August 07, 2007

Putting the Brakes on Technology

In a dramatic twist of fate, one of the world’s premier heart surgeons recently underwent cardiac surgery utilizing a technique he had devised, at the hospital where he had practiced. What gave the story added interest was that the surgeon, Dr. Michael DeBakey, was 97 years old at the time of the operation, and it was carried out against his express wishes.

As is recommended for all patients, Dr. DeBakey had an advance directive: he had stated, while in good health, what approach to medical care he would want if he became ill and was unable to speak for himself. He specifically indicated that he would not want to undergo major surgery. A cardinal principle of contemporary medical ethics is that it is the right of patients to make just this sort of decision and the obligation of physicians to follow their wishes. To respect a patient’s preferences as long as he is able to speak for himself—as happened with Dr. DeBakey during the nearly six weeks following the onset of symptoms—and then to disregard those wishes once the patient loses the ability to make decisions—as occurred when Mrs. DeBakey reportedly stormed into a late night hospital ethics committee meeting and demanded that the surgery take place—violates the hard-won respect for their autonomy that patients have gained over the past twenty years.

Much of the commentary about the case has centered on whether a patient’s wishes can be overridden, even by loving family members. What has largely been left out of the discussion is whether it is ever appropriate to perform invasive, dangerous, and expensive surgery on 97-year olds—even if they want it.

The operation performed on Michael DeBakey involved putting him on cardiac bypass and opening the aorta, the artery that carries blood from the heart to most of the major organs of the body. The damaged part of the aorta was then replaced with a synthetic graft. The risks were high—in a group of elderly patients who had the procedure, the oldest of whom was 77, 18% died. Moreover, simply surviving the surgery does not mean returning to one’s usual state of health in a matter of a few weeks. It typically means, as DeBakey experienced and as his physicians anticipated, an extended hospitalization marked by reliance on machines, marred by multiple complications, and fraught with considerable suffering. Dr. DeBakey spent three months in the hospital, much of the time unable to speak or eat, let along get out of bed, read, or interact with others. He was attached to one machine for breathing and to another machine to clear wastes from his system. He was fed through a stomach tube. The cost of his hospital stay is estimated to have exceeded one million dollars.

Dr. DeBakey is glad to be alive—and I am delighted for him that he survived his ordeal. But how many people should we subject to the grueling treatment DeBakey endured for a chance of a few more weeks or months of life? Is it reasonable for 99 or perhaps 999 people to suffer for days or months, only to die from complications of the surgery, because very occasionally, one person might live?

The number of potentially life-prolonging technologies offered by contemporary medicine is proliferating rapidly. The implantable cardioverter defibrillator jolts the heart back to normal if an irregular, life-threatening rhythm develops in patients who have had a heart attack. The left ventricular assist device is a partial artificial heart used in patients dying of heart failure. Sophisticated biopharmaceuticals created by biotechnology are also multiplying, drugs typically used in patients with extremely advanced cancers. Some of these technologies offer a chance of additional months or even years of life to people in their prime; but do they make sense, especially when they are invasive and costly, in the oldest old?

When the baby boomers begin turning 65 in the year 2010, they will account for 13% of the U.S. population; by 2050, they will make up 20.6% of the population. Medicare expenditures for this group—the money spent by the government insurance program for the elderly alone—are projected to soar from the current 2.6% of the Gross Domestic Product to 9.2% in 2050, and technology will account for over 50% of the increase in costs. If we are to have the resources to spend on public goods other than health care—on education, on national parks, on highways—not to mention to spend on medical care for poor people and for children—we need to put the brakes on technology.

In a rich country like the U.S., this does not have to mean rationing care based on age alone. But surely the place to start is to limit treatment that is burdensome and expensive, that has a miniscule chance of success, and that is proposed in someone who is at the very end of life. We need to accept human mortality and, as a matter of practice and of policy, concentrate on improving the quality of life of older people. This means assuring compassionate nursing home care, coordinated management of chronic diseases, and competent palliative care as death approaches, rather than using ever more technology to try to eke out a little more life. And it means systematically considering cost and life-expectancy in decisions about reimbursing high technology medical care.

An abridged version of this article appeared on Project Syndicate (www.project-syndicate.org). It was translated into 7 other languages and distributed to over 300 newspapers worldwide.

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