The Washington Post had an article discussing the problem of “saying no” to limit health care.

I have no problem saying no to a yuppie for his third arthroscopic surgery on his knee so he can jog, or saying no to pay for teeth or nose straightening for cosmetic reasons.

But one suspects what they mean is deciding not to dialyzed grandmom (age 70, estimated, lifespan five years) if she is a poor Lakota Indian with end stage diabetic kidney disease, but paying for a kidney transplant for a rich Washington insider (age 62 estimated lifespan 15 years).

If you don’t think that this type of rationing will cause societal problems you are living in CloudCukooland, because most poor people will see such a decision as a race based decision, not one based on the “quality-years adjusted life”.

“QYAL” is a measurment beloved of health care planners.

The Euro QOL questionaire is one version of the idea, and if you download it, you see it is an estimate to see if you are independent or dependent on others.

So of course, our Lakota grandmother on dialysis might also have other problems, such as a foot amputation from end stage diabetes. She can’t walk or care for herself so her “quality of life” index measure low, whereas the rich slightly younger affluent woman, who could afford a decent diet, going to the gym, and frequent clinic visits would rate high.

Yet the Lakota grandmother might be the one who is holding the family together, and providing a lot of the emotional support for the children and grandchildren who live in her house.

Another problem with healthcare rationing is something called the “futility index”. This means not doing extraordinary care if the physician decides the treatment is “futile”. Right now, most of these cases are about intensive care, and ethically delicate. I’ve advised a lot of families to stop prolonging dying many times. And I’ve advised “intermediate” care of an elderly person: treat them in a quite room with family there, not in a noisy ICU.The danger is when someone decides against ordinary treatment to save a life to save money.

In the article, they note reformers were “spooked” by the thought that they might be accused of not doing a hip replacement on an 80 year old.

Well, they should be “spooked”. One “example” that some stories discussing health care rationing bring up is that of President Obama’s grandmother, who broke her hip although she suffered from cancer.

They operated, and she died of complications, but some stories hint that in the future the “alternative” would have been to let her die.

Reality check, please.

My mom had her hip pinned while dying of cancer, and although she was very ill for ten days, she ultimately she went home and was able to live in her apartment for another six months. Theoretically, the President’s Grandmother could have similarly lived comfortably for months if she had lived.

But the “choice” is not between a quick death and expensive surgery, because the dirty little secret is that people don’t die quickly.

I’ve treated two patients for hip fractures with “conservative” treatment (they had osteoporosis and their bones couldn’t take a pin/replacement) : both survived, with good nursing care, adequate pain relief, and aggressive prevention of bedsores.

Similarly, here in the Philippines, a distant cousin broke his hip and was not a candidate for replacement. So once the fracture had “stabilized” (about a month) he was sent home on bedrest. The extended family managed to give him the 24 hour care that he needed, but after a few months of misery he died of sepsis: either from bedsores or urinary infection.
In short, it was a miserable “quality of life”, and one cannot see a small American family being able to find enough relatives to do round the clock nursing that he would require.

So in the US, refusing Grandmom a hip replacement would mean a nursing home.

I am not up to date on costs, but I suspect six months of hospital and nursing home care would be almost as much as hip surgery: but with hip surgery, the patient has a fifty fifty chance of walking again, versus never walking again after it heals by itself.

Of course, the way medical ethics is going, what will probably happen is that a family’s “non treatment” decision would have meant high doses of pain medicine, a variation on “terminal sedation”, where you keep a person pain free but nearly unconscious. IF they are terminal, this might mean without giving nutrition.

But even then, if the physician is not trying to kill but keep her pain free, she just might continue to live, and once the fracture starts to heal, she might just wake up and ask for food or water.

You see where this is all leading.

The danger is that fixing a fracture will be denied as “futile care”, and once you decide not to treat with surgery, you interpret this an not treating at all…or even that the person is terminal, so why not just help her along a bit.

Which is why most pro life physicians are afraid of trends in the Obama administration: removing job protection from those refusing to give certain “care” to patients, or now removing the President’s Bioethics Council six month prematurely.

In the words of the president’s old friend from Chicago: You don’t need a weatherman to see which way the wind is blowing.

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Nancy Reyes is a retired physician living in the rural Philippines. She has written on medical ethics in the past.

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