Archive for the ‘health care’ Category

What’s Fair

July 18, 2018

I liked very much Alice McDermott’s The Ninth Hour. One of the characters is Sister Jeanne, a small, cheery nun in the Little Nursing Sisters of the Sick Poor. Spending every day nursing poor people in 1930s New York, she’s very familiar with suffering. Here’s what she believes about its unfairness:

Sister Jeanne believed with the conviction of an eye witness that all human loss would be restored: the grieving child would have her mother again; the dead infant would find robust health; suffering, sorrow, accident, and loss would all be amended in heaven. She believed this because, because (and she only possessed the wherewithal to explain this to children—trying to say it to angry or grieving or bitter adults only left her tongue-tied), because fairness demanded it.

It was, to her mind, a simple proposition. The madness with which suffering was dispersed in the world defied logic. There was nothing else like it for unevenness. Bad luck, bad health, bad timing. Innocent children were afflicted as often as bad men. Young mothers were struck down even as old ones fretfully lingered. Good lives ended in confusion or despair or howling devastation. The fortunate went blissfully about their business until that moment when fortune vanished—a knock on the door, a cough, a knife flash, a brief bit of inattention. A much-longed-for baby slid into the world only to grow blue and limp in its mother’s arms. Another arrived lame, or ill-formed, or simply too hungry for a frail woman already overwhelmed. There was a child in the next parish with a skull so twisted his mouth couldn’t close, and every breath he took, every word he spoke, even his childish laughter, rattled through dry and swollen lips. Another with a birthmark like a purple caul. Blindness. Beatings. Broken or bring bones. Accident, decay. Cruelty of nature. Cruelty of bad men. Idiocy, madness.

There was no accounting for it.

No accounting for how general it was, how arbitrary.

Sister Jeanne believed that fairness demanded this chaos be righted. Fairness demanded that grief should find succor, that wounds should heal, insult and confusion find recompense and certainty, that every living person God had made should not, willy-nilly, be forever unmade.

”You know what’s fair and what isn’t, don’t you?” Sister Jeanne would ask the sick child, the grieving orphan, Sally herself when she was old enough to understand the question. And us.

“And how do you know?”

Sister Jeanne would put a fingertip to the child’s forehead, to the child’s beating heart. “Because God put the knowledge in you before you were born. So you’d know fairness when you see it. So you’d know He intends to be fair.”


“Who’s the dumbest boy in your class?” she once asked us. This was in the Hempstead house where we were young. “And if the teacher’s dividing up sweets and gives him only one while everyone else gets two, what will he say? He’ll say it’s not fair, won’t he? If you call him out playing ball when everyone can see he’s safe by a mile, what will he say—dumb as he is in school? He’ll say it’s not fair, see? And how does he know? Did he learn what’s fair from a book? Did he take a test? No, he did not.”




Healing Power

January 21, 2016

I’m very grateful that I can still run. However, with age comes injury. It’s one ticky-tacky problem after another. I get over plantar fascitis, and a week later I have a mild calf strain. Then it’s my ankle, then it’s my knee.

I’m talking minor problems–nothing life threatening. Nevertheless, these injuries are extremely annoying.

This morning I went out on a cautious run, fearing that a calf strain would shut me down, as it has for most of the last week. To my surprise, everything worked fine! I had a good run, and when I was almost home I remembered that I had asked God to heal my leg. Apparently he did! So I thanked him for answering.

He’s been doing this, not just since I turned 65, but my whole life. How many hundreds, maybe thousands of flus, colds, strains, sprains and fevers have I recovered from? How miserable would my life be if I had not?

I think this is what Psalm 103:3 means when it exclaims: “Praise the Lord, my soul, and forget not all his benefits, who forgives all your sins and heals all your diseases.” The psalmist is not saying that nobody need ever die of disease. He’s noting the ordinary nature of life in God’s world. Sin is ordinary–it happens every day and perhaps every minute. God forgives it in his children. Disease is ordinary too–and God ordinarily heals it. He made the world such that we get well. I don’t want to take away anything from the spectacular, miraculous healing. Who doesn’t wish to see that? But we should not overlook the equally supernatural reality of the ordinary.

Being Mortal

April 1, 2015

I wish every doctor in the world would read Atul Gawande’s Being Mortal, because it speaks so eloquently—and practically, as well—to a fundamental change in the way we live. It’s a change we owe partly to modern medicine: we not only live longer but we die slowly. It used to be, Gawande says, that the majority of deaths came without much warning—heart attacks, sudden infections, strokes, or even the sudden onslaught of cancer for which medicine had no healing response. (TB was the one great exception.) Now our mortality tends to a long, slow decline.

Medicine tries to beat back this trend, fighting for life, but not paying much attention to what will make our lives worthwhile day by day. Because medicine is so dedicated to resisting death, it does a terrible job acknowledging its inevitability; and because it focuses more on disease than on the human beings who are diseased, it is quite capable of making our lives worse. Caught up in the dramatic imperatives of the medical system, people get lost and end up with miserable existences.

Gawande, a Harvard surgeon who writes for The New Yorker, tells the stories of many patients, including his own father, who had to negotiate this journey without much help from their doctors and sometimes with the doctors’ actual interference. He also introduces us to medical professionals who have thought long and hard about these matters, and gives us hope that a long, slow, miserable death is far from inevitable. Something can be done to make it better.

Gawande is attracted to the holes in medicine—not to modern miracle stories of bizarre diseases and heroic science, but to medicine’s blind spots and failings. He has written extraordinarily well about why medicine costs so much, and about why there are so many medical errors (and what can be done about it). But in writing about mortality, he has landed on a subject with deeper, more fundamental implications.

“The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet—and this is the painful paradox—we have decided that they should be the ones who largely define how we live in our waning days. For more than half a century now, we have treated the trials of sickness, aging and mortality as medical concerns. It’s been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs.”

This social experiment has many sides, but perhaps the most pernicious is the loss of autonomy by the aging. Gawande quotes a colleague: “’We want autonomy for ourselves and safety for those we love.’ That remains the main problem and paradox for the frail. ‘Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.’”

Gawande explores the institutions we have designed for the elderly and the chronically ill—nursing homes and assisted living facilities—and helps us see how, by eliminating autonomy in the name of safety and care, they often create an inhuman environment. He describes in detail how 911 and ICUs and heroic cancer-fighting tools may actually shorten life as well as make its end horrible and inhuman. But he does much more than identify the disease, he probes for a cure.

It is hard to imagine that Gawande is really a surgeon, given that he is so willing to admit his own failings as a doctor, his own ignorance of how to treat his desperately ill patients.

The result is a very moving book, one that often brought tears to my eyes. It also made me think long and hard about my own life and the lives of others, about the kinds of questions and responses I myself make to friends who are seriously ill or dying.

The Case Against Assisted Suicide

February 4, 2015

We are once again experiencing a wave of heartfelt appeals for assisted suicide. Two reasons for it are usually cited. One is that a prolonged death is painful and horrifying; the other that a person’s individual autonomy includes the right to choose when to die.

Against the first reason stands hospice, which enlists both medical science and personal compassion to ensure that death is not painful or horrifying. Many people have awful ideas about the process of dying, but hospice is extraordinarily effective in alleviating suffering and indeed encouraging a sense of meaningful care. Nobody has to have a dreadful death. On the contrary, as many, many families who have relied on hospice can testify, my own included.

Take that fear away, and the argument is really about suicide. Is it an acceptable option? Should each individual choose whether to go on living at any moment?

One strong argument against assisted suicide is the “assisted” part. It is impossible to be sure that relatives, doctors or friends are not giving a sad and frightened person a little push; not just assisting but enabling. There exist many reasons why those closest to the concerned person may want to get on with it—financial reasons, emotional reasons. None of those should be reasons to end a life, but under what regime of safeguards can we be sure they are not in fact the true underlying motives? Older people are often obsessed with “not being a burden.” It might not take more than a slight suggestion, a mere tone of voice, to convince them that they would be less of a burden if they put an end to themselves.

But suppose you hedged in the act of assisted suicide with laws that made it unlikely for such suggestions to overwhelm a person’s choice. Then you have the question of suicide, period. Is there a right to suicide?

If you have had any involvement with someone who ended their life, you know the horrible ripping it does to the fabric of family and society. It is a terrible act of violence that does not affect just the one who ends their life; it changes everybody, forever. Of course it is most violent when done by the young, but who is to say it is benign when done by someone old or sick? This is not to blame the suicide—but it is to suggest that we ought never to encourage self-inflicted death, and always to put as many barriers in the way as we can, at any age and in any condition. In this we are voting not just for the life of the potential suicide, but for the life of the community he or she will leave behind in the wake of choice.

Ultimately, we face a fundamental clash of values in assisted suicide. Do we love life, all of life? Or do we love autonomy more? Life is what comes to us: we open our eyes on it each day, not knowing what great or awful things it will hold. We do not choose life, only how to respond to it. Autonomy, when held as the highest value, asserts that life is material for us to mold, or not to mold. We can turn off the game any time we like. In the final analysis, the choice of values is about God. Who rules? Someone or Something who gives life, and to whom we owe a response? Or Me, the Maker and Destroyer of Worlds?

People will commit suicide, with or without the assistance of others. We cannot help that, and they are our fellow human beings, to be treated with compassion.  I would never, however, pave the path for their self-inflicted death.

George and the urges for darkness

June 2, 2014

For the past year I’ve been volunteering as a “coach” at the Redwood Gospel Mission (RGM) near my home. I meet with men in the 10-month residential drug and alcohol rehab program. It’s a program that the 30 men in the program mostly run themselves, cleaning, cooking, doing laundry and serving other homeless men who come for a bed and a meal (but aren’t in the program.) The men in the program work, they take classes, they go to 12-step meetings, and they follow certain disciplines such as memorizing Scripture.

Since I meet with the men individually for 45 minutes to an hour each week, I get to know them pretty well. That’s why I like it: they are very interesting people whom I genuinely enjoy. They all have stories, pretty interesting stories.

A few observations stand out. First, these guys are terribly vulnerable to their own addictions. At any moment they can give up the cause, leave, and relapse. And they do, very often. They seem like normal, unstressed people most of the time, but they live on edge. I’ve seen them making very good progress until one day, without warning, something had switched off in them, their attitude was negative, and within days they were back on the street.

Second, there are no programs that can “fix” them. The RGM says that they give men an opportunity–a safe, clean place where they don’t have to worry about food and shelter–to learn and grow and experience God’s working in their lives. They have to engage and make the changes, the program can’t do it for them. I think that is exactly right. I’ve often slipped into thinking that good programs are the magic elixir. But what we are offering is not a fix-it. It’s an environment where they have a chance. Out on the street they don’t have much of a chance, realistically.

When you see these realities, it can be pretty discouraging. The success rate isn’t all that high. (It isn’t anywhere, I believe.) I’d say ten months is a minimum to establish real change that will last, and for most it’s not enough.

However, this week one of my guys, I’ll call him George, told me a story that gave me encouragement.
He’s a heroin addict. If you met him you wouldn’t guess it: he’s clean cut, young, smart, articulate. But he’s on the verge of losing his life to heroin. We’ve talked about the urges: how he tends to isolate himself, get down on life, isolate some more, and then find drugs to ease the pain. An impulse wells up in him that’s almost impossible to control. He might put it off, but not for too long–certainly not for the rest of his life. You could call it a death wish and not be too far off. It’s a wish to forget, to avoid, to obliterate self. It’s an overwhelming wish to slip into darkness.

Before I met him, George went nearly to the end of the 10-month program and then relapsed when he had just a few weeks to go. The RGM will take you back any number of times, but you have to start over. So George is in his second time through the program. (Plus he’s been in other, shorter programs before. Most of the RGM men have been through multiple programs.)

This time he says it’s different. The difference is in his relationship to God. He says that now God is involved in everything, not just some things. He has given his life to God and he wants to live for God.

Of course, there is a lot of God-talk frequently associated with recovery. Some of it is just hooey. But I know George pretty well, and I am fairly sure this is genuine. Not just sincere seeking, but genuine finding. He seems grounded. Nevertheless, there are those urges.

A few weeks ago he had a scare. He was with the RGM truck picking up stuff for the thrift store. The owner of a house was moving out and wanted to donate everything, so he called RGM and they sent the truck to help him clean it out. George went into the bathroom and immediately saw some pill bottles. He glanced at the labels–keeping his distance as though from a black widow spider–and glimpsed words that he associated with pain medications. He turned and almost ran out of the room, found the driver of the truck, and told him what had happened. “You have to keep me out of that bathroom,” he said. “Keep an eye on me,” he said. “Don’t let me go in there again.”

When George told me about it he was still almost trembling, recognizing how close he had come. He took encouragement from his spontaneous decision to run away from the temptation–he had never done that before–but at the same time he had brushed up against his vulnerability, and it scared him.

Last week, George went on a run and hurt his knee quite badly. He could hardly walk, so he visited a doctor who x-rayed it and told George he didn’t see any structural problem. It was probably a torn muscle that would recover with time. He said he would give George pain medication. George said, politely, that he doesn’t take pain medications. The doctor said he understood, but urged George to take the prescription just in case. George politely said no. The doctor continued to urge him, and George continued to say no, four times.

Finally, the doctor stopped offering. Then as George was leaving, the nurse asked about his prescription and urged it on him. It was almost comical how much they wanted to help his pain through drugs.

George says he didn’t even think about what he was doing until later. His refusal was completely automatic. It didn’t seem hard; it was simply a matter of doing what he knew he should do. He didn’t feel any temptation, not at the time, nor even later when he reviewed it. For the first time, George really began to believe that his addiction could change. That it is changing, in fact.

I’m not drawing any conclusions from this. I’m hopeful for George, but still wary. He is too. However, I think it’s good to stop and notice when something happens that has never happened before.

One Data Point on Obamacare

November 7, 2013
Tuesday I signed up for Obamacare at the Covered California website. My wife and I are both self-employed and, unlike many Americans, have never been without health insurance. We have been able to buy insurance by keeping a  catastrophic-care policy with a well-known major insurance company, but we were locked in to that provider because (though we are both quite healthy people) we have “pre-existing conditions.” (It’s hard to reach 60 years of age without a pre-existing condition.) That meant  the price kept going up and up and up, to obscene levels.
The good news is that I purchased a comparable policy that lets us stay with our present physicians for less than half what we have been paying. Applying online took me about half an hour. I will save a lot of money, and–also significant–if I don’t like it I can switch.
I know it’s just one person’s story, and proves nothing about the future of Obamacare. But it does provide a glimmer of hope.

Why Abortion Won’t Go Away

April 23, 2013

Ross Douthat has an outstanding short essay on the media response to Kermit Gosnell, the doctor who killed newborns. He quotes, at length, from abortion rights advocates, and gives them their due. They are right in saying that doctors like this would be a lot less likely to exist if there were easy, convenient access to professional abortion clinics. In a perverse way, restrictions on access actually enable devils like Gosnell.

Where such abortion rights advocates never go, however, is the bloody and physical reality of late-term abortions. They don’t focus on the actual fetuses/babies –one different from the other only by the matter of whether a doctor is operating on them inside the womb or outside. And that, Douthat points out, is what is so awful and compelling about Gosnell’s case.

One might have expected abortion controversies to have dried up long ago. The reason they persist–the reason why abortion is not really accepted after forty years of legal practice–is simply those fetuses/babies. It is very difficult to focus on them and remain free and easy about abortion.

Clearly, we live in a time when people want to go about their sexual business without minding anybody’s moral scruples. Most would rather live and let live and not think about it. Given that strong current of sexual individualism, I can’t see abortion rights really becoming threatened in the foreseeable future. But at the same time, I don’t see the issue quite disappearing, either. We don’t have to think about those fetuses/babies most days. But cases will surface to remind us of them.

Bitter Pills and American Medicine

February 28, 2013

My brother-in-law Hank Herrod, former dean of the University of Tennessee medical school, encouraged me to read Time Magazine‘s cover story on the cost of medical care. I always pay attention to my brother-in-law, especially when he tells me something about medicine, so I read the article online. It took a long time–it’s a long, long article–and it made me sick. The guts of the article follow patients through their hospital care and the back-breaking charges they incur. It explains in detail what those charges are and how they are decided. If you think American medicine is based on market economics, think again.

The Three Pound Alien In You

October 23, 2012

The latest New Yorker (10/22/12) has a fascinating article on your microbiome, the roughly three pounds of bacteria that roam your body. (You have approximately 10,000 different organisms, all together weighing as much as your brain.) Only subscribers can read the whole piece online, but you will find a short abstract here.

Researchers have realized that the bugs we have been killing off with such zest are fundamentally part of our system, sometimes doing good and sometimes doing bad. They are like an extra organ, just discovered. For example, there’s evidence that microbial populations help us keep our weight down by controlling our appetite–that’s probably why farmers feed antibiotics to pigs and find that they gain weight faster. The widespread use of antibiotics in children may be the reason for the epidemic of obesity, the article suggests, not the size of the colas available. Antibiotic use may also be linked to the dramatic rise in asthma. And who knows what else.

It makes sense: if you have ten thousand species weighing three pounds swimming around in you for your entire life, their interactions would have to be complicated. (If you had a three-pound cat sitting on your head, those interactions would be complicated too.)

Where do you get your microbiome? Mostly at birth, from your mother’s vagina. Those who are born by C-section don’t get nearly all the bugs, which may explain why C-section children can have special health issues.

With the increase in C-sections, and the greatly increased use of antibiotics, there seems to be a serious downward trend in the organisms, generation by generation. That could spell serious trouble. We don’t really know, because research into the microbiome is just in its infancy. We do know this: medicine just got more complicated.

Health Care Chains

August 9, 2012

Atul Gawande, a surgeon at Harvard, has emerged as our most engaging and thoughtful writer on health care. He has a don’t-miss article in the current New Yorker in which he reflects on the trend in medicine away from private, stand-alone practice and toward large, standardized chains of hospitals and clinics employing physicians. (Did you know that only a quarter of doctors are self-employed today?) In it he compares these chains to The Cheesecake Factory, in a way that leaves you admiring the Cheesecake Factory for their advanced thinking. Corporate control and attempted standardization make up the face of health care change (reform?) that will proceed with or without Obamacare. It’s scary and hopeful all at the same time. Gawande gives you both sides, telling about his visits behind the scenes in both Cheesecake Factory restaurants and in hospital chains, and detailing his mother’s knee replacement surgery. It’s fascinating and subtle. Parts of it gave me the chills.