The hard reality is that we live not in the world that recognizes health care and medical treatment as a human right – which is as it should be – but in the United States of America, a hyper-capitalist society governed no longer by its citizens and according to human needs, but by large private corporations whose sole interest is in profit. In such a society, everything – including human life (the conservative Right’s so-called “Culture of Life” notwithstanding) must have a price tag in order that someone higher up the economic food chain can profit and become even wealthier.
In human terms, this is an obscenity and a crime. Unfortunately, in the United States we do not think in such terms. Only the financial bottom line is important. Donald Dax is a cripple. He is blind, without hands, and suffers from disfigurement that will make it difficult for his to function in society. It can be argued that others with similar or even more challenging disabilities, such as former Georgia senator Max Cleland (a triple amputee) have gone on to survive, undergo rehabilitation and make significant contributions to society. However, there is one other element in the case of Mr.
Dax; he has expressed a desire to end his life rather than live in his present condition. If Mr. Dax himself had a strong desire to live, it would be the opinion of this office that the hospital should offer such treatment, regardless of cost, and use whatever legal means it has at its disposal as well as public opinion to force the greedy and corrupt insurer and party responsible for the patient’s injuries to cover these costs. However, the “right to die” is becoming more universally recognized; the states of Washington and Oregon have recently passed
9 legislation that has legalized doctor-assisted suicide. While our own state has yet to embrace such legislation, it is the considered opinion of this office that regardless of other issues, be they financial or otherwise, the wishes of the patient should be paramount. Legally, we cannot assist Mr. Dax in taking his own life, but as he wishes no further treatment, any resources available would be better served by making them available to patients who in fact do wish to survive. B. On The Wishes of the Mother
Mrs. Dax has expressed the desire that her son’s treatments continue. There is at this point no guarantee that his insurer will continue to cover payment, and the gas company whose pipelines exploded, causing Donald’s injuries, continue to deny any responsibility – meaning that the Dax family is in for a long, costly legal battle, should they choose to pursue such action. If Donald himself wished to continue living, it is certain that out of humanity, our institution would find ways of making this possible.
However, he has unequivocally stated that he finds his present existence unbearable and wishes to end it in the fastest, least painful way possible. While we respect and sympathize with his mother, the fact is that her son is legally an adult, of sound mind and thus capable of making his own decisions. In a society in which financial considerations a corporations’ need for profit far outweigh human needs – meaning that fighting for Donald’s human right to treatment would be an uphill battle – it makes little sense to expend such energy and resources on a patient who has no desire to live.
We are sorry for Mrs. Dax, but in light of financial realities combined with the patient’s own wish to die peacefully, we feel that the hospital’s resources would be better spent on patients who have a stronger wish to recover and live on. 10 C. On Surgeries to Restore Function and Appearance Assuming that Donald does wish to live and as is typical, the corporate entities responsible for his care and his injuries are able to escape responsibility – leaving the hospital (and ultimately, the taxpayer) responsible for his care, to what extent does our humanitarian obligation go?
If we are able to save is life, are we then responsible for making him a functional human being again, i. e. , rehabilitate him? In the hyper-capitalist, profit-driven society that the United States has become, it is not considered reasonable to think of people as potential “assets” or even “investments. ” Despite the hypocritical declarations about their “culture of life,” the extreme conservative government and the corporations to whom they are beholden consider people an “expense” and a “liability” – even dispensable.
This is a fact of life in the USA today. Human considerations aside, we believe this to be “false economy. ” If Donald is not rehabilitated and therefore unable to become a productive, contributing member of society, he will indeed become an expense and a liability. He will have to be supported by the taxpayers, while unable to do much more than eat and sleep. Donald suffers from grave injuries, but his higher brain functions are unaffected.
It is likely that given proper rehabilitation, Donald will be able to find a way to contribute to society as a productive, tax-paying citizen. We therefore believe that it is not only in Donald’s interest, but the interest of society as a whole, to see that he is given back as much function as is medically possible. Cosmetic restorative surgery is another matter. While in an ideal world we would like to go so far as to restore Donald to some semblance of a normal appearance, we must 11
acknowledge that in the face of a profit-driven system controlled by private corporations who have little concern for anything beyond next quarter’s P & L statement, our resources and ability to allocate care is limited, and triage is necessary to insure that the greatest amount of good can be done for the largest number of people under the circumstances. In short, if it comes down to a choice between Donald’s face and another person’s heart surgery, the choice is painfully obvious. D. On The Purchase of Organic Materials
One would hope that we never get to the point at which the poor are forced to sell their body parts to the rich in order to eat (as indeed was the case during the Middle Ages and in ancient Rome). Yet, despite laws against the practice, out dysfunctional economic system has already let American society down this path to an extent. But let us for a moment assume that Donald and/or his family have the resources to privately purchase the organic tissues he needs (such as skin for grafts, etc. ) in order to recover from his burn injuries.
Do we as medical professionals have a right to interfere with the actions of private and (hopefully) consenting individuals? It would seem that if he or his family were to do this, there is little we could do to prevent it other than to withhold treatment – and to do so under any circumstances would be wrong. We need not condone such behavior, nor should be go out of our way to enable it – but given the dysfunctional state of the U. S. health care “system,” it is not our place to judge, nor should we go too far out of our way in attempts to regulate such behavior. 12 E. On The Question of Age
At age twenty-six, Donald was prior to his tragic injuries, in the prime of life, with several productive decades ahead of him. As things stand, he still has a functioning mind and may yet become a productive member of society. Does this make him of greater value than someone aged sixty-six? If so, should the allocation of resources be based on this consideration? This is not a simple question. Even someone in their sixties may yet have productive years ahead of them, and from a strictly human perspective, why should someone much older be of less value and less deserving than someone who is young?
In fact, if anything it might be the opposite; a person in their sixties has experience and wisdom that comes only with having lived so long – and today, a healthy person in their sixties may look forward to twenty to forty more years. On the other hand, older bodies heal more slowly and take more time in doing so. If we are to simply look at it as an economic question as is the uniquely American fashion, it seems as though a younger, healthier person with years of potential productivity ahead of them should get priority when it comes to the allocation of resources.
If we look at it in terms of humanity, we should give priority to those in the greatest physical and medical need. The answer to this question is dependent upon whether or not we subscribe to the market principle of profit before all, or acknowledge the issue in a human way. F. On Cost-Effective Treatment In a profit-driven capitalist society such as the U. S. , seems imperative to “get the most bang for the buck” – in other words, to provide the most effective treatment for the least 13 expense. This is not simply a capitalist imperative – it’s a wise strategy.
Medical care needs to become more frugal in the traditional sense, which means to waste nothing. This does not mean “cutting corners” or using inferior equipment, medications, supplies, etc. It really means working efficiently, using resources in the most effective manner possible, and using up everything rather than discarding it. The second consideration is based on the principles of triage – determining who is likely to receive the greatest benefit for the least expenditures of time, energy and resources.
To use an extreme example, two patients – one with a long, yet relatively shallow knife cut, and the other with a deep puncture wound – may run the risk of infection, yet there is only enough antibiotic for one. Chances are that the first patient could do very well with simple soap and water followed by a sterile dressing. Yet a third consideration might be the effect on others. Consider the case of two patients, one of whom is a single male, the other a mother of three children. Both have sustained equally life-threatening injuries. Yet the former is alone, whereas the latter is responsible for the care of a family.
In such a case, we must consider which course of action will result in the greatest good for the largest number of persons. Finally, we must consider how a few resources expended today can save a large amount of resources tomorrow. One of the great weaknesses of the U. S. health care “system” (beyond the fact that it is a for-profit system) is that there is little focus on preventive care. There are numerous tragic stories of lab tests that were not provided due to cost considerations that resulted in a serious or fatal, yet preventable illness later on – an example of false economy at its worst.
14 G. On the Decision to Allocate Care If we assume that Donald has chosen to live (not a foregone conclusion), if the decision as to whether or not to provide treatment is left to accountants and business managers, Donald will surely die. That such decisions made by the proverbial “bean counters” are profit-driven cannot be overemphasized in light of the fact that more Americans die each year because of an economic inability to access health care care than have died in combat duties over the course of the present occupation.
That the physicians responsible for his treatment – those who have treated him, are familiar with his case and know best what must happen in order to restore him to some level of function – should have a major role in determining how medical resources should be allocated seems patently obvious. Ultimately however, the decision belongs to the patient. From a humane perspective, no-one – not the accountants in the business office nor the physicians – have a right to deny a patient care if they ask for it. However, Donald has repeatedly asked not to be treated, but rather allowed to die with some semblance of dignity.
Assuming that a patient is not a hypochondriac who suffers from Munchhausen’s Syndrome and is abusing the system (admittedly, there are a few such cases) and the physician has enough objectivity to know exactly what is required and what is best for the patient, the decision of treatment, what to use and how to use it, should be a decision that is made jointly between the patient and his/her physician. Again, this assumes that such decisions are made on a human basis and not on the basis of the “bottom line. ” 15
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