Today, that confusion between the realms of nature and choice continues to plague efforts to develop a sensible health-care system. Nowhere is it more evident than in our attitudes toward medicine and mortality. As a health-obsessed society, we do not know what to do with death, other than to try to control it. In all of the debate about health care, virtually no one has confronted this central problem: our determination to prolong life has distorted the mission of American medicine.
What might be called the death fallacy–the notion that our mortality should be wholly under our control–has two components, one moral, the other medical. The moral part is the belief that we have an unlimited obligation to combat death and lethal disease. That is essentially the mission of biomedical research, which, with enormous public support, conducts unrelenting wars against death. The medical part is the potent assumption that death is essentially an accident, correctable with enough money, will and scientific ingenuity: if smallpox could be conquered, then so can heart disease. If typhoid fever was eliminated, someday Alzheimer’s disease will be beaten as well.
I don’t want to be misunderstood here. Doctors at the bedside understand that death is a continuing part of life, and they try hard to deal with it with sensitivity and medical palliation. However, the science that nourishes them refuses to acquiesce in any of the known causes of death, including–increasingly–old age. For research medicine, there are no tolerable causes of death, and therein lies this society’s great ambivalence toward it. In many ways Americans appear to be growing more accepting of their own mortality–as evidenced in the hospice movement and the demand for living wills. Yet our medical system continues to encourage us to view death as a medical accident, the result of some mistake or research failure. When death itself is seen as problematic, it becomes all the more difficult to come to terms with agonizing moral questions about when to stop treatment of the terminally ill–especially if the patient, as in a recent case, is an anencephalic infant or, say, a young sufferer of AIDS in the final weeks of life.
In other industrial countries neither a very-low-birth-weight baby nor a seriously ill elderly person is likely to be subjected to aggressive treatment. They have made judgments that in certain cases the price of continued treatment is simply too burdensome to the patient and society. It is not just that we believe death is one more ailment to overcome. We also seem to believe that health care should be at the top of our domestic priority list, ahead of job creation or public education. Does it make any sense that in the past 35 years or so, we have spent more than twice as much on health care as we have on education?
Our peculiar cultural attitude toward death is reflected in the priorities of federal funding on medicine. The National Institutes of Health gives its largest share of money to cancer and heart disease, the two greatest killers. Far behind are those conditions that affect the quality of life rather than the length of life, such as arthritis, mental health and the dementias. Medicare provides fine coverage for a stay in an ICU for a heart attack, but terrible support for the person chronically ill from heart disease–or simply suffering from the frailty of advanced old age and in need of continuing home care.
Any serious health-reform effort should rethink the meaning of medical “progress.” It should place a heavier emphasis on preventive medicine than on high-technology rescue medicine. It should accept openly the need for rationing, not just as a way of controlling costs, but also as a symbol of the need to curb our insatiable appetite for improved health and longer lives. And it should seek to educate physicians to see death not as an accident that medicine has failed to eliminate, but as a permanent part of the human condition that requires medicine’s good care, a fitting and inevitable final goal of the entire enterprise.
Only fundamental changes of this kind will allow our nation to cope with the coming economic and social pressures on the health-care system. The combination of an aging society and ever more expensive ways of keeping alive grievously ill people will bring eventual financial grief or a bizarre skewing of social priorities. Maybe the much-publicized high costs of care at the end of life can be reduced, but not by much, in my estimation. The cumulative costs well before the last days are the real problem, especially the long, slow decline associated with cancer or heart disease.
In the meantime, American hospitals and nursing homes might consider framing and putting in their lobbies the American philosopher George Santayana’s reflections on death: “The end of an evening party is to go to bed; but its use is to gather congenial people together, that they may pass the time pleasantly. An invitation to the dance is not rendered ironical because the dance cannot last forever.”
