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Health care and quality of death issues

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Over the past couple of years four people I’ve had some sort of relationship with were diagnosed with pancreatic cancer, so I’ve gotten to know more than I ever wanted to know about this especially terrible disease. It’s estimated that about 43,000 Americans will be diagnosed with pancreatic cancer this year, and around 38,000 will die from it. The most common form of the illness remains almost incurable, with a five-year survival rate of less than 5%. Only 20% of cases are diagnosed soon enough to allow for anything other than palliative treatment; this “lucky” minority undergo a grueling operation (the so-called Whipple procedure) that produces a median increase in life expectancy of about a year. Pancreatic cancer is usually a disease of old age: the average age at diagnosis is 73, and America’s aging population has seen a steady increase in its incidence, to the point where it is now the fourth-leading cause of cancer death. (For similar demographic reasons it is beginning to become much more common in the developing world).

Recently I looked at the data from a couple of major academic medical centers who specialize in the Whipple procedure, and I was struck by, among other things, how many of these surgeries are done on patients in their 80s. The ethics and economics — or perhaps the economic ethics — of performing this surgery on very elderly patients in particular are troubling. For all patients, the median survival after the Whipple procedure is about 18 to 24 months (for patients who don’t receive the surgery because their cancer is too advanced it is around six to ten months). But these medians are age-adjusted rather than absolute. In other words, median survival is measured relative to the overall mortality rate in the patients’ age cohort. Since an 85-year-old man without pancreatic cancer has about a 50% chance of dying over the next five years, to say that the five-year survival rate for 85-year-olds undergoing the surgery is 20% means that 90% of these patients will be dead within five years. (And this is assuming that the mortality rate from the surgery and its aftermath will not be higher among the very elderly than among patients in general, which seems like a very optimistic assumption).

How much do these treatments cost? The standard treatment protocol includes post-surgery chemotherapy, and sometimes radiation treatment as well. Re-hospitalization is very common as most patients will suffer a recurrence of the disease within a year or two. In sum, treatment costs can easily exceed six figures. Indeed treatment costs are often high even in the context of the large majority of cases in which surgery is not an option: palliative chemotherapy regimens that have some value in lessening suffering but that generally extend life by no more than a few weeks can cost thousands of dollars a month.

All this raises difficult issues. On the one hand, any time anyone raises the question of whether the cost of keeping very sick people alive for a year or two longer via extremely expensive treatments should be socialized, someone is sure to start shouting about “death panels” and the like. On the other, it’s not as if there are easy answers to the dilemmas these situations raise. After all, a small minority of people live for several years, and on rare occasions even a decade or more, after undergoing the Whipple surgery. Furthermore even if purely palliative treatments are quite expensive, we’re (still) a rich country. As a society should we be less willing to spend money on lessening the suffering of the dying than we are on, for example, building yet more big beautiful bombs? Furthermore some of the money spent on pancreatic cancer ends up funding clinical trials, which at least hold out hope for developing better treatments.

Of course another issue is why these treatments, whether potentially curative or merely palliative, are so expensive. What do rich nations with more just and efficient health care systems than our own, i.e., all of them, do when confronted with the dilemmas that diseases like pancreatic cancer engender? (I have no idea).

In the end we can’t pay for everything, but our current health care “system” pays or doesn’t pay for things in ways that have little apparent relation to justice, efficiency, or any other value beyond the continuing enrichment of those who benefit from the present state of affairs.

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