When it comes to health care, we in the United States expect a lot. In many ways it’s not hard to see why. The U.S. is where the vast majority of medical innovations, the development of new drugs and medical devices, and the pursuit of important research takes place. We have access to top care at the top institutions. People are living longer and better lives because of it.
At what point, though, do we cross the line and begin to expect too much? Should we do everything possible just because it’s possible? Is "everything possible" invariably the better choice? These are questions I found myself asking after reading this intriguing essay, from the New York Times, about the need to start saying "no" in medicine:
Deep down, Americans tend to believe that more care is better care. We recoil from efforts to restrict care.
Managed care became loathed in the 1990s. The recent recommendation to reduce breast cancer screening set off a firestorm. On a personal level, anyone who has made a decision about his or her own care knows the nagging worry that comes from not choosing the most aggressive treatment.
This try-anything-and-everything instinct is ingrained in our culture, and it has some big benefits. But it also has big downsides, including the side effects and risks that come with unnecessary treatment.
I think all of us – providers, the media and consumers – have been complicit in perpetuating the belief that we should expect everything possible, and that if we’re not receiving it, it means we’re getting inadequate care. This happens even in the face of evidence that aggressive screening and treatment isn’t always medically useful and doesn’t necessarily lead to better outcomes for the patient. And you have only to look at the escalation of health care spending in this country to realize this attitude has gotten us into a heap of trouble.
Our great expectations aren’t the only thing contributing to rising health care costs, of course. But they’re surely one of the factors, and I suspect they will be one of the most difficult to change.
Unfortunately, it’s not easy to say no – and those who try to go against this cultural grain will probably lay themselves open to accusations of rationing, writes David Leonhardt, the author of the New York Times essay. Like dishing out bad-tasting medicine, however, it’s necessary, he writes:
From an economic perspective, health reform will fail if we can’t sometimes push back against the try-anything instinct. The new agencies will be hounded by accusations of rationing, and Medicare’s long-term budget deficit will grow.
So figuring out how we can say no may be the single toughest and most important task facing the people who will be in charge of carrying out reform. "Being able to say no," Dr. Alan Garber of Stanford says, "is the heart of the issue."
Read some of the 280-plus comments on the story to get a good look at why this is going to be so difficult. From one person: "Maybe you can say no… but not me." From someone else: "I want the same level of health care that I have always had, and I am willing to pay for it." "Crank up the death panels," one reader sarcastically advised.
Not everyone thinks this way. Studies have found that when patients are given all the information about risks and benefits of a given treatment, they often choose more carefully and are more willing to opt against it, especially if they perceive the risks are unacceptable or the benefit is minimal. When the Center for Healthcare Decisions, a California think tank, engaged the public in identifying priorities for how health care dollars should be spent, one of the things learned was that people are more ready to understand the tradeoffs than they’re given credit for.
I don’t think there’s going to be any delicate or diplomatic way to have this national conversation. It will probably expose a whole new Grand Canyon of disagreement over American health care. After all, not all of us draw the line in the exact same place; what’s reasonable to one person looks to someone else like rationing or government interference. Painful as it’s likely to be, however, it’s a conversation that’s long overdue.
Photo: Mount Everest. Courtesy of Wikimedia Commons