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The Left Atrium
Contents
• Cost and effect [PDF] • One thousand words [PDF] • The end of the other [PDF] • The gaze of history [PDF] Cost and effect
Pricing life: Why it's time for health care rationing Peter Ubel, a general internist who has published extensively on ethics, equity and medical decision-making, has written a book on health care rationing that deserves to be widely read and discussed among health care decision-makers at all levels and by health care providers in particular. Well-argued and written in an accessible style, Pricing Life is peppered with concrete clinical examples. Ubel's discussion integrates a wide-ranging literature in economics, ethics and medicine, and directly confronts an issue central to the future of health care. Ubel also strives to be explicit with respect to both his argument and its implications, forgoing the temptation to hide behind euphemisms, hidden assumptions and rhetorical tricks to make his conclusions more palatable. Although Ubel recognizes (and gives due weight to) the numerous caveats, qualifications and subtleties that inevitably surround discussions of rationing, the essence of his argument is straightforward. First, the increasing cost of health care makes rationing necessary; second, bedside rationing by clinicians is an essential element of any effective approach to health care rationing; and, third, cost-effectiveness information should be an integral part of rationing decisions. The book begins with a discussion of alternative notions of what constitutes health care rationing. Because a great many ambiguities are inherent in concepts central to most definitions of rationing (e.g., appropriateness, scarcity), Ubel settles on a broad definition: "health care rationing includes any implicit or explicit mechanisms that allow people to go without beneficial services." He then argues that the following conditions are necessary for a clinical decision to represent bedside rationing. The clinician must (1) withhold, withdraw, or fail to recommend a service that, in the clinician's best judgement, is in the patient's best medical interest; (2) act primarily to promote the financial interest of someone other than the patient, including an organization, society at large, or the clinician himself or herself; (3) have control over the use of the medically beneficial service. This conception of bedside rationing — in which a clinician consciously withholds, due to a financial consideration, an intervention that can reasonably be expected to provide positive (even if small) medical benefit to the patient — is crucial to Ubel's larger purpose, which is to explicitly challenge the ethic that the physician has an absolute obligation to do only what is best for the individual patient. He argues, instead, that not only is it acceptable to allow considerations of others to influence the pursuit of a patient's best interest (as physicians commonly do, for instance, when considering issues of community resistance in choosing antibiotics for a patient), it is acceptable to do so out of consideration of costs borne by others. Specifically, it is acceptable for clinicians to withhold a service when the benefits to the patient do not justify the costs. How do we know when such instances arise? Cost-effectiveness information, he argues, should play an important (but not exclusive) role in guiding such decisions. Why is bedside rationing (as opposed to rationing solely through higher-level managerial and allocation policies) essential? It is because of the nature of health care services and the distribution of information in the health care system. Very few services are either totally ineffective or effective in all instances, and so rationing through all-or-nothing coverage rules is too blunt an instrument. An effective system of rationing on the basis of health care need requires that each service be provided when it is effective (and in some sense cost-effective) and not provided when it is not effective. The information required to make such a judgement, however, emerges only during the clinical encounter. Hence, such rationing decisions must ultimately be made "at the bedside." Ubel's argument poses a broader challenge to the traditional medical imperative that physicians have an absolute obligation solely to their patients. Unlike the period during which the traditional ethic was developed (in which clinicians had only a small number of low-cost interventions to offer), modern health care is expensive and the required systems of finance create complex interdependencies among members of society (even those that rely primarily on private finance). Physicians can therefore no longer focus solely on their role as the patient's agent. Rather, they are unavoidably in a position of dual agency: agents for their patients and agents on behalf of society in allocating health care resources. I concur with Ubel on this fundamental point and with many particular elements of his analysis. There are two areas, however, where I differ on the strength of his conclusions (our differences are more of emphasis than opposition). The first relates to the role of higher-level guidelines and policies that set the context for the practice of individual clinicians. Ubel is right that they do not avoid the need for clinicians to practise bedside rationing, but — for three reasons — I give them more value than Ubel does. First, assuming that physicians participate in their development, creating such guidelines (at any level — a practice, a medical unit, a hospital) provides an opportunity for physicians to exercise their social-agency obligation outside the patient encounter, allowing physicians to discharge their sometimes conflicting dual-agency roles in distinct settings. Second, by setting a context for individual practice, guidelines and related protocols can make tough bedside decisions easier by providing the physician an external reference standard for the decision. Lastly, the process of developing such higher-level guidelines can foster a greater awareness of the central issues we confront. The second point relates to the role of cost-effectiveness analysis. Ubel presents an excellent, balanced discussion of cost-effectiveness analysis, its strengths and its weaknesses. Yet, in the end, he has more faith in its usefulness than I do. Even if we develop better ways to measure health benefits and to incorporate equity concerns and other community values, the nature of the information generated by cost-effectiveness analysis is such that at best it can serve as a rough guide. Useful, yes — but more limited, in my view, than Ubel believes. Regardless of whether you agree with Ubel's argument and conclusions, this book will challenge and teach you much.
Jeremiah Hurley Contents
• Cost and effect [PDF] • One thousand words [PDF] • The end of the other [PDF] • The gaze of history [PDF] One thousand words
Contents
• Cost and effect [PDF] • One thousand words [PDF] • The end of the other [PDF] • The gaze of history [PDF] Room for a view The end of the other
"Humanity does not have a long fuse and this
The postulate of the death instinct has not endured. It flies in the face of intuitive knowledge that our basic instincts are always in the service of survival. Yet humanity, on a number of fronts, appears to be heading for its own extinction. Are we, as a species, realizing Freud's prediction? Do we, as a species, have a death wish?
We are first fed by blood. It flows from our mothers, whose nutrients become ours. We are, in a physical sense, connected. In birth, the cord is broken and we must find connection again to survive. So blood becomes milk. But whoever or whatever thwarts our hunger evokes a desperate rage. On the substrate of these biological imperatives rest the social constructs of connection, competition and control. These are the generic forms of motivation that drive all human activity. The alchemy of human culture and civilization transforms them from their biological roots into their social manifestations. Milk in this world becomes, among other things, money. Yet, at some level, the dictates of survival persist: the pleasure of being fed, and the aggression that results from the fear that we won't be. Paradoxically, the instinct to survive has brought our species to the brink of self-extermination.
The paradox stems from the separation of self and other. Identity exists at the level of the individual — you and me — or of the group — them and us. An individual or group against whom we are competing is not us. They are foreign, alien, other. For a group to survive and thrive, it must somehow resolve or contain the competitive strains within itself; in that sense, it must overcome its own biology or else self-destruct. But no such limitation applies to the other — to them. In the vigilantism of war, either we kill them or they will kill us.
The surrounding environment is also other. The process of civilization attempts to control the physical world and the other species for our own uses. Thus, the human race has grown more and more to see itself as separate from the surrounding natural world rather than as a part of it.
With the proliferation of annihilating weaponry and ever-increasing environmental degradation we have reached the edge of the other. The weapons that defeat our enemies also destroy us. Victory now equals defeat. Taming nature has become destroying it. Competition and control are no longer an adaptive means of survival but rather, if unrestrained, a potential means of collective suicide.
By far our most pressing common concern is surviving our aggregate selves. In this predicament, self and other collapse. No nation is safe unless all are safe. The natural world, if not provided for, will not provide for us.
We have arrived, unintentionally, at Thanatos, not by a drive to die but by a wish to live. We have arrived here by striving for what we hoped would ensure and benefit the survival of ourselves and our peoples.
In the full reality of competition and control the self is inextricably intertwined with, rather than separate from, the other. It is an illusion that we can eradicate our enemies or ransack the earth with impunity. This is a lesson that challenges the biological legacy of our innate brutish survival instincts. It is one that we learn, forget and must keep relearning as our increasingly complex and interconnected societies encroach more and more on the planet. At the dawn of the 21st century, we have reached the point where every individual fate is tied directly and vitally to the greater group of all humanity and the larger sphere of the entire natural world.
We are at the end of the other. The last frontier — ourselves.
Mark Leith Contents
• Cost and effect [PDF] • One thousand words [PDF] • The end of the other [PDF] • The gaze of history [PDF] Room for a view The gaze of history William Butler Yeats (1865–1939), poet, playwright, Irish nationalist, theosophist, Nobel Prize winner and sometime fascist, wrote one of the most frightening poems in the English language when he composed "The Second Coming."1 Here is the first of two stanzas:
Turning and turning in the widening gyre
Yeats had discovered, four days after his wedding in 1917, that his bride had a gift for automatic writing. Her ostensibly involuntary scribbling provided material for Yeats' mystical text, A Vision (1925), in which he constructed an arcane schematization of human history. Historical eras waxed and waned like phases of the moon; human events played themselves out in catastrophic cycles lasting 2000 years. Yeats represented the tension between successive eras and the next as two interpenetrating cones, or gyres. At the apex of each gyre a new civilization, antithetical to the last, sprang up from a well of irrationality; it played itself out in a weakening spiral, ending in decadence and dissolution. "Each age," he wrote, "unwinds the threads another age has wound."
"The Second Coming" invokes the unravelling of the Christian era, or, on a more local scale, the birth pangs of Irish independence. The sleeping sphinx stirs; revolution is imminent, waiting for a concentrated moment of conviction.
Surely some revelation is at hand;
Despite his fascination with the gyrations of history, and his two terms as a senator of the Irish Free State, Yeats lamented the loss of civility and grace that resulted from political struggle. Repulsed by the waste and brutality of violence he was, nonetheless, fascinated by its transformative power.
The fascist undertone of Yeats' aestheticized politics, his deterministic view of history and the maddening nonsense of his fabricated occultism became too much for me in the strained hours of a night spent cramming for a graduate exam in modern poetry. I never read Yeats after that, until the terrorist attacks on New York and Washington drove me to the comfortless harbour of this poem.
Indisputably, Yeats had a gift for carving out a perfect, harrowing phrase. "A gaze blank and pitiless as the sun." Blank and pitiless is the gaze of the terrorist.
So, too, is the gaze of vengeance.
Anne Marie Todkill Reference
Copyright 2001 Canadian Medical Association or its licensors |
Freud theorized that the duality of human nature sprang from two instincts: Eros and Thanatos. He saw Eros, the life instinct, as love and sexuality in the broadest sense and Thanatos, the death instinct, as aggression. For Freud, Thanatos, also termed the death wish, was grounded in the law of entropy — that is, the tendency of all systems to eventually reach their lowest level of energy. Eros is the drive toward attraction and reproduction; Thanatos, the drive toward repulsion and destruction. The former leads to multiplication of the species; the latter, to its elimination. Freud saw the two instincts as being in a constant dynamic tension with each other.
It was January 1919. Yeats had on his mind, among other things, the Great War, the Bolshevik Revolution and the Easter Rising of 1916, a failed revolt of Irish nationalists against English rule.