When we believe the lie that we can beat death, we end up with a do-everything system that is as illogical and it is expensive.
War metaphors can make us lose perspective on the battles we can win.
I’m beginning to detest the casual overuse of the war metaphor for every issue coming down the pike. There was Johnson’s “War on Poverty” – how did that work out? – followed by the government’s “War on Drugs,” in which we tied up a third of our penal budget and introduced the single largest source of corruption in our border patrols, city police and judicial system. Whenever you define any situation as “war,” you have decided it’s us against them, do or die, no retreat, no intelligent thought, just winning or losing.
You can imagine how pleased I was, in my libertarian mode, to read in the New York Times that a “war against disease” has been declared. No, really? We’re going to fight against cancer until they pry our cold, dead fingers from the bottles of chemotherapy biologics. It was another one of those human interest pieces describing a courageous fight by a 40-pack-a-year smoker against lung cancer. The author railed against the government for not spending more to conquer disease. And, horror of horrors, the victim was a veteran who had fought for his country. How could this country not invent a cure to save this brave fellow?
In the 175,000 years that homo sapiens have been around, why does it fall to our generation to cure all diseases? The guns and butter debate is really over, I guess. The new economic theory must be butter plus guns plus radiation therapy plus surgery plus chemotherapy . . . and damn the cost! How can we dare suggest any less when a life is at stake?
Be it known by all parties, I hereby declare a war on war metaphors. They really don’t fit. Worse than that, they give us a license to sensationalize, to produce television shows like The Night Shift. (I have previously reviewed this artistic disaster, so I won’t put you through my diatribe here.) Most situations we deal with are not on a second-by-second battlefield type crisis mode. The news media bring a false sense of immediacy and hope to every situation. The flashing lights and blaring sirens of a speeding ambulance are cultural theater not backed by scientific evidence. In fact there’s plenty of accident data suggesting that ambulances are the most devastating vehicles per highway mile.
If the young have now come to view themselves as at war with death, they have already lost. Death is as natural a process as birth. We know the end of the play. The cycle of life demands death. To be thinking in terms of defeating death is to deny the Seventh Seal. Bergman had our knight playing chess with the devil. The outcome was preordained.
This acrimonious disagreement on how medicine should function must at some point come to a head in either an intelligent assessment of evidence or in a true schism. Maybe there is a fork in the road. Maybe people will simply buy the healthcare plan that they like – one driven by data, expectation and an understanding of diminishing returns to the point of zero, the other a plan driven by do-all, spend-all, with CPR as our final handshake. Maybe the answer is tubes: feeding tubes, rectal tubes, tubes everywhere for everyone.
We need to dismantle the deeply-held idea that more is better. It doesn’t really matter what we’re talking about, from bombs to schools to jails. We believe as a people that if some is good, a lot has got to be great. This American ethos has been injected into the healthcare debate and has dominated thinking over the last five years. The Democrats think the federal government should buy healthcare: the more the better. The Republicans think that you should buy your healthcare: the more the better. Both of them are wrong. The debate should be about quality, not quantity. And above all, it should deal in reality.
Here’s a dose of reality. There is only a casual relationship between health and healthcare. Children who are without complaint do not benefit from yearly physicals by doctors. Forty-year-old generally healthy women with a negative history don’t need frequent mammograms. Fifty-year-old men with two negative EKGs and negative enzymes don’t benefit from stress tests. End of discussion.
Why do we promote healthcare at the expense of actual health? Because we don’t recognize our own conflicts of interest.
So now I’m going to break my own rule and use a war metaphor. Two thousand years ago, Lucan, when reviewing the procurements by the Roman army, commented: multi simulitus utili bellum. This loosely translates to: war is profitable for many. Today there are as many people getting rich off disease as dying from it. There is nothing new under the sun. And war profiteering has taken place since the Egyptian military hordes entered the Nubian Empire on the Nile. We have a strong tendency to interpret fairness in a way that will favor our interests, while sincerely believing that we are being impartial.
And I’m not just pointing the finger at Big Pharma. In the Second Book of Samuel, Nathan tells David a parable in which a rich man steals a poor man’s sole possession, a beloved lamb. Nathan waits until David has passed his stern judgment before revealing that “thou art the man.” The more-is-better philosophy with regard to healthcare has infiltrated our own ranks, and it has got to stop. It must be replaced with a doctrine of intelligent, planned intervention.
The second of the American truths that requires questioning is the belief that technology will solve everything. No, it won’t. Did the ultrasensitive troponins solve which patients have real heart disease? Did the rapid strep test really make the sore throat visit better than using clinical judgment? Does every risk really require a CT? The intelligent application of scientific breakthroughs is the key. And we don’t have a great track record in restraint. Before the ink was dry on two small journal articles on cooling for cerebral resuscitation in patients with return of spontaneous circulation, people were promoting “centers of excellence” for brain survival. The only brains which really needed resuscitation were the people who plunged headlong into this form of therapy on the basis of mediocre science. All change is not progress, and there needs to be a process to differentiate the two.
Lastly, we have turned to science as a sort of absolute final word authority, when the only real authority is the patient receiving the care. We have all been overly impressed with surrogate markers. Does a drug that drops an 80-year-old woman’s systolic blood pressure from 160 to 140 really make her patient better, live longer or have a more meaningful existence? I want real outcomes research. We thought lowering blood glucose to 90 would be a good thing. Not so fast. We proved we could treat their subdurals when they went hypoglycemic and fell. But did we change the outcome for the majority of patients? Not a bit. Before we go advocating change in the best practices and standards of care, we better be darn certain we are moving the ball down the field towards happier, healthier people.
Bella detesta matribus.
“Wars, the horror of mothers.”
Fear not, I have no grandiose illusions of the philosophical impact of this column. Journalism, as commented upon by David Bentley Hart, is the act of translating abysmal ignorance into execrable prose.
I hope to stir a thought, and perhaps spark a smile. One reader complained that I was “in desperate need of focus and editing.” He may be quite right. I shall close with one final thought, a rambling remembrance, to prove my critic correct. I was privileged a few months ago to write a tribute following the death of my high school English teacher who I dearly loved and with whom I’d remained in contact. In 1961, he took a kid from an immigrant household and opened the world of literature to him. I was from a working class people. There wasn’t a sophisticated bone in my body. I thought that “Rhine” wine was made from the husks of watermelon. I finished drywall, built cabinets, wired houses and fixed plumbing. This man gave me a paperback copy of “A Pocketbook Of Modern Verse,” and my life was never the same.
For the four years of high school, we traded jazz records, complex puns, and enjoyed a mutual love of great writing. That worn paperback sits before me as I write this piece; pages yellow, cover torn, binding taped. I treasure that book as much as any physical thing I own. It’s unexplainable how much of a sense of continuity and pleasure I get from turning its pages. I have oft- times quoted from it in this column. I would share with you the final Shakespearean words I used in his tribute: “Goodnight, sweet prince, and may flights of angels sing thee to thy rest.” We really never know where small acts of kindness may change another person’s life. He certainly changed mine.
“sit tibi terra levis”
May the earth rest lightly on you
Well, I enjoy your writing style. Your pieces are both entertaining and logical. Your metaphors are always spot on! Unfortunately, your pie-in-the-sky dream of basing our tests and treatment on actual life-altering outcomes will likely never happen in our entitled and litigious society; you can’t deny that as a powerful driver for this type of practice. But I agree with you none the less!