End of Days: A Guest Post

We recently featured a Q&A with Julie Salamon, author of Hospital, and last week Julie wrote her first guest post for us. Here is her second. It touches on a subject of great interest to me, something we hope to address empirically in future writing: the cost/benefit dilemma of end-of-life medical care.

End of Days
A Guest Post
by Julie Salamon

The law of diminishing returns is hard to accept when confronted with our own mortality.

When Teddy Kennedy was diagnosed with malignant brain cancer a few weeks ago, the senator who championed universal health care opted for the rarest and most expensive treatment — surgery followed by radiation and chemotherapy. But with or without surgery, the prognosis for patients with glioblastoma like Kennedy’s is poor, with an 18-month survival rate for those over 60 less than 10 percent.

Kennedy’s decision reminded me of Susan Sontag‘s terrible last days. Her son David Rieff recalled the moment when physicians told Sontag, then 71, that a bone-marrow transplant had failed and her virulent leukemia had returned. In the New York Times Magazine article that became a book, Rieff described his mother’s reaction. “She screamed out, ‘But this means I’m going to die!”

Sontag was shocked even though she had been told survival rates for myelodysplastic syndrome, or M.D.S., were slim — 20 percent across generations and much worse for someone of Sontag’s age, who had already survived two previous cancers.

Yet she chose to endure gruesome treatment (which her insurance didn’t cover) at her own expense — at least $300,000.

Robert Cohen, a New York City internist involved in public health issues, told me he wished Teddy Kennedy had issued this statement instead of opting for surgery:

“Because I am not a young man, the cancer in my brain will progress rapidly and is likely to incapacitate me in the near future. I trust that my doctors will do everything they can to prevent further seizures and to keep me in comfort. I will not endure extraordinary excess pain and suffering, while hundreds of thousand of dollars will not be spent on surgical debulking, radiation, and chemotherapeutic regimens which do not work.

Modern medicine cannot cure my cancer, but it can keep me comfortable and free of pain. I have already contacted the Massachusetts General Hospital Hospice program.”

Dr. Cohen added, “I’m not suggesting that Kennedy has an obligation to choose hospice rather than therapy, but I do think it would be very reasonable for him not to adopt the false ‘struggle against cancer’ model.”

Dr. Michael Salcman, former chairman of neurosurgery at the University of Maryland School of Medicine (and for full disclosure, my step-brother), had a different view:

“It is true that we spend most of our health care dollars in the last 6 months of life, but who or what is to tell a relatively intact, feisty, willing-to-fight, rich person that he is supposed to simply go into hospice in a free capitalist country like ours.”

The choice, he argues, is a philosophic debate between two competing visions.

“… an individual’s right to his personal freedom of choice and life (in the logical extreme, the freedom of the American frontier) vs. society’s right to limit the economic damage from such choices and life-styles (in the logical extreme, socialism). As usual, Aristotle is correct when he says that the true answer to most problems is somewhere near the mean.”

What is the appropriate cost/benefit analysis — financial, medical, and emotional — to apply to the ebb tide of life?