Difficult Decisions – Ethical and Economic Dilemmas

I have not and will not make a habit of writing about my "other" job, the one in medicine, the one that pays most of my bills, but I recently took part in a case that gave me plenty of food for thought and which I must write about. The salient part of the case is not the medical detail, although that was interesting from that point of view as it was the first of its kind that I have seen in 27 years of studying and practicing medicine. No, the salient part is the ethical and social part, the part that involves very difficult discussion and even more difficult decision making.

The patient was an elderly woman in her late eighties, of sound mind, who suddenly developed excruciating pain and leg weakness that was felt to be due to an extremely rare and potentially devastating problem known as a spontaneous spinal epidural hematoma (blood clot overlying the spinal cord), which if not treated promptly can lead to paralysis and/or other significant problems. Not a problem that fixes itself, the only chance the patient had for recovery was an operation, although, for a woman in her late eighties with additional medical problems (who doesn't at that age?), the result of the operation would more than likely be as bad as or possibly worse than the the original problem. The patient, who stated that "she could not live like this," faced what was essentially an impossible decision. The risks and likely outcomes were explained to the patient and her family as well as the surgeon and I possibly could. She asked me what I would do, a question that not being in her position, I could not honestly know or answer. The decision was ultimately made by the patient and her family to face surgery, through which the patient fared as well as could have been hoped for. However, her road to recovery at best, will be a long one, likely filled with considerable pain, through which she may or may not survive.

The reality is that despite the likely difficult post-operative course and the mind-numbing costs associated with that, it was highly unlikely that any other decision, such as one to not undergo surgery and go ahead with comfort care only, would be made or could or should have been made given the circumstances. Even with comfort care, the patient would likely have continued to suffer, all the while she and her family wondering if they made the right decision, with the family in particular likely feeling guilt at not having taken the only course offering some, albeit small, "hope." Meanwhile with the surgery, even with a poor outcome, all can feel that they at least "tried." Should the procedure be somewhat successful adding some additional time and possibly even quality to the patient's lifespan so much the better.

Two questions follow. First, can we continue to afford offering options like this to people with only the most remote hope for recovery or quality of life improvement and at that only for what is likely to be at best a very brief time, at extremely considerable cost? Second and more importantly, is it fair to force people to choose, when the only real option one can choose is not necessarily the truly best option for either the patient or society? Is it fair or reasonable  to even put the decision in the hands of the physician or team of physicians, where to some degree it still resides? I don't relish the idea of playing God, and as with the case cited, I can not put myself directly in any patient's position. One obvious solution is to have society draw lines as they do in Great Britain and other countries. Beyond a certain age, one can not receive certain treatments such as, for example, renal dialysis.

Of course, any one can think of exceptions to the rule. A famous case that raised similar issues was that of Dr. Michael DeBakey, the legendary cardio-vascular surgeon, who at the age of 97 was faced with a high risk, but potentially life saving surgery that he himself had devised. One of the dilemmas was that at the time of his ordeal, he had delayed entering the hospital even though he was fully aware of what was happening, then became unresponsive and unable to make further decisions for himself. Despite a prior directive of his forbidding surgery and the fact that no-one his age had previously undergone this surgery, his wife and his surgical colleagues wanted to press on. The anesthesiologists at his hospital refused (please refer to this NY Times article for the detailed story and further discussion) to participate on ethical grounds. To make a long story short, the surgeons brought in other anesthesiologists, performed the surgery and the patient survived and recovered to a very functional level before passing away this past July 12th at the age of 99. In this case, the patient recovered and proved that a person his age could undergo and survive surgery like that with a reasonable recovery. Of course, his care was well above and beyond typical care, extremely costly and likely would have been afforded to or by few others due to that cost, which returns us to the question: can our society afford, especially in today's spiraling health care cost environment and rapidly deteriorating and extremely shaky economy, to continue to allow people to make expensive decisions that in reality they have little choice but to make when given the opportunity? While everyone seems to focus on the day to day costs of health care it is scenarios like these that are the real source of the economic problems that have placed our entire health care system on the brink of collapse. As much as it goes against the grain of our society to not be able to offer everything to everyone at all times, I am afraid that it is up to society to make these difficult decisions. Without this, I fear for the ultimate demise of our entire health care system and more.

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5 Responses to Difficult Decisions – Ethical and Economic Dilemmas

  1. Gerald Erchak says:

    I have read that we spend something like 50% of our health care budget on the last 2 months of life. The woman you discuss should have been given morphine (preferable, heroin were it legal) and made as comfortable as possible, but nothing more. Our “heroic” responses to elderly problems such as this should be curtailed.

  2. Marco says:

    Interesting quandry. I have to agree with Gerald. Provide the person with enough palliative drugs to relieve the pain.

  3. John Sconzo says:

    Gerald is on target with the financial numbers though I think the percentage may actually be higher. Palliation, Marco, is certainly the alternative, albeit an imperfect one as it can be difficult to fully take away someone’s pain without actually causing their death (that is a whole ‘nother discussion!).
    An addendum to the specific situation. The patient had surgery and got through it quite well. Post-operatively, the patient was much improved symptomatically, however, a few days later, the patient developed a pulmonary embolism (blood clot to the lung) and died. In retrospect, the surgery was a success, even though the patient died several days later. The patient’s was lucid and feeling much better. One of the problems with surgery for such a serious condition at an advanced age is a greater propensity for serious complications such as a pulmonary embolism though that could happen to anyone. In some respects, this may have been the most reasonable outcome for the patient and the patient’s family. They were able to feel good that the patient’s original, horrific problem had been dealt with, the recovery had been progressing well and the death was relatively quick and painless without having to go through the long and difficult period of rehab.
    Unfortunately, it is because of outcomes like this, that the ethical aspects are so murky and difficult.

  4. Jamie says:

    The dilemma for us as a society starts with the fact that, because of medical advances, we are living longer and longer, able to sustain life under so many situations which, in past times, surely would have lead to an early death. How long and in what ways can we honorably keep people alive? And, if so, what are our responsibilites to the elderly and ill that, thanks to medicine, are living longer? We have come to the point where we are forced to make these kind of decisions which never existed before. We decide that we want to live forever, but under what circumstances, under what conditions? And who, ultimately, is responsible for deciding that old enough or sick enough is enough? No argument coming from me, just questions that whirl around in my mind and in my livingroom from time to time.(ps my sister is a doctor specializing in geriatrics).

  5. John Sconzo says:

    You are absolutely correct, Jamie. The reason we even have dilemmas like this today is because we have become better at simply keeping people alive. Twenty or thirty years ago, a situation like this would never have been an issue. Now we have very elderly and very sick people coming in for elective surgery that would previously been unthinkable. The vast majority of these cases don’t present great ethical conundrums. These tend to fall to the medically urgent or emergent cases like the one discussed. In the end it will, of course, come down to money. What can our society afford without totally self-distructing?

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