life issues are driven by new technologies these days, without hardly anyone stopping to consider towards what hey're driving us. I've tried to start a conversation about it in several venues, but the subject seems to create so much anxiety that most people can't talk about it without personalizing it or referring to religious, unquestioned tenets.

    Yet, as the world population increases at a time when the sustainability of life on this planet is becoming one of crucial concern, i think life and death issues must be talked about.

    i am delighted, therefore, to see this modest beginning of a conversation.
    It's an extremely complicated topic, and I'm clear about it only as it pertians to me., personally. How to go from that to a general policy position is a much more difficult intellectual undertaking.

    In trying to address the topic, I'm very frustrated by the circumstance that we have laws in place deciding many of the questions that arise long before we've had the necessary discussions and debates. We've put the cart before the horse,

    I'm struck with the parallels to how the availablity of pharmaceuticals has driven our expectations about life in general. Way beyond the elimination of extreme pain and sufffering, we have come to rely on chemicals to shield us from the tiniest of discomforts, both physical and psychological. It's almost as if we want to live without really living. If perfect contentment is the goal, how will we recognize it without the contrast of discontent.?

    Similarly, technologies are extending possible life spans to the point where it seems we are searching for eternal life. Without death, what will be the meaning of 'life'?

    I agree to the observation that Kennedy's crucial vote demonstrated the value of a life. I'm not sure, though, how that can be extended as an across-the-board principle. How are we to judge whose life is worth extending?
    • ^
    • v
    I can only question Robert Stein's sanity for risking opening this debate in the wake of yesterday's gleeful meltdown of happiness...across the Left blogosphere...at Snow's death from cancer.

    However, I find the absence of gleeful chortlings from conservative commenters about Kennedys imminent demise testimony to conservative decency.

    That said, Stein raises an important issue. Personally, I feel the internist is a hypocrite. I suspect, were he/she in Kennedy's shoes, they would not take a dispassionate view of saving resources for the system as a whole . . . but would do everything possible to stay alive rather than just conceding defeat and giving up.

    I have a personal view of this, given my mother's death from cancer last year. I know I jiggered the system, used legal threats and everything at my disposal to ensure she lived as long, and as comfortably, as possible. It only amounted to a few more months of life for her, but I am glad I did it.

    As Stein points out, in a system of finite resources, devoting considerable resources to likely terminal cases is wasteful. However, this is also a very human response.

    I am not a supporter of Kennedy, but I respect his record (note, for example, the emphasis Kennedy placed on public health care in his amazing "the hope will never die" speech at the 1980 Democratic convention). I believe he will do everything possible to extend his life . . . and why should he not?!

    The internist's snark is, I submit, cold and inhumane.
    • ^
    • v
    Runasim. . . your discussion of the issues involved here is excellent!

    I point particularly to your last sentence: "How are we to judge whose life is worth extending?"

    Yes, is that not one of the real questions here? At the risk of politicizing the question: this goes to the need for health care reform in the U.S.

    The U.S. spends more than anyone else on health care per capita, with a disproportionate expenditure on a few. The system is extraoridinarily economically inefficient. . . to say nothing of immoral (IMO).

    While I like McCain, I find his "Do Nothing" approach to health care policy very troubling. I was, correspondingly, interested to hear the Obama campaign making sounds about expanding the Obama plan for health care.
    • ^
    • v
    just a two cent's worth: just speaking as a former chair of the Colo State Grievance Board for many years, I think the internist, who is not an oncologist, not a brain surgeon, has a right to his opinion, certainly as a person, just the average Joe.

    He also would likely be within ethical guidelines were he to speak as a specialist in internal medicine.

    However, a doc from another specialty, commenting 'as a clinician' as though he has intimate knowledge not only about Sen Kennedy's diagnosis, interventions and prognosis but as though being an internist carries the same weight as being a brain and oncology specialist does not put such a clinician at the cutting edge in the latter highly complex specialty.

    Just to mention, every day I receive, 3x a day, an email of requests for physicians and shrinks from various in media (this comes from a clearinghouse, I think) asking for quotes on numberous subjects.

    The internist may have been caught up in replying to one of those solicitations for quotes, or may be an aquaintance of the author/ journo.

    Also, as the internist knows FULL well, end of life decisions are more precious and more to be protected and not bandied about publicaly for gain in any way, and hold a sanctified place more than most any other affliction-decision other than removal of limbs or critical body parts, which also merit huge privacy in terms of the grief alone of family members and often the patient as well.

    Just my two cents worth, respect for those who are dying faster than the rest of us, is part of the principle of ethics amongst physicians. There's a reason. .. to not make a mockery or a circus out of something that is already, in several ways, unbearable

    dr.e
    • ^
    • v
    runasim and Marlowecan: I agree with you comments and especially this from runasim, "I agree to the observation that Kennedy's crucial vote demonstrated the value of a life. I'm not sure, though, how that can be extended as an across-the-board principle. How are we to judge whose life is worth extending?"

    Kennedy and everyone else should have the right to make the decisions that they feel are in their best interests. Whether the insurance companies will actually pay for treatment which they feel would not be beneficial to the patient is the million dollar question. Kennedy may have financial resources that many people don't, but if someone with few financial resources wants expensive treatment, then they should receive it...

    Marlowecan, on your mother's death: I'm sorry to hear that. But good for you that you and she fought to keep her alive as long as possible. We should never give up on life. When we're ready to die, we will go and hopefully we will be at peace with our decision.
    • ^
    • v
    Marlowecan,
    This is too important for me to go the Dem vs Rep route.

    The corollary question to "How are we to judge whose life is worth extending?" is, however, "How many lives can we afford to extend?"
    We can't escape paying the bills, no matter how morally pure the intent.

    Given that resources are limited, there is a danger of overspending on extending life and, consequently, underspending on maintaining life.for those needing less drastic and expesive care.

    Babies born prematurely can now be saved at increasingly earlier stages of gestaton. Lives are saved. On the other hand, premies often require extensive ongoing medical investment due to developmental complications. Does health care for full term babies suffer as a result?
    Budgets are finite. Adding to one item, means subtracting from another.

    I'm not advocating for any final answer. i am advocating for a more pragmatic and less heads-in-the-clouds discusssion.
    • ^
    • v
    Archangel,

    I appreciate very much the sentiments in your comment.

    I am also troubled by them. When you talk about the 'sanctitified place'' end of life decisions should hold, I agree in the sense that they should not be used for political advantage. i don't agree in the sense that making any topic sancified implies taking it off the table for discussion.

    The internist's qualifications are not at issue here. Raising an important question for medical experts, social philosophers and all thoughtful citizens to consider is what is important. Sometomes from the mouths of babes.....
    • ^
    • v
    Dr. E makes a good point re: the internist.

    The media have one interest, and often find quotes to justify that from public figures. God knows, there are numerous examples of out of context or dubious quotes.

    Still, I believe ... as with StockboySF...that most people would pursue the route of Kennedy in such a situation. I would never question someone's determination to live.

    Runasim: "Adding to one item, means subtracting from another. . . . i am advocating for a more pragmatic and less heads-in-the-clouds discusssion."

    But then, how do we make these measures?

    I am not just speaking of access to medical care. Sadly, even in highly regulated public system, studies have documented how celebrities, the rich, and connected are able to jump the line.

    That is a pragmatic approach, but I find it morally troubling.

    I confess to some uncertainty about my own conduct in this regard . . . though I would do it all over again in a heartbeat.

    I suppose my belief is to ensure the best care for all. I don't really have any answer for the specific care under what circumstances.

    Do we give Donald Trump a free pass to the head of the line, while StockBoySF or Jim Satterfield must wait their turns? Certainly that is the system now.

    BTW: There is an excellent essay by George Orwell sort of on this topic: "Benefit of Clergy: Some Notes on Salvador Dali". Orwell notes that Dali was certainly crazy...and probably often dangerous. He discusses the relative merits of geniuses and celebrities, even when they are evil, and why (and if) they be given the modern equivalent of the medieval "benefit of clergy"...given a free pass in life.