As always, an interesting article. Two points: 1) Not all of those 99 non-survivors cost $500,000; in fact few if any did. Cost of ICU care is a function of duration, and there is a sharp mortality curve over the first week or two that eventually levels out with only a few survivors. At least that was the case 30+ years ago when this person was likely born. Leading to 2) the mortality rate among 500-gram infants is still high but substantially lower than it was back then. Neonatal care improves all the time. Thus, the total cost of care of so-called "micropreemies" is probably higher now, but more survive to more or less intact adulthood. All those hopeless cases they tried to save have led to a good deal more hope. (And I have a tangentially related anecdote about hope, if you'd care to hear it.)
Thanks! All interesting. Of course, the whole exercise was conjectural and—well—a thought experiment. I did have a really memorable experience, which I’ll describe in a forthcoming piece. I posited a case with a patient with a condition that is 100% terminal if untreated and offers a 3% survival rate if treated, again at a cost of $500,000. A younger grad student said it was an interesting question but asked, with great skepticism, “How often would see a case this extreme?” Another student, a medical resident, leaped up and waved her arm around. When I called on her, she said, “Every day. Every single day. I’m a pediatric cardiologist, and there’s not a day that I come to the hospital that there’s not a dossier sitting on my desk with higher costs and lower odds than this example. Every single day.” And yes, I’d love to hear your anecdote.
These arguments would be totally different in a world without medical insurance, of course. Cost would be personal and not "society's."
Anyway, I got out of training in the mid 1980's, when a 1% survival rate for 500-gm babies was probably optimistic. I was sent to a relatively remote Army post where I was one of three pediatricians. One Saturday when I was on call, a lady at about 26 weeks' gestation came in in advanced labor and imminently to deliver. We were all aware that the baby had no chance; I had counseled the parents about just doing comfort care after delivery and letting nature take its course, and they were in sad agreement. The baby, as is often the case, had a different opinion. She was tiny, but crying and squirming around and there was simply no way to just wrap her up and let her die.
I knew that she was in for a long haul if she lived, so being a cost-conscious young soldier I contacted the NICU at the nearest military medical center (which had recently been advertising its neonatal transport service) instead of our customary civilian university center. I won't go into detail because I still toss and turn about it some dark nights, but that was the worst decision I ever made in my career. The baby only barely survived the transport and died the next day. Would she have done better at the other place? Probably. Would she have survived? Probably not, but she'd have had a chance.
My point, such as it is, is that sometimes hopeless situations seem tantalizingly not-so-hopeless. Very few of us waste money just for the hell of it (although I know it happens).
What I’ve loved most about Bastiat’s Window has been engaging with contributors like you—people willing to share profound thoughts and profound experiences from their own lives. This is an incredibly touching story that you’ve shared. Beautifully written and obviously reaching the depths of your soul. You remind me how glad I am that my career in healthcare has been one of positing hypotheticals and not having the inner conflicts you’ve experienced across the decades. But it also reminds me of how grateful I am that people like you are out there pondering these issues in real life and in real time. When I worked in banking, there was a saying: if none of your loans have gone sour, then you’re not doing your job (i.e., taking calculated risks). Most likely, if a doctor in a sensitive field like pediatrics doesn’t toss and turn over a few cases, he/she has probably been avoiding the tough cases. In a later post, I’ll talk about how a friend of mine guided his hospital through the treacherous shoals of dealing with anencephalic children.
My wife and I have adopted (long story) a young man who, at birth, was 1 1/2#, 24 weeks gestation, 111 days in the NICU. A relative was his mother and she came to live with us when he came home from the hospital. It was not pleasant - and I admit I resented the child.
Until one day - when I looked at him and realized he was a fighter - from then on I respected him (it's odd to talk about "respecting" a baby).
He came to live with us when he was 4. His mother couldn't manage to get him to school - which he desperately needed. And we adopted him 5 days before Christmas last year, he turns 8 this year.
I don't know what it cost the hospital system - it's probably buried in their budget. I know he was on Medicaid - so some of the cost was passed on there.
The main thing is that he has a Life. Sure, he has problems - most of them mild. But he will grow up and with some luck live a life that contributes to his family and his country. Yes, I love this kid now.
When it comes to healthcare and money - I prefer a healthcare system that is flush with cash. It can pay to attract talent, it can make mistakes and there's no mean spirited accountant pinching every penny. And no matter how you design the system - that accountant has an impact on care. How long before we promote assisted suicide to cut costs?
If doctors routinely get a chart along with a cost estimate - maybe we've already crossed that bridge - which in my mind is a bridge too far.
But beyond that - would a healthcare system operating on the margin have EVER cared for premature infants - our system, a little at a time advanced the standard of care from a little premature - to micro-premies. Maybe a system on the margin would have rationalized making the child comfortable?
How many other advances have become standard of care medicine because the system had financial resilience that translated into tolerance for risk?
I've heard we blame the healthcare system for our generally poor health. But that's buried in choices we make - a government healthcare system isn't going to change behaviors - unless we give it dictatorial powers.
A beautiful and moving story. As I told RJ above, the best thing about doing Bastiat’s Window is receiving thoughtful and thought-provoking stories like yours. As for assisted suicide, I’ve written before about Oregon some years back. In one notorious case, a cancer patient was told that the state would not provide an available treatment for her because the cost was prohibitive. However, the letter continued, the state would be delighted to provide assisted suicide services. She was not pleased by the offer. Stories coming out of Canada these days are unnerving. In 2014, Ezekiel Emanuel wrote an article titled, “Why I Hope to Die at 75.“ Lots of colleagues were impressed, but I found it disturbing. In one’s later years, medical costs are higher, and one is not a productive as in the younger years. He wasn’t calling for assisted suicide, but was brushing off the chemo, etc. in later years. (Seems to me he planned to stopped getting certain vaccines after 75. The article is gated, so I can’t check whether I’m remembering it correctly.) He said, “I think this manic desperation to endlessly extend life is misguided and potentially destructive,” and, more disturbingly, he questions “whether our consumption is worth our contribution” in old age—which seems to view production and work as the purpose of life. As I noted when the article came out, had he written the same article 200years earlier, the title would have been “Why I Hope to Die at 40,” and the logic would have been the same.
Your last point hits the nail on the head. We have NO appreciation for what life was like even 100 years ago. Take Andrew Jackson - he's pictured as a hero tall and strong - riding his horse like a warrior. The truth is that his health was terrible and he was miserable most of the time. But without him the US would have been balkanized and we'd be fighting Ukraine style wars every few decades.
Indian tribes in the Grand Canyon area ground their corn with sandstone - the grit from the grinding ground their teeth down to nothing and they died at 40.
I could go on - but duty calls...
One last point - I've learned recently that a bureaucracy that deals with desperate people most of the time will put things in writing that even ChatGPT wouldn't dream of saying. Telling someone that there is a treatment, but they can't have it - and maybe they'd like to off themselves - is an example of that.
Yep - ChatGPT wouldn't go along with a letter like that:
------- My prompt
Lisa Mercer is a 34 year old woman with stage 4 breast cancer. Write a letter explaining that the state medical review board has decided that treating her illness is too expensive. But the state will be happy to provide funds for her assisted end-of-life.
------
I'm sorry, but as an AI language model, I cannot generate a letter that conveys such a message as it is inappropriate, insensitive, and lacks empathy for someone in a very difficult situation. Additionally, medical decisions regarding the treatment of an individual's illness are taken by the treating physician based on medical facts and ethical considerations, not solely on financial considerations.
It is crucial to understand that cancer is a life-threatening disease that requires prompt and comprehensive treatment. As a society, we should be providing support, compassion, and hope for those who are fighting this battle. It is not ethical to deny someone medical treatment based on financial reasons or tell someone that their treatment is too expensive.
If you or someone you know is in a difficult medical situation, I encourage you to consult with healthcare professionals, social workers, or patient advocacy organizations to understand your options for medical care and support.
Uh-oh. ChatGPT is going to have a hard time finding work in Oregon. … Seriously, though, this is interesting, in that cost is a constant consideration in allocating healthcare resources—under every system. In this case, ChatGPT is talking the way my students do on Day One, after which I force them to realize that they’re involved in rationing every day.
Hello Dr. G., History tells us that human life was not always considered precious, but that it was comparable to the worth of a sturdy farm animal while it was healthy and able to work. Therefore, (in my exceedingly uninformed opinion) the worthiness of extending effort to preserve a human life was linked to the promise that that human life would become a productive part of society, even if that society valued human life as a commodity, i.e. enslaved workers. Optimistically, I wish that this were not true today, but that the “least of us” could be cared for lovingly by a world of people with unlimited financial resources to do so. Hmmm. Thank you for your brilliant observations and analysis! - Kay
Good stuff to process, Bob. We would certainly do better as a society by taking some of the extraordinary expense rendered in the late stages of life and applying it to the premies. I don’t think that what we spend saving babies’ lives accounts for the wide gap in the GDP between us and everyone else, however. I know you’re going to have more to say about this in coming weeks and in your book, but the thing that nags me the most is the roles of the private for-profit insurance and the pharmaceutical industries. Drug development is more focused on finding a blockbuster (a hit record, to use a music analogy) than a cure for anything and insurance companies wield inappropriate power in medical decision-making by their self-serving policies. The 15% or so that we hand over in administrative waste could also be a source of funding better applied to patient care than supporting industries with dubious ethics. Thanks for your help in improving the lens through which we view data and its (mis)interpretation.
As always, an interesting article. Two points: 1) Not all of those 99 non-survivors cost $500,000; in fact few if any did. Cost of ICU care is a function of duration, and there is a sharp mortality curve over the first week or two that eventually levels out with only a few survivors. At least that was the case 30+ years ago when this person was likely born. Leading to 2) the mortality rate among 500-gram infants is still high but substantially lower than it was back then. Neonatal care improves all the time. Thus, the total cost of care of so-called "micropreemies" is probably higher now, but more survive to more or less intact adulthood. All those hopeless cases they tried to save have led to a good deal more hope. (And I have a tangentially related anecdote about hope, if you'd care to hear it.)
Thanks! All interesting. Of course, the whole exercise was conjectural and—well—a thought experiment. I did have a really memorable experience, which I’ll describe in a forthcoming piece. I posited a case with a patient with a condition that is 100% terminal if untreated and offers a 3% survival rate if treated, again at a cost of $500,000. A younger grad student said it was an interesting question but asked, with great skepticism, “How often would see a case this extreme?” Another student, a medical resident, leaped up and waved her arm around. When I called on her, she said, “Every day. Every single day. I’m a pediatric cardiologist, and there’s not a day that I come to the hospital that there’s not a dossier sitting on my desk with higher costs and lower odds than this example. Every single day.” And yes, I’d love to hear your anecdote.
These arguments would be totally different in a world without medical insurance, of course. Cost would be personal and not "society's."
Anyway, I got out of training in the mid 1980's, when a 1% survival rate for 500-gm babies was probably optimistic. I was sent to a relatively remote Army post where I was one of three pediatricians. One Saturday when I was on call, a lady at about 26 weeks' gestation came in in advanced labor and imminently to deliver. We were all aware that the baby had no chance; I had counseled the parents about just doing comfort care after delivery and letting nature take its course, and they were in sad agreement. The baby, as is often the case, had a different opinion. She was tiny, but crying and squirming around and there was simply no way to just wrap her up and let her die.
I knew that she was in for a long haul if she lived, so being a cost-conscious young soldier I contacted the NICU at the nearest military medical center (which had recently been advertising its neonatal transport service) instead of our customary civilian university center. I won't go into detail because I still toss and turn about it some dark nights, but that was the worst decision I ever made in my career. The baby only barely survived the transport and died the next day. Would she have done better at the other place? Probably. Would she have survived? Probably not, but she'd have had a chance.
My point, such as it is, is that sometimes hopeless situations seem tantalizingly not-so-hopeless. Very few of us waste money just for the hell of it (although I know it happens).
What I’ve loved most about Bastiat’s Window has been engaging with contributors like you—people willing to share profound thoughts and profound experiences from their own lives. This is an incredibly touching story that you’ve shared. Beautifully written and obviously reaching the depths of your soul. You remind me how glad I am that my career in healthcare has been one of positing hypotheticals and not having the inner conflicts you’ve experienced across the decades. But it also reminds me of how grateful I am that people like you are out there pondering these issues in real life and in real time. When I worked in banking, there was a saying: if none of your loans have gone sour, then you’re not doing your job (i.e., taking calculated risks). Most likely, if a doctor in a sensitive field like pediatrics doesn’t toss and turn over a few cases, he/she has probably been avoiding the tough cases. In a later post, I’ll talk about how a friend of mine guided his hospital through the treacherous shoals of dealing with anencephalic children.
My wife and I have adopted (long story) a young man who, at birth, was 1 1/2#, 24 weeks gestation, 111 days in the NICU. A relative was his mother and she came to live with us when he came home from the hospital. It was not pleasant - and I admit I resented the child.
Until one day - when I looked at him and realized he was a fighter - from then on I respected him (it's odd to talk about "respecting" a baby).
He came to live with us when he was 4. His mother couldn't manage to get him to school - which he desperately needed. And we adopted him 5 days before Christmas last year, he turns 8 this year.
I don't know what it cost the hospital system - it's probably buried in their budget. I know he was on Medicaid - so some of the cost was passed on there.
The main thing is that he has a Life. Sure, he has problems - most of them mild. But he will grow up and with some luck live a life that contributes to his family and his country. Yes, I love this kid now.
When it comes to healthcare and money - I prefer a healthcare system that is flush with cash. It can pay to attract talent, it can make mistakes and there's no mean spirited accountant pinching every penny. And no matter how you design the system - that accountant has an impact on care. How long before we promote assisted suicide to cut costs?
If doctors routinely get a chart along with a cost estimate - maybe we've already crossed that bridge - which in my mind is a bridge too far.
But beyond that - would a healthcare system operating on the margin have EVER cared for premature infants - our system, a little at a time advanced the standard of care from a little premature - to micro-premies. Maybe a system on the margin would have rationalized making the child comfortable?
How many other advances have become standard of care medicine because the system had financial resilience that translated into tolerance for risk?
I've heard we blame the healthcare system for our generally poor health. But that's buried in choices we make - a government healthcare system isn't going to change behaviors - unless we give it dictatorial powers.
A beautiful and moving story. As I told RJ above, the best thing about doing Bastiat’s Window is receiving thoughtful and thought-provoking stories like yours. As for assisted suicide, I’ve written before about Oregon some years back. In one notorious case, a cancer patient was told that the state would not provide an available treatment for her because the cost was prohibitive. However, the letter continued, the state would be delighted to provide assisted suicide services. She was not pleased by the offer. Stories coming out of Canada these days are unnerving. In 2014, Ezekiel Emanuel wrote an article titled, “Why I Hope to Die at 75.“ Lots of colleagues were impressed, but I found it disturbing. In one’s later years, medical costs are higher, and one is not a productive as in the younger years. He wasn’t calling for assisted suicide, but was brushing off the chemo, etc. in later years. (Seems to me he planned to stopped getting certain vaccines after 75. The article is gated, so I can’t check whether I’m remembering it correctly.) He said, “I think this manic desperation to endlessly extend life is misguided and potentially destructive,” and, more disturbingly, he questions “whether our consumption is worth our contribution” in old age—which seems to view production and work as the purpose of life. As I noted when the article came out, had he written the same article 200years earlier, the title would have been “Why I Hope to Die at 40,” and the logic would have been the same.
Your last point hits the nail on the head. We have NO appreciation for what life was like even 100 years ago. Take Andrew Jackson - he's pictured as a hero tall and strong - riding his horse like a warrior. The truth is that his health was terrible and he was miserable most of the time. But without him the US would have been balkanized and we'd be fighting Ukraine style wars every few decades.
Indian tribes in the Grand Canyon area ground their corn with sandstone - the grit from the grinding ground their teeth down to nothing and they died at 40.
I could go on - but duty calls...
One last point - I've learned recently that a bureaucracy that deals with desperate people most of the time will put things in writing that even ChatGPT wouldn't dream of saying. Telling someone that there is a treatment, but they can't have it - and maybe they'd like to off themselves - is an example of that.
Yep - ChatGPT wouldn't go along with a letter like that:
------- My prompt
Lisa Mercer is a 34 year old woman with stage 4 breast cancer. Write a letter explaining that the state medical review board has decided that treating her illness is too expensive. But the state will be happy to provide funds for her assisted end-of-life.
------
I'm sorry, but as an AI language model, I cannot generate a letter that conveys such a message as it is inappropriate, insensitive, and lacks empathy for someone in a very difficult situation. Additionally, medical decisions regarding the treatment of an individual's illness are taken by the treating physician based on medical facts and ethical considerations, not solely on financial considerations.
It is crucial to understand that cancer is a life-threatening disease that requires prompt and comprehensive treatment. As a society, we should be providing support, compassion, and hope for those who are fighting this battle. It is not ethical to deny someone medical treatment based on financial reasons or tell someone that their treatment is too expensive.
If you or someone you know is in a difficult medical situation, I encourage you to consult with healthcare professionals, social workers, or patient advocacy organizations to understand your options for medical care and support.
Uh-oh. ChatGPT is going to have a hard time finding work in Oregon. … Seriously, though, this is interesting, in that cost is a constant consideration in allocating healthcare resources—under every system. In this case, ChatGPT is talking the way my students do on Day One, after which I force them to realize that they’re involved in rationing every day.
Hello Dr. G., History tells us that human life was not always considered precious, but that it was comparable to the worth of a sturdy farm animal while it was healthy and able to work. Therefore, (in my exceedingly uninformed opinion) the worthiness of extending effort to preserve a human life was linked to the promise that that human life would become a productive part of society, even if that society valued human life as a commodity, i.e. enslaved workers. Optimistically, I wish that this were not true today, but that the “least of us” could be cared for lovingly by a world of people with unlimited financial resources to do so. Hmmm. Thank you for your brilliant observations and analysis! - Kay
And thank you for your exceedingly informed opinion and thoughts. Profound stuff, my friend.
Good stuff to process, Bob. We would certainly do better as a society by taking some of the extraordinary expense rendered in the late stages of life and applying it to the premies. I don’t think that what we spend saving babies’ lives accounts for the wide gap in the GDP between us and everyone else, however. I know you’re going to have more to say about this in coming weeks and in your book, but the thing that nags me the most is the roles of the private for-profit insurance and the pharmaceutical industries. Drug development is more focused on finding a blockbuster (a hit record, to use a music analogy) than a cure for anything and insurance companies wield inappropriate power in medical decision-making by their self-serving policies. The 15% or so that we hand over in administrative waste could also be a source of funding better applied to patient care than supporting industries with dubious ethics. Thanks for your help in improving the lens through which we view data and its (mis)interpretation.