Maggie Mahar: How Doctors Stymie the Wishes of the Elderly

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Yves here. I had mentioned yesterday that Maggie Mahar, author of the must-read book Money Driven Medicine, had an important post in the works on how doctors and medical facilities can refuse to comply with the clear wishes of elderly patients and their families. By happenstance, her post was published the day after we ran our reader, Mark L’s account of the considerable difficulties his mother had in getting her husband released from a “rehabilitation center” that was doing him more harm than good.

The story Maggie tells is longer and in many ways more alarming because it gives a more detailed picture of how the deck is stacked against aged patients and their relatives.

By Maggie Mahar, a financial journalist who wrote for Barron’s, Time Inc., The New York Times and other publications. (Her first book, Bull: A History of the Boom and Bust 1982-2003 (Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report. For more on her books, click here. She also writes regularly at Angry Bear. Originally published at The Health Beat

Thanks to better diets, exercise, and advances in medical knowledge, more and more of us are living to four score and seven. But the downside is that in too many cases, our bodies are out-living our minds. As I note in the post below, since 2011, 40% of the increase in Medicare’s outlays can be attributed to spending on Alzheimer’s patients.

Why is the incidence of Alzheimer’s (AHD) spiraling? Because we are less likely to die of heart disease or strokes, millions of Americans are living long enough to be diagnosed with senile dementia. One could say that longevity is the proximate cause of Alzheimer’s.

Because women live longer than men, they are more likely to fall victim to AHD, the most common form of dementia. If a woman lives into her 60s her risk of being diagnosed with Alzheimer’s at some point over the rest of her life is 1 in 6. By contrast, for breast cancer, her risk is 1 in 13. By 2050, the number of people age 65 and older suffering from Alzheimer’s may well triple, rising from 5 million to as many as 16 million.

Why then don’t we hear more about this scourge? Because at this point there is little or nothing that doctors can do to stop it. The Mayo Clinic’ website explains: while some drugs can “temporarily improve symptoms of memory loss and problems with thinking and reasoning . . . these treatments don’t stop the underlying decline and death of brain cells. As more cells die, Alzheimer’s continues to progress.”

Last month Consumer Reports warned that “the overall results” for Alzheimer’s drugs “are far less encouraging than the ads portray. Most people who take them don’t experience a meaningful benefit.”

More than half experience side effects. And they’re expensive, costing anywhere from $140 to more than $656 monthly..

Even a small benefit or chance of improvement might be worth it if Alzheimer’s drugs were risk free,” Consumer Reports observed. “But they are not. They can cause side effects such as insomnia, nausea, muscle cramps, diarrhea, and reduced appetite, all of which can be troublesome for people with dementia.” Occasionally, the drugs may cause more serious side effects such as internal bleeding and a slowed heart rate that could be potentially dangerous.

Meanwhile, the average Alzheimer’s patient lives 8 years—and 40% of those years are spent enduring the most severe, late stages of that disease. Some patients linger for 20 years. This is what makes Alzheimer’s so expensive.

The Need for Long-Term Care

At this point, we cannot cure senile dementia, but we can reduce the suffering that patients and their families endure by creating the long-term palliative care system that millions of baby-boomers and many of their parents will need. First, this means figuring out how to fund such a system. Medicare pays for some treatments, but it does not cover long-term care.

Up until now relatives have provided much of that care at home, but increasingly, the burden is becoming too great for aging spouses. And even if their children live close to home, daughters as well as sons have jobs that they cannot leave.

Medicaid will pay for nursing home care, but only after the patient and spouse spend down nearly all of their resources. (New laws now make it very difficult families to transfer assets to heirs when they see Alzheimer’s coming.) And even when families exhaust their assets, nursing homes and hospices often do not provide the combination of palliative care and skilled nursing that patients require.

Finally, and most importantly, we need to think about how to ease the path to death. Here, I am not talking about euthanasia. (In a later post, I will address ”aid in dying” –a.k.a. “physician-assisted suicide”–and explain why some palliative care specialists have had second thoughts about that solution.)

In this post, I am focusing on reducing the fear, the panic, the overtreatment, and the medical flailing about that makes what I have called “the American way of dying” so traumatic. Death always will involve loss and suffering, but it does not have to be impossibly cruel, and it does not have to wreck families.

Aggressive Medicine Can Leave Patients Stranded, Phantoms of their Former Selves, Waiting to Die.

In Knocking on Heaven’s Door: The Path to a Better Way of Death, Katy Butler describes what happened when a doctor insisted on outfitting her father with a pace maker a year after he had suffered a stroke that shattered his mind.(This month (May 2014) you can download a digitalized version of this book,, via Amazon, for $2.99.)

At 80, Jeffrey Butler’s personality and his brain were dissolving—and he knew it.

While he was still able carry on a conversation, his daughter reports that he told her he felt his wife would have been better off if the stroke had proved fatal. “‘She’d have wept the weep of a widow,’ he told me in his garbled, post-stroke speech, in the fall of 2002. ‘And then she would have been all right.’”

Katy added: “It was hard to tell which of them was suffering more.”

A year after the stroke, Jeffrey Butler needed a hernia operation. Dr. Rogan, the cardiologist who was asked him to clear him for the surgery, told his wife that first, he needed “a pacer.: Otherwise, his heart might stop under the stress of general anesthesia.”

This was the second time that Dr. Rogan had seen Butler. A year earlier, when Jeffrey Butler was still vigorous and intact, Rogan had recommended the device. But at the time Butler said that, unless was absolutely necessary, he wasn’t interested. His internist, Dr. Fales, agreed– he considered the pacemaker overtreatment.

But now Dr. Rogan presented the pacemaker not as a choice, but as a necessity. As a cardiologist, he was focused on the part of the patient’s body that he could fix—the heart.

Valerie Butler agreed. “I wasn’t ready for his dying,” she later told her daughter. “I still hoped we could improve things.” Of course, senile dementia is a progressive, chronic diseases that does not “improve.” But Hope trumped Acceptance.

She did not call Dr. Fales. He was notified of the decision by Fax. He tried to intervene, but without success: “Because the surgeon and the cardiologist went a couple of extra years in their training, my opinion didn’t weight in heavily, even though I knew Jeff better than anyone else,” he later told Katy Butler.

Often a family doctor who has known an elderly patient for years is in the best position to understand his or her desires and fears. Before letting a specialist who has seen the patient a few times make a decision, the family should consult the family should consult that doctor and/or a palliative care specialist trained to listen to patients and their families, ask questions, and help them make difficult decisions.

Years later, Fales also told Katy Butler that if her father had not received the pacemaker, “finally, his heart would have just stopped beating. He would have died peacefully. But nowadays we don’t get to see this natural course much, because everyone gets devices.”

“Not having a pacemaker would not have guaranteed my father a quick or easy death,” Katy concedes. “But having a pacemaker deprived him of his best chance of one.”

If Butler had been 65 when he suffered a stroke, a pacemaker that helped him through the surgery would have been appropriate. At 65, his mind was still intact. But, as the Butlers would later realize, for an 80-year-old in his condition, the implant was totally inappropriate

Fast Medicine

Yet in 2002, there wasn’t time to consider other options–or so it seemed.

Butler explains: “A sense of urgency, combined with the assumption that the treatment offered has no alternatives and no downsides are common ingredients in medical decision, later regretted, involving the frail and the elderly.”

Thus her father fell victim to what some call “Fast Medicine,” a term invented by Dr. Alberto Dolara, an Italian cardiologist. In 2002 he published an essay comparing “fast medicine” to “fast food.”

“It involves a barrage of rapidly prescribed tests and treatments, ‘fixing’ rather than healing,” Butler writes.. “Death by fast medicine is protracted, traumatic, and expensive.”

Slow medicine, like slow food, values restraint, calm and above all, time: time to weigh the physical and emotional costs of medical treatment; time to evaluate new methods and technologies; time, as the end of life approached, to stop frenetic doing, and to take care, instead, of the broader needs of patients and their families . . . . .

A Slow Death

Butler’s heart was weak, but the pace-maker would keep his body alive for five more years– five long summers and five long winters– as he slid “into dementia, incontinence, near-muteness, misery and helplessness.”

“My father’s strung-out dying and my mother’s suffering were the consequence of our culture’s idolatrous, one-sided worship of maximum longevity,” Butler observes.

Ultimately, the suffering would crush both Jeffrey Butler and his wife, Valerie, who was caring for him roughly a hundred hours a week.

In the autumn of 2007 Valerie Butler was 83, “’as lucid and bright as a sword point, and more elegant in her black jeans and thin cashmere sweater than I could ever be,’ her daughter recalls. Still, Valerie had come to end of her rope and her hope: ‘She put down her teacup . . . put her hand, hard, on my arm‘ and said, ‘Please help me to get your father’s pace-maker turned off. He is killing me. He. Is. Ruining My Life.’”

This was a request Katy Butler had both “dreaded and longed to fulfill.”

A reporter, she knew what to do next: research.

Incredibly, she managed to find a bioethicist who had been an engineer for Guidant, the third largest U.S. manufacturer of pace-makers and other implantable heart devices. Her source told her that a pacemaker could be turned off painlessly, and without surgery. A white ceramic device that functions like a TV remote could be placed on her father’s chest, just below his collarbone, and when “someone pressed a few buttons, the electrical pulses that ran down the pacemaker’s spiraled wires to his heart would slow until they were no longer effective. My father’s heart would probably not stop. It would just return to its old, slow rhythm. If his aging heart had deteriorated since the pacemaker was put in, he might die within weeks. If he were unlucky, he might linger for months.”

As it turned out, it would not be that easy.

In a phone conversation, Katy told me: “There is an American fantasy which says ‘I can sail along completely healthy and at the exactly the right moment –tell the doctor I want to pull the plug. I can be immortal thanks to the blessings of technology, and the flip side of that is the notion that I can leave this planet without woe and suffering.’”

Not true.

The cardiologist refused to deactivate the device . . . Turning off the pacemaker would be “like putting a pillow over his head,” Dr. Rogan declared.

He explained that “he’d feel okay about not replacing the pacemaker’s battery when it ran down. But turning it off would be ‘too active.

Mother and daughter then went to Dr. Fales. “He had been opposed to the pacemaker from day one, ‘but turning it off, he said, was ‘something else again.’”

“Without the device, my father might get dizzy or faint, fall, break a hip, and end up in the hospital. . .

‘Keep him out of the hospital at all costs,’ Dr. Fales said. ‘Try not to call 911.’ As he looked at my mother, Butler remembers “his eyes were filled with tears.”

Fales knew that, once in the hospital, Butler would become part of “the system” — a system that follows the institution’s own protocols as to what is best for patients. Butler could end up dying, alone, in an intensive care unity. By then, Katy’s mother had come to think of doctors as “skilled technicians who have their own agenda.” Some feel that it is there duty to “do everything possible.”

Dr. Fales then suggested: “Why don’t you just let the batter run out? It probably only lasts five years, and it’s getting close.”

When they got home, Katy and her mother found the file her mother had kept on the device. The battery of this particular pacemaker had a ten-year life.

They had another five years to go.

A Living Will and a Medical Proxy– No Guarantee

Katy Butler ed Compassion and Choices, a successor to Hemlock Society, the organization that first advanced the notion that the fatally ill had a right to die without interference. The law was clear, she was told. “Her father had the right to ask for the withdrawal of any medical treatment—included an implanted device. She and her mother, as his designated health-care proxies, had the right to insist that his wishes be followed when he could no longer express them.”

But “in an era of advanced medical technology,” Katy Butler soon learned that, “having legal and moral rights was not the same thing as having power. . . . Those who knew my father best– Dr. Fales my mother and I –wanted to let him die naturally. Those who knew him least and least understood his suffering were eager to prolong his life, and had the know-how and power to do it.”

Katy Butler was advised that she “should not be rude or threaten a lawsuit. When family members become agitated or disruptive, “hospital bioethicists. . . may decide that the surrogates lack ‘decision-making capacity’ and the medical team may simply ignore them, or go to court and ask to have the troublemakers removed from the job. If that happened, my father’s medical proxy wouldn’t be worth the paper it is written on.”

Katy was learning that advances in medical technology represent a double-edged sword. On the one hand, devices like the pace-maker were saving lives.On the other hand, savings lives had become a big business.

What Butler calls “cardiac hypermarketing” grew as both Medicare and private insurers paid more for procedures than they did for the time it would take a doctor to discussion benefits, risks, and alternative options with a patient and his family.

Meanwhile, over-treatment supportes a burgeoning industry: “Reimbursements for advanced medical technologies, which become forms of medical torture when inappropriately deployed, help cover the cost of a sales rep’s mortgage payments, a hospital’s money-losing ER, a surgeon’s 2nd or 3rd home, or dividends to stockholders of Siemens or St. Jude Medical,” Butler reports. “Nothing much will change until we pay doctors and hospitals when they appropriately do less as well as we do when they inappropriately do too much.”

The danger, of course, is that if physicians and hospitals are paid to “do less” Americans who have become accustomed to overtreatment will claim that reformers are “rationing care.” The truth is that the opposite of overtreatment is not “under treatment”—it is “appropriate treatment.” As Butler told me, “the word ‘rationing’ avoids the reality that our current way of dying maximizes both death and suffering.”

Yet, in the last few years, our ,medical culture has begun to change. As Butler observes: “Reclaiming death from medicine, the way the natural childbirth movement recaptured birth in the 1970s’s, is already underway in the form of open rebellion by families like mine, the growth of hospice and palliative-care programs, and the widening number of doctors who practice Slow Medicine—though they may not call it that.”

Jeffrey Butler’s Pacemaker Was Never Turned Off.

Jeffrey Butler finally died of “the old man’s friend,” pneumonia. After his death, his daughter tells us, “The Heart Rhythm Society and the American Heart Association issued guidelines declaring that patients or their legal surrogates have the moral and legal right to request the withdrawal of any medical treatment, including an implanted cardiac device. It said that deactivating a pacemaker was neither euthanasia nor assisted suicide, and that a doctor could not be compelled to do so in violation of his moral values. In such cases, it continued, doctors ‘cannot abandon the patient but should involve a colleague who is willing to carry out the procedure.’

“This came, of course, too late for us,” Katy Bulter reports.

Butler’s death was hard work: “My father just breathed a terrible loud, ever louder breathing, like someone building a wall, like someone delivering a baby. His lungs filled with fluid. “

But he did die in the hospice unit of a local hospital, with morphine to quiet the pain. And Katy tells us, by “refusing to give him water, food or antibiotics,” Valerie Bulter “fulfilled her marriage’s final, tender and brutal vows.” She was at his side when he died.

NOTE to Readers: “Knocking on Heaven’s Door” may sound like a painful tale that could be difficult to read. But in truth, it is an easy read, because it is so beautifully written. Here, I have provided only a bare-bones précis of what is really a non-fiction novel. The prose is filled with compassion as Katy Butler struggles to love (and feel loved by) her seemingly perfect mother—and to understand the knotty romance that her parents shared, even toward the end.

Next month“Knocking on Heaven’s Door” will be available in paperback. This month (May 2014), and this month only, you can download a digitalized version” via Amazon, for $2.99.

    In Part 3 of this series on longevity, long-term care, and the art of dying,

I will describe how Valerie Butler, always a warrior, took charge of her own death. In that post, I also will discuss “voluntary stopping of eating and drinking” (VESD) in order to hastens one’s death, which is legal throughout the United States.

When supervised by hospice or palliative care specialists, withholding food and liquids is not painful. Both palliative care specialists and those who advocate for “aid in dying” assure us that VESD offers an opportunity for a “merciful death.”

In future posts, I will explore how we might organize and fund long-term care for everyone who needs it (not just Alzheimer’s patients), discussing the limits of private-sector long-term-care insurance, and the possibility of ear-marking inheritance taxes to pay for the care that millions will need, as well as proposals that we make “physician-assisted suicide” legal.

I also will discuss a proposal that Medicare cover up to two years of home and palliative care in exchange for the patient agreeing not to expect Medicare to pay for last-ditch efforts such as a $35,000 defibrillator, or a $300,000 hi-tech death in an ICU.

Finally I will consider how and where we should provide long-term care–in the patients home, in community homes, or hospices–and who might best provide that care.

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111 comments

  1. ambrit

    This post and tales of family experiences with medicine and mortality highlight a major maladjustment in our culture; the abandonment of the extended family as a template for living. A family with few resources would end up essentially split and eventually estranged. Our experience with my wifes parents demises exhibited traits of this dysfunction. With two of their four children within easy commuting distance, John and Kathy ended up in a Nursing Home. Taken out of their own home and thrown amongst strangers, they both died in under a year. I’m not saying I have a magic bullet to solve the problem, but there isn’t any high profile discussion of this subject in the public discourse that I can find. This is a direct conflict between the myth of the rugged individualist and the communitarian spirit. What is a rugged individualist to do when he or she grows old and feeble? Wander off into the wilderness and die? That sounds suspiciously close to savagery. If balance is the optimal state, then we have a problem. I don’t see any thesis anti-thesis action going on yet. When the next big ecological crunch comes, the weak and powerless will be the first to go. That’s not my idea of civilization.

    1. Maggie Mahar

      Ambrit-

      In the past the extended family was more likely to care for the elderly.

      But keep in mind people did not live nearly as long– often they died in their late 60s..

      Moreovver, 90% of the burden fell on woman–daughters and daughters-in-law. who felt that they had no choice. Today, those same women have jobs and could not stay at home to care for an elderly relative, even if they wanted to.

      In addition, our memories of those “good old days” are mythy –and sanitized. Many elderly
      people were abused by family member’s who were at their wit’s end.
      In “Knocking on Heaven’t Door” Katy Butler tells us that her mother admitted to “clobbering” her husband a few times, and Katy recounts one incident where she overheard her mother screaming while he “whimpered.”

      There is much to be said for professionals caring for the elderly , especially in cases of senile dementia. It is very, very hard for a relative to watch a loved one’s personality change as their mind crumbles. Moreover palliative care specialists are trained to interpret what is wrong when a patient who can no longer communicate clearly begins screaming and hitting. .
      This may mean that he is in pain, or thirsty, or needs to go to the bathroom. A trained
      caregiver may be better able to comfort the patient.

      But of course many nursing homes are not staffed with professionals who know how to comfort.

      In later posts I’ll talk more about the type of long-term care community homes that we need.

      1. ambrit

        Dear Mz Mahar;
        Thanks for curating this post. I understand where you are comong from about the hazards of in family care for the elderly. This being an economics blog, I’m thinking more about the dysfunctions inherent in a monetized elder care system. We were “lucky” that John and Kathy died before their financial resources ran out. Otherwise, it was made plain to us by the operators of the facility, they would then be shunted aside to make room for the next available paying customers. What about those with no resources? I suspect you will be addressing this issue later on in the post progression. Since, as I alluded to above, I see our social construct today swerving towards more primitive and savage norms, I see the solution, or the best I can think of on short notice, as being a push for communitarian social values. The neo-liberals have co-opted the “higher learning” centres. Time for a “lower learning” movement.
        I look forward to reading the rest of your posts.

        1. Maggie Mahar

          Ambit-

          I agree this is an economic problem–a huge one.

          The best solution is to pool our resources to fund long-term care for everyone’s parent. This would be best be done through progressive taxes (I favor raising inheritance taxes, particularly for those in the top 10% to 15%. The top 1% cannot fund this alone.)
          An alternative is to make “physician assisted suicide” legal nationwide–and at any time after a patient is diagnosed with a disease that we know will be fatal
          (Right now, even in states that allow PA suicide, it only is legal if the patient is within 6 months of death. This provides little help to demented patients who
          may well live another 8 years.
          Someone arguing for this solution told me: if we do this, wealthy people will still be able to pay for very expensive assisted living centers with palliative care. Few will want to end their lives. But middle-class and low-income people
          will take advantage of PA suicide. They won’t be able to afford decent long-term care, their families can’t provide it, and they won’t want to be a burden.

          I find this Darwinian solution horrifying. (By Darwinian, I am referring to social Darwinism).
          Another alternative is to mandate that everyone must buy long-term care insurance. I doubt this would fly politically,and we still would have to raise taxes to provide subsidies for the half of the population that wouldn’t be able to pay for it out of their own pocket.

          Bottom line: we need to tackle this economic problem collectively: no one knows which of us will live “too long”: we’re all in the same boat, and should
          work together, as a society, to create and fund long-term care for everyone who needs it.

          1. Kokuanani

            Thank you for mentioning physician-assisted suicide.

            Anyone [like myself] above Medicare age, and many below it, who’s witnessed folks sitting [literally] “absent-mindedly” in their deck chairs or beds at a nursing home has vowed not to let this happen to him/herself.

            And yet, what are the options? Strangely enough, now that keeping old folks alive and bleeding them of their resources has become profitable, maybe the fear that “they’ll just kill off all the old people” will be reduced. Of course, in the minds of many, the alternative to being “killed off” is far worse.

            We need to have some honest discussions, and develop some compassionate solutions. The current alternatives are awful.

            1. Maggie Mahar

              Kokuanani

              As part of this series on longevity, long-term care (and outliving our minds) I plan to do an entire post on
              assisted suicide on HealthBeat (www.healthbeatblog.com) .

              I had always thought that would be my choice if my mind began to dissolve, and I realized that I was disappearing. .

              But then I discovered that, in this country, assisted suicide is never legal unless you are within 6 months of dying.

              What is more troubling is research showing that if you give patients 2 or 3 months, they change their minds about wanting assisted suicide. . . , And of course, you have to give people space and time enough to think about it.
              It’s a hard thing to pull the plug on yourself –at least for most people.

              I tend to think that I would possess the resolve –but one never knows about such things unless they have been in the situation.

              I totally agree that we need to have some very honest discussions. And recognize that there is no solution that would be best for everyone. We need to offer multiple options –and none of them will be ideal.

              As Diane Meier, the pioneering palliative care specialist, once told me, “Getting onto this planet is not easy., And getting off is not easy either.”

              At the same time, as Katy Butler points out, in the 1960s
              natural childbirth advocates began to figure out ways that women could take charge of bringing into this world (again different choices for different women: some would want no
              painkillers, others would like to be conscious but not in so much pain; still others would want to give birth at home . .)
              And now, people are beginning to figure out how to take
              charge of our deaths.

              This does not mean that we will have “total control.” We can’t control Nature. But we don’t have to deliver our bodies over to
              the imperatives of for-profit advanced medical technology.

              “Shared decision-making”: is, I think, a big part of the answer.

              I’ll also be writing more about that as part of this series.

              (It strikes me that I may be starting to write another book, though I think it would be tough to find a publisher who wants to put out a book on this subject.)

          2. Katniss Everdeen

            With all due respect, Maggie, I find the emphasis on the economics of this situation the horrifying thing. Long term care is, quite often, sub-standard, neglectful and even abusive. It’s impossible to imagine it will get any better, with tens of millions of “customers” waiting in the wings, and a desperate population looking for ways to “pay” for it. I’ve no doubt the “healthcare entrepreneurs” are licking their chops.

            While I certainly cannot presume to speak for Katy Butler and her family, I wonder how they would have felt if her father had been unable to pay for the pacemaker, for then he surely would not have gotten it. I know that my own father would gladly have refused the blank check of Medicare, which turned the end of his life into a living hell. In this country, many times the only NO that is understood is NO MONEY. While I appreciate the sentiment, maybe I don’t want you to “pool your resources” so that I have no way to say, “NO!!!”

            The emphasis should be on the fact that WE SEE THIS COMING. It’s hard to believe that anyone who sees the devastation of dementia, the wretched way in which sufferers are treated and the toll it takes on their loved ones would decide, while they still could, that they would demand a way to “pay” for this warehousing.

            If you want to “fund” something, fund a powerful network of advocates who believe that humans have the right to choose the circumstances of their own deaths. And the passage of laws that prohibit the hijacking and degradation of the lives of those humans for profit, self aggrandizement or some twisted notion of “ethics.”

            1. Maggie Mahar

              Katniss Everdeen

              First, I appreciate and respect the fact that you care so much about this topic, and continue to comment.

              In your latest comment, you write:
              “If you want to “fund” something, fund a powerful network of advocates who believe that humans have the right to choose the circumstances of their own deaths”

              Ths is exactly what I am talking about: Funding palliative care professionals who believe that “humans have the right to choose the circumstances of their own deaths”

              See my post on palliative care here:

              I wonder why you and your family did not ask for a palliative care team to become involved in your father’s care.

              In any hospital in the U.S. you have a right to do that–and if they have palliative care, they must provide the consult.

              I don’t know how long ago your father died–or where you live.

              Perhaps this was many years ago and you were in an area where there was little palliative care, and your family was not
              aware of it.

              But today, in most of the country, palliative care is available at almost all large hospitals. For the past 7 years, I have told readers: if you or a loved one is seriously ill, do not let him be admitted to a hospital without first asking if they have palliative care. If an ambulance takes your to a hospital that doesn’t have palliative care, immediately ask to be transferred to one that does. In a polite way, make it clear that you have called your lawyer to find out more about your right to be transferred.
              The word “lawyer” gets a hospital’s attention.
              Here is an unfortunate, but true:fact: great many hospital CEO’s are not doctors or medical professionals, but MBAs who think they are running a business like any other. They think their job is to “grow” revenues and avoid losses.

              As for the cost of Butler’s pace-maker, that would have been
              automatically covered by Medicare –or Medicaid, There was no question about whether the family could afford it. Once hte cardiiologist said he needed it (or might die) Medicare, Medicaid, or any private insurer would have covered it.
              The power to decide what patients need lies with doctors and hospitals–not insurers.
              Beginning in 2000, the backlash against “managed care” caused insurers to stop second-guessing doctors. They began saying “yes” to virtually anything providers recommended–and then insurers passed those sky-rocketing costs into everyone in the form of escalating premiums.
              Premiums went up because hospitals and doctors were “doing more”–and many patients liked this, believing that “more care must be better care.”

              Meanwhile pacemaker companies made a great deal of money from Medicare and Medicaid.

              What we need now, is for families and patients to ask questions about risks and benefits, ask for that palliative care consult and decide whether they want to say “yes” or “no” to the pacemaker.

              As my post post explains: at this point, the law if clear: tTe patient (or the family if the patient can no longer speak for himself) can refuse the pacemaker–or insist that it be turned off.

              Finally, I emphasize the economics of funding compassionate, PALLIATIVE care because if you want high quality care available to everyone, you must begin by asking: how do we pay for it in a way that will be fair for everyone?

              Any other approach is simply impractical and naive.

              (In a future post I’ll be talking about this. We can’t bury our heads in the sand and pretend that, somehow, the money will
              materialize. If we do that, the wealthiest 10-15% will get compassionate long-term care and the rest of us (and our
              parents ) will not..

              Again, thanks for your comments

  2. John

    Belgium just enacted into law euthanasia — for kids. Of course, the right-wing in the US went bananas when they heard about it. You would think right-wingers would standfast on this one since it is all about individual responsibility. Not a chance. They petitioned the king to reject the bill. By constitution the king is obligated to sign a bill passed by parliament, so he signed it.

    Patients cannot just pull the plug to end it all. They or their families must go through an extensive background review by the authorities, doctors, etc before a decision is made. I saw an older guy on TV who was approved for this treatment because of long-term ailments celebrate with some of his buddies with cava a day before the inevitable. Yes, he went through with it.

    The pacemaker industry is sneaky. The makers of such devices, and there are not that many of them, are experiencing declines to their profit margins from 90% to something smaller. This is bad news for the CEO. What is a good CEO to do? They do everything they can to get the numbers up for the next quarter. I will just say some industries deserve better oversight, especially life sustaining ones.

    1. Maggie Mahar

      John-

      I totally agree about device manufacturers. Far more oversight is needed.
      Katy Butler writes about some of the scandals in her book.

      On Euthanasia–It’s more complicated than it sounds. Research shows that when patients choose euthanasia, most of them change their mind after two or three months. (Google
      “euthanasia” and Dr. Ezekiel Emanuel. And of course, they need to be given time to think it over.

          1. Maggie Mahar

            Lambert–

            Have you ever read Zeke Emanuel’s book or his many articles?

            Have you ever met and spoken to hiim?

            Or is this just sterotyping based on his family and his name.

            See my reply below. I know Zeke pretty well. He is very, very different from RAhm. (I also know people who know both of them very well and would confirm this.

            I’m not sure what you mean about a medical ethicist being “captured” by the
            “rental-extracting hospitals.”

            1. Maggie Mahar

              Lambert–I should add that I know what the phrase “rent-extracting” means (I read Marx and taught Marx when I was a professor at Yale), I just don’t know how it applies to
              Zeke.
              And I find the use of ideological jargon less than useful in
              blog threads like these, especially when you don’t offer
              evidence to support your argument.
              Finally, I’m curious: why do you use a pseudonym which suggests that you think of yourself as a character in a novel by Henry James? (I also used to teach James.)

              1. Lambert Strether

                Jargon: Name it and claim it, as they say. “Rent extracting” isn’t alien to NC readers; this is a finance blog, after all! And I’m a blogger, not an academic, which I mean in a good way, coming from an academic family; I’m sure if you mentally reframes “rent extraction” from “ideology” to “useful analytical tool,” you could do a far better job of explicating our situation than I ever could.

                My pseudonym: 10 years ago when I started blogging, all bloggers had pseudonyms; I came up under Atrios (now Duncan Black) at Eschaton. I was a much bigger James fan when I was much younger than I am now; but Strether’s moment of insight — “Live all you can; it’s a mistake not to” — was one I took to heart later in life than perhaps I ought to have.

            2. Lambert Strether

              Maggie:

              I loathe on the basis of principles not personalities so, no, I’m not stereotyping on the name. Both brothers have policies I strongly object to (though Rahm’s politics on schools and privatization are policies Zeke hasn’t had the opportunity to put in place).

              I don’t move in circles where I would be likely to meet Rahm or Zeke.

              Ethicists would be captured by the hospitals through the same process of “cognitive regulatory capture” that William Buiter identified with financial regulators and banks. They would work together and come to share the same interests and ideologies. It would be great if this didn’t happen, and I don’t have evidence other than anecdotes for it happening, but the same process of capture seems to be happening wherever we look, so I don’t see why it wouldn’t happen.

              1. Lambert Strether

                Adding here’s the Buiter paper. I don’t know the institutional setting o ethicists in hospitals well enough to test/apply Buiter’s idea at all precisely; we only started talking about this topic a couple of days ago, after Yves’s post on elders as a source of profit.

              2. Maggie Mahar

                Lambert —

                I don’t “move in social circles” at all.

                Zeke sought me out– emailing me when I began
                writing HealthBeat. From the beginning, he was a fan of my thinking and writing..

                1. Lambert Strether

                  I read “I know Zeke pretty well” (below) as a social relationship of some sort, therefore necessarily in a social circle of some sort.

                  Zeke will never, ever seek me out. That’s fine with me. When he writes an article on single payer, I’ll applaud the guy. Loathesomeness can be shed by right action.

        1. Lambert Strether

          Yes, Ezekiel is the loathsome Rahm Emanuel’s equally loathsome brother.

        2. Maggie Mahar

          Yes, he is. I know Zeke pretty well. He, Rahm and the third brother (a Hollywood agent whose name I forget) are very, very different–and very competitive. I think there father brought them up to compete with each other.

          When Zeke was health care adviser to the head of CBO in the Obama administration, he was strongly in favor of the Affordable Care Act. (He wrote an excellent book suggesting a different approach to reform, but as Ezra Klein noted at the time, it was such a brilliant idea–and so rational–that there was No Way that it would every happen. So Zeke got behind the ACA.

          Meanwhile, Rahm feared that it would be political suicide for Obama to focus on trying to get universal health care in his first term in office and Rahm had some pretty sarcastic things to say (publicly) about Zeke and health care reform.

          Zeke is brilliant and fearless—an oncologist and medical ethicist who is not afraid to say things that upset doctors, the medical establishment, and, of course, conservatives.
          He also can be very funny. I recall an interview where the host asked him about the three brothers, and how such three very different people could come out of one family. Zeke smiled: “It’s pretty simple. One brother got the good looks (the hollywood agent) One brother got the Power (Rahm, of
          course.) And I got the Brains. (Big grin.)

          1. Lambert Strether

            I’m sure that Ezekiel is a very nice person and very intelligent. Lots of people in DC are. I don’t loathe him for who is. I loathe him because of his views on policy and the effects those views have on me and people like me because of the powerful position he holds. PNHP:

            [R]ead this statement by Ezekiel Immanuel and co-author Victor Fuchs, a celebrated senior Stanford economist.

            “The biggest problem with single-payer is its failure to cohere with core American values. Single-payer puts everyone into the same system with the same coverage and makes it virtually impossible to add amenities and services through the private market.”

            Let’s skip over the weirdness of that “core American values” statement and skip to the neo-liberal part, which translates almost straight up to: “We can’t have single payer because markets.” That is, we can’t even have single payer because an industry that shouldn’t exist save for services like, say cosmetic surgery — Canada being the proof — wouldn’t be able to extract rents. Talk about core values!

            Of course, Zeke could change his views and come out with a book supporting single payer. That would have a great impact! Sadly, I doubt that he will. So many say “it’s not possible,” and then do nothing to make it possible.

            1. run75441

              Hi Lambert:

              After all of the issues with the state exchanges, would you really want to have the federal gov. design a healthcare computerized system? Even if we did Medicare for all, it too involves supplemental insurance as purchased from commercial insurance companies. If we were to look at what many European counties have which the US is constantly compared to, their healthcare is a combination of both. There are few countries (Canada, Taiwan, England, etc) with single payer healthcare to my knowledge. Most countries are a combination of both. Maybe I am missing something here; but, I believe what you really want is for the gov. to set pricing the same as it is in Switzerland, Holland, France, etc.

              What we need is a combining of people and insurance companies to negotiate with healthcare (pharma, hospitals, and clinics). We are too fragmented today to really struck a deal with them. Even yet Medicare has not been turned loose to negotiate with healthcare and while its pricing is cheaper than commercial insurance, it is not the best yet and insurance companies follow suit with Medicare. Consolidation of buyers to negotiate with sellers who are consolidating as we write here to negate even more so the power of the buyers. Today we do have market constraints as imposed by must have hospitals which exercise a large degree of price setting in order to be included. It is here the next threat will arise as we gain those efficiencies from consolidation.

              As it is now, Congress likes to screw with Medicare and if it was not for the elderly getting out and voting, they might succeed in doing something to Medicare. Imagine if it was single payer? Today’s voter is swayed by politics.

              Anyhoo Lambert, My $.02! Good thread and I enjoyed reading it.

              1. run75441

                Forgot, here is an Ezra Klein Article on Single Payer and its short comings. http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/13/what-liberals-get-wrong-about-single-payer/

              2. Lambert Strether

                Single payer (I’m in a rush to hit the garden) makes oodles (technical term) of the complexity of ObamaCare just go away like the useless cruft it is.

                ObamaCare’s fundamental problems are architectural, and a simpler architecture would be much easier for the implementers.

    2. Jerry

      My wife and I are “right wing” in our believe but “left wing” in our politics. Having said that, we are 67 years old and are not afraid of death because we believe in eternal life after death on earth. It is our plan to die when it is time, probably by heart attack, stroke, or cancear (the leading killers) We believe we are called to love others so there is no reason for us to stay around and crowd the planet or use any more benefits of the natural world (clean water, etc.) or government (social security, etc). So please don’t put us right wings all in the same basket. Thanks and Blessings!

      1. F. Beard

        Ah, Christians for social justice? I knew there had to be a few who were not ignorant of the Old Testament.

      2. Maggie Mahar

        Jerry–
        Thanks for your response.
        I have known people on the right who were truly Christians and not terribly afraid of dying. In particular, my mother-in-law (the wife of a Lutheran minister) did become
        senile in her later years, and was in a nursing home where she seemed quite happy.
        She carried a doll around–thought it was her baby (she had had 7 children) and her grown children report that she was quite content.

        It has always seemed to me that many political beliefs that are identified as “left”
        (for instance that we should think in terms of what is best for “we” as a society, not just me and my family) are also Christian beliefs. I just wish there were more people like you.

  3. Banger

    All this is a result of the bizarre system of medicine based on an industrial model. Healing is something much different–I won’t get into the differences but rather advocate for a marriage between compassion and science with the former trumping the latter.

    Our dilemmas are based on the fact we lack a moral framework that is consistent. It starts with articulating a general philosophy about the meaning of life–not that we can arrive at a final solution (meaning is always emerging) but that we at least emphasize that level of depth rather than the endless sentimentalism that seems to infect our morality. Sentimentalism is not in itself bad but in our world it has become a confused hodge-podge of un-thought-out detritus from the past unfiltered by either genuine compassion or reason. When we can focus on the main issue of meaning, then we can come to understand end-of-life issues.

    1. Lambert Strether

      “a marriage between compassion and science with the former trumping the latter.” Institutionally, how does that work, though? The example of a medical ethicist — who should be on the side of compassion, I would think — having been captured by the (rental-extracting) hospitals horrified me.

    2. Maggie Mahar

      Banger–

      I agree that sentimentality is not compassion, and we tell ourselves many fairy-tales about death and dying.
      In particular, we want to believe that, thanks to advanced medical technology, we can live to 105 without suffering.
      But coming up with a “moral framework” that most Americans would agree to would be very, very difficult, in part because many people have strong religious views about death and dying.
      They believe that it is not up to humans to decide when life is or isn’t meaningful This is up to a higher power.
      I don’t agree (I’m not at all religious.) On the other hand, probably not everyone would agree
      with my version of 19th century humanism.
      I think the best we can do is to give patients and families palliative care consults so that they can think about alternatives, and choose how they want to die.
      Some people will want to fight to the end. Some won’t. W
      We shouldn’t pay hospitals for Extreme treatments that we know will do no good (organ transplants for an 80 year old suffering from dementia), but some patients (the fighters) will want that second line of chemo. Others will choose a more peaceful death. The goal of palliative care is to make sure that each individual has a
      chance to die “in character” rather than having his death co-opted by technology.

      1. Banger

        One of my friends is deeply involved in the movement (in the U.S.) to provide alternatives to people who are suffering–there’s a lot of activity these days on that front. As a spiritual person I have trouble with the issue but, really, I see no real problem with ending the pain and the constant medical interventions that go nowhere other than the profits of the medical industry.

    3. Kate

      The problem is most people consider Death the ultimate bad outcome. It is a mixture of not having a way to really know what happens when we die, and the selfish wish to keep our loved ones here in our lives no matter the cost. I have come to the conclusion that even if I find out for absolutely certain what happens when I die and decide I do not like that ending I still can not keep it from happening. It is going to happen, you can not stop it for long and you sure cant stop it for cheap. Certainly I consider keeping a loved one around at the cost of daily pain and suffering too selfish to believe. So my philosophy in my living will is, if my death is inevitable in the near term and I can not make decisions I want no treatment. Get a minor infection, do not treat it. I develop situational diabetes, do not treat it. Heart arrhythmia, do not treat it. Let anything that goes wrong take me. Only intervention to be palliative. I would be appalled to find my spouse beggared by my medical care.

  4. Katniss Everdeen

    “(New laws now make it very difficult [for] families to transfer assets to heirs when they see Alzheimer’s coming.)”

    How, exactly, does the “law” establish that Alzheimer’s is “coming?”

    1. jagger

      They don’t and you can’t for the most part. But if you apply for a medicaid nursing home, they are going to look back 5 years at the financial resources of the patient and spouse. Medicaid will want justification/documentation of how money was spent over the last 5 years. And if it appears money disappeared without justification, the patient will be inelgible for medicaid and you will either have to pay nursing home costs yourself or reimburse any disappeared money before medicaid will accept the patient. Use to be 3 year lookback.

      If people can afford it, they create irrevocable trusts and hope they created the trust 5 years before a nursing home is necessary. And with end stage Alzheimer’s, a patient requires 24 hour a day care. They can’t themselves, clean themselves, use the toilet, nothing. Imagine taking care of a 3 month old, except it is a very old man or woman. Very few people or families can take care of an end stage alzheimers patient. The nursing home is the final option but Medicaid ensures the price is very, very high.

      1. Lambert Strether

        And Democrats keep harping on how great Medicaid is and how many people have been herded into it. Five year lookback, eh? We’re now five years into an economic and financial catastrophe, and now Medicaid is going to judge what people did to get through it? “You bounced a check. No Medicaid for you!” “You moved three times looking for work and your records have gaps! No Medicaid for you!”

        No wonder Krugman and the “progressives” like Medicaid so much.

        1. Maggie Mahar

          Lambert–
          You completely misunderstand the “look, back.”

          Medicaid does not look back to see how well you handled your fianances.
          If you wasted money, made poor bets, etc. you still get Medicaid.

          Medicaid looks only at whether you transferred assets to heirs during those 5 or 6 years in an effort to “protect” that money so that Medicaid will pay for all of your care while your son & daughter inherit $2 million.

          If you did transfer assets, they simply will have to be paid back to cover your care–even if that means a son or daughter has to sell a second home that they bought with the windfall. (The alternative is that they can take you into their home and provide your 24/7 long-term care themselves).

          This seems to me fair. Other citizens should not be paying higher Medicaid taxes to provide your long-term care while you “protect” your $$$ and consolidate wealth in your family.

          1. OIFVet

            “Other citizens should not be paying higher Medicaid taxes to provide your long-term care while you “protect” your $$$ and consolidate wealth in your family” I agree in principle in conjunction with the example you provided, but what of those great many elderly people whose only asset is the family home? Should they be forced to be stripped of their only asset that they could possibly pass on to their children? IMO a Medicaid without homestead protection from asset recovery is exceedingly unfair to those who are already too poor to even afford Medicare.

            1. run75441

              OIFvet:
              If the healthy (community) spouse dies before the one on Medicaid, then the house goes to Medicaid person who must sell it and surrender proceeds. If the Medicaid person dies first, then the house remains with the spouse. Here is an article which explains it better than I can: http://www.nolo.com/legal-encyclopedia/retitling-assets-when-spouse-needs-medicaid-pay-nursing-home.html

              1. OIFVet

                I appreciate the link but it really does not address my point, which is really quite simple: the homestead should be exempt from medicaid estate recovery under all circumstances, period. For many people it is the sole asset to pass on to their children, and many do not know about irrevocable trusts as a way to protect the home from estate recovery, or if they do they could not afford the legal fee to set up the trust. One of the problems with the for-profit system that we have is that it often forces people to sell their home in order to afford care, even if they have insurance (which only shows what a defective product it really is). It is perverse that a putative public program forces people to do the same.

              2. Margaret Mahar

                Run–

                But after the healthy spouse dies, the proceeds from the house must pay back Medicaid.

            2. Maggie Mahar

              OIF Vet-

              Twenty-eight years ago, I bought an apt. in Manattan. In two years I pay off the mortgage. Over 28 years, I have renovated this apt. inch by inch, built a garden (roses, blueberries, iris . . ) and I love it.
              At the same time, I have told my children that when I become ill, I plan to sell the apt. to pay for long-term care in an assisted living facility (my husband is quite a bit older than I , so I am probably doomed to outlive him.)
              If I am not competent to sell it, I expect them to do it.
              By then my retirement savings will have run out. I want them to use the proceeds to pay to have me cared for in a nice place, preferably in the country, that provides palliative care.

              They don’t expect to inherit anything. The legacy I will leave them is knowing that they don’t have to worry about me–or taking care of me.

              Because I spent so many years at Yale, I knew quite a few
              people who inherited large sums. Often people coming from “old money”.” Nice people. But the inheritance, and waiting for it–weakened them.

              On the whole, I don’t think we do our children any favors when we leave them $$$. I feel strongly that we should do our best to support our kids through college (If we have the $$$ do to that). But after that, they should be independent and on their own.
              This has worked out well for my kids– they’re not wealthy–my daughter is a public school teacher, self-sufficient and proud of her independence. The same is true of my son.They’re both happy, strong people.

              1. Salamander

                You’re clearly an intelligent woman, and I admire both your decision and principles.

                But you went from very clear and succinct arguments to… what? Suggesting that your personal philosophy should be imposed on all of us? Wow. It would be hard to find a better expression of the arrogance and incomprehension of our current political elites.

                I don’t WANT my homestead used to prolong my imprisonment in a nursing home while I, delusional with dimensia – or not! – process oatmeal and fester in my adult diapers and old-age body odor, spending every waking moment parked in front of a TV screen, barely comprehending the unending stream of puerile advertising and half-hour morality tales .

                I prefer to leave it to my loved ones. And if I must be left to die, exposed to the elements, like a defenseless Spartan… so be it.

                How is it that I live in a society where no matter what I do, my wishes in this respect are unlikely to be honored by a profiteering machine that sees an easy opportunity to poach my life savings? WTF? I pay off a mortgage over thirty years of scraping by, home improvement, professional and marital strife… and some disgusting nursing hires a team of shift working immigrants with – at best – secondary school education to change my diapers and me jello… and IT gets to keep the asset that I earned?

                Seriously… even if the care given really were worth that life savings – and trust me, if you haven’t lived through this yet, it is NOT – should it not be up to me if I want to pay that price or not?

                Do what you want with your apartment in Manhattan. Delude yourself that by surrendering to the machine the meager wealth you’ve accumulated through a life of hard work as academic, you make your children Steve Austin-like, better, stronger, faster!.

                But please don’t argue that this is good for all of us.

              2. OIFVet

                I appreciate the reply Ms. Mahar, but I have to reject your second to last paragraph in its entirety. The family home is not money, it’s shelter, the center of family life as I understand it. It is not riches like those of the trust-fund Ivy League babies you mentioned.

                Pardon me for saying it, but the attitude you convey strikes me as elitist, here is what I do and if it is good enough for me it’s good enough for everybody else. That’s fine and well, but I assume that you could afford to support your children through college; many people can not and the skyrocketing student loan indebtedness testifies to this reality. So do the stories of so many college graduates in their 20’s and 30’s moving back in with their parents, in the same family home subject to medicaid estate recovery. No jobs available, what jobs the “recovery” has produced are low paid. High student debt load. Do you honestly expect these children to be able to afford even rent, much less afford to purchase a home? And yes, there are studies that link the decline in home sales to student loan indebtedness. In short, the family home is the only hope of many of these kids to have shelter security, a basic human necessity. The trust fund babies benefit from their parents’ money AND connections (think Bush Jr.), these regular kids can only benefit from the family home. To even compare this reality with that of a Yalie trust-fund baby is quite tone-deaf, to put it mildly.

                In short, you describe the problems of elder care very well but you appear to be too far removed from the reality of millions whose one and only asset is the family home to appreciate just how inhumane it is to be forced to sell it to obtain crappy medicaid coverage for crappy and inhumane elder care. It’s not about pride in being self-sufficient, 99.99% would want that. It’s about the fact that most are now denied the opportunity to become that, something I suspect your own children did not have to deal with.

              3. Lambert Strether

                Do you argue for the confiscation of inherited wealth as public policy? That would seem to be the logical extension of your experience at Yale. Because if not, I’m not sure how this is responsive to the issue of whether Medicaid assert recovery programs are fair, or not.

          2. Lambert Strether

            Here is a case where I’m glad to be wrong!

            However:

            1) ObamaCare is cruel and wrong to force over-55s into Medicaid based on an income formula, thereby placing their estates at risk, while higher income people aren’t placed at the same risk. (That’s why I was predisposed to think ill of Medicaid in this case.)

            2) It’s only fair in the sense that Sophie’s Choice is fair. If we had single payer, people wouldn’t be placed in this position at all.

          3. Lambert Strether

            Returning to the issue of Medicaid asset recovery:

            Medicaid looks only at whether you transferred assets to heirs during those 5 or 6 years in an effort to “protect” that money so that Medicaid will pay for all of your care while your son & daughter inherit $2 million. …

            This seems to me fair.

            I don’t see why it’s fair. What it says is that if (a) you’ve got a good family lawyer who thinks ahead and (b) the money to pay them, you can shield your assets from Medicaid. Surely that’s biased? It’s certainly biased against anybody who was 50 five years ago, in the depths of the last depression, and lost their job. Big overlap between that population, many of whom will never work again and aren’t going to be spending money on lawyers, and those will have turned out to need Medicaid now, 5 years on, today.

            It’s also — and if you addressed this, I don’t see it — unfair for ObamaCare to force people to put their estates to at risk because of an income threshold. Accepting for a moment the private health insurance paradigm, which I don’t, why shouldn’t they be able to trade more risk for a secure estate? Richer people — even people who are a single dollar over the income threshold — don’t have to make that choice, so why is that fair?

            NOTE My misunderstanding was based on this paragraph:

            But if you apply for a medicaid nursing home, they are going to look back 5 years at the financial resources of the patient and spouse. Medicaid will want justification/documentation of how money was spent over the last 5 years

            But you say the look-back doesn’t apply to “how money was spent” as such, but is more like an audit to see if they’ve hidden assets?

    2. Maggie Mahar

      Katriss–

      See Jagger’s comment below. Though I think the “look back” period is six years, not five.

      This seems to me fair. If someone transfers $1 million dollars worth of assets to his children over a period of three or four years before he become seriously ill, the rest of us have to
      pay higher Medicare/Medicaid payroll taxes to pay for his care–while his children buy second homes. The middle-class cannot afford to pay higher FICA taxes so that the wealthy can inherit. . .

      We need to find a way to pool our resources so that we can afford to care for everyone’s parents. Raising inheritance taxes is a solution that the UK is considering.

      1. bluntobj

        “We”, in this case, being the government paying the sickcare industry.

        There will be no “afford, ” by the way. The cost of a thing rises with the pool of resources available to pay for it. Using tax revenue as a way to pay a private industry to warehouse elderly that have disconnected (or been disconnected) from their family except for a financial umbilical used to extract resources from later generations is going to fall under the old school definition of “horrific.”

        You talk of the middle class not being able to pay higher FICA rates, yet you propose taxation plans and “pooling” projects that ensure that the middle class will have little to no resources to pass on to the next generation. You intend to “tax” the rich, who have captured government to allow them to pass their wealth down to the next generation, and expect that this will work?

        Rather than look at how to pay for sickcare, perhaps it would be best to look at how the price got so high in the first place. In short, prices rose due to insurance, both private and public. Where there is more money to pay for a service, especially a service in demand, the price of that service will rise. If you’d like to lower the cost of that service, perhaps you should look at returning to a cash basis medical system.

        You may complain that its brutal to the poor and sick, but the post above just told a story of horrific suffering over decades! A system where insurance pays more to keep a patient alive and in pain, or as a mindless hulk that is a drain on their family in a way that they never would have wished for in life.

        ““‘She’d have wept the weep of a widow,’ he told me in his garbled, post-stroke speech, in the fall of 2002. ‘And then she would have been all right.’””

        A cash basis medical system would have stopped this horror, and bring dignity back to death.

        1. Maggie Mahar

          bluntobj-

          A “cash basis” medical system means that the poor and middle class would get little or no care.
          In the past, we did ration healthcare based on ability to pay, but now we’re
          moving away from that.
          By taxing inheritance we do not hurt the middle class. Median income
          couples earning around $60,000 a year– this is the true “middle class”
          Half of all Americans earn less than that.
          They usually have very little or nothing to leave to their heirs. Maybe a house though it is usually mortgaged, and there are other debts.
          Clearly you care only about the other half of Americans.
          But with the passage of the ACA, this country is turning in another direction, and will leave you behind.

      2. Lambert Strether

        “We need to find a way to pool our resources so that we can afford to care for everyone’s parents. Raising inheritance taxes is a solution that the UK is considering.”

        Yes but no.

        One way to “pool our resources” is through taxes. I don’t know whether other single payer countries pay for eldercare that way, but it does seem reasonable.

        I know this is mind-bending — and people who want to have this discussion, the relevant post is over there — but you might want to look into the idea that taxes don’t fund spending. That idea solves a lot of policy puzzles and may, given time, solve some political puzzles as well.

  5. Katniss Everdeen

    …. “voluntary stopping of eating and drinking” (VESD) in order to hastens one’s death, which is legal throughout the United States.”

    Judging from what’s going on in that little piece of US heaven known as Guantanamo Bay, Cuba, I’d be pretty careful about when and where I decided to exercise that right, and whom I told of my intentions.

    1. scraping_by

      Yes, at present physicians don’t have statutory authority to require treatment except in the case of children and dangerous mental illness.

      http://www.bostonglobe.com/metro/2013/12/15/justina/vnwzbbNdiodSD7WDTh6xZI/story.html

      Since out of professional courtesy the workers at CPS or APS won’t question a physician’s diagnosis, if they ever had the authority to detain a patient, or insult their bodies without express permission, it’s a sure thing would do so with abandon.

      These days, they’re left with scary stories and professional arrogance and other steamroller tactics to persuade. If they ever can rule by fiat, medicine will certainly get messier, more expensive, and less healthy.

      1. Maggie Mahar

        Scraping by–

        Palliative care has grown to a point (available in most large hospitals) that
        more and more patients and families are demanding a palliative care consult.
        That is their legal right.
        The palliative care specialists will then spend hours with them, outlining options, asking them questions about their hopes and fears, answering questions about possible risks and benefits. Then the patient can decide. (Or if he is not competent, whoever has his proxy can decide)

        Paliativecare physicians can and do make it clear to patients that just because your oncologist wants to try another surgery does not mean that you have to do it.
        (There are very arrogant “dinosaur” surgeons out there who don’t like this; but they also don’t want to be accused of bullying a patient into something he didn’t want.
        Palliative care physicians can protect patients. And increasingly, surgeons and other
        specialists work with palliative care specialists as a team. Younger physicians, in
        particular, understand that medicine is now a team sport.

        1. Lambert Strether

          Thank heavens!

          Of course, there’s the issue of whether palliative care specialists and physicians are in network when needed….

          1. Maggie Mahar

            mbert-

            I don’t know of a single pallilativecare phsyician who doesn’t take all insurance. They are not well paid (by Medicare or private insurers) and unlike too many cariologists, orthopods, opthamologists and some other specialists, they are not money-driven.
            I once went out with an eye surgeon and asked him how he picked his
            specialty. He looked directly at me and said “How much are your eyes worth?”

            I notice that very few doctor involved in PNHP talk about how many doctors are over-paid, or about over-treatment in our “fee-for-service” system.

            The doctors who are not “in network” are charging more than their peers and refuse to negotiate lower fees that would help keep insurance premiums down.
            Yet much research shows that docs who “charge more” do not provide better care. Sometimes the care is not as good because they tend to overtreat.

            Some of the very best docs (based on outcomes) work on salary for
            places like the Mayo Clinic, Group Health Cop of Seattle, Kaiser
            Permanente, etc. At Mayo, after the first 3 or 4 years, all docs in a given specialty make exactly the same salary. Almost all of them could make far more in private practice but they prefer to work in a close network where care is well-coordinated, doctors look over each others’ shoulder, consult and give advice, everyone is expected to
            practice evidence-based medicine, and there are no “solo flyers.”
            The same is true at the other places I mention.

            Using NCQA data, Consumer Reports has published a number of studies showing that HMOs (closed networks) provide higher quality care and patient satisfaction is higher . . .

            1. Lambert Strether

              Yes, palliative care doctors seem to be better. But, as you say, I’d like some evidence that ObamaCare plans will always cover it. I’ve got to hit the garden, but IIRC it’s not on the list of essentials. And exactly because it’s not money-driven, I wonder how much clout they have. (They may take the insurance, but will the system steer me to them?)

              On PNHP and overtreatment (modulo the idea that doctors don’t get to speak up for interests as well as values)–

              1) I’m coming from the perspective of those who are outside the system (many millions even when ObamaCare is fully implemented), those who are “underinsured” and/or can’t get treatment they need, and those who are given unequal or unfair treatment by a system that as a whole often does not operate in good faith because markets.

              From the perspective of those who are outside the system and get no treatment, or little treatment, or treatment too late, over-treatment must be of secondary concern. (Elsewhere I have expressed horror at being hooked up to rental extraction devices billed, in both senses, as treatment. So a focus on overtreatment seems, from my perspective, a wee bit technocratic.

              2) That said, if we whacked (what?) $200 billion out of the system from overtreatment, and then another $400 billion+ by ridding ourselves of the health insurance parasites — Canada shows they serve no useful purpose whatever — then “pretty soon we’ll be talking real money.” [typo fixed]

    2. Maggie Mahar

      Katriss–

      This is a right that you (or the relatives who have your medical proxy) exercise
      in a hospice, or in your home with palliative care doctors and nurses supervising so that
      you do not suffer.
      A long time ago my husband and I made living wills saying that we would be happy to have food, lilquids, and antibiotics stopped (rather than taking extreme measures to keep us alive) and we gave the proxy to our son.
      We have talked to him about it; he understands, and completely agrees.
      He also realizes that this would be much harder to do in a hospital, unless we are in the hospice unit of the hospital, and that we would prefer to die at home with palliative care.

  6. James Levy

    I thought the Terry Schiavo case was very interesting in this regard. I am a great admirer of Joan Didion, but after losing her own daughter she wrote a long essay in the NYRB basically calling Schiavo’s husband a creep, a cad, and coward for not keeping her alive so long as there was any chance she might, in some way, “recover”. Meanwhile, mom and dad, who didn’t like their son-in-law, were determined that he was going to be saddled with this brain-damaged coma patient indefinitely.

    In other words, our emotions are so powerful, and so confused, around this issue that most people cannot be trusted to make wise choices in life-and-death situations. The Medical Establishment knows this, and so can exploit it to make money and cover their asses against legal retaliation by people who, after someone dies, suddenly feel that everything that could have been done wasn’t and the doctors and hospital must pay for this. If people were reasonable and principled and could accept responsibility for taking these kinds of tough decisions, then we would not be burdened by this medical overreach. Or, if we had a fatalistic religious or ethical ethos that was near-universally held that told us all that death, a necessary end, will come when it will come, then again we wouldn’t have this problem. But neither of those conditions apply in contemporary America.

    1. Maggie Mahar

      James–

      This is why we have living wills–and why family physicians are urged to talk to patients about these very difficult decision before they are dying–while they are still well.
      These talks are time-consuming –and doctors should be paid for that time.
      Originally, the ACA called for paying them for those hours, but then Sarah Palin began talking about “death panels” and that part of the ACA disappeared.
      Neverthless a great many family docs and palliative care docs are having these docs with patients, and there is every indication that Medicare will be providing more funding for palliative care as it becomes more and more popular.
      One tenet of palliative care is that, if at all possible, it is up to the patient–not the family-to decide how he wants to die.
      The Schiavo case was a circus–largely because Jeb Bush (Gov of Florida at the time) decided to get involved.
      I have talked to palliative care specialists who have run into very difficult cases where
      the parents disagreed with the spouse, or adult children disagreed. But they are are trained to be very patient, letting everyone express their feelings while pointing out, gently and kindly, that what the patient wants (or would have wanted) is most important. It can take some time, but eventually everyone comes around. . . .
      I too like much of Dideon’s writing, but in this particular case she was simply overwrought and lashing out.

    2. Banger

      Exactly why we ought to start discussing the meaning of life and related issues–if we don’t do that we can’t really do anything but hurl invective over what are, essentially, religious questions. You can be “religious” and still be an atheist, btw.

  7. Dr Duh

    Part of this goes back to our malpractice system.

    Mr Butler was at high risk because when you give general anesthesia the blood vessels relax and your blood pressure drops, at that point your heart needs to speed up to compensate. If his heart couldn’t do that, he would run the risk of dying, stroking out, or having an abdominal catastrophe.

    If I operate on someone and they die there’s a good chance I will be sued. This goes double for an elective ‘minor surgery’ like a hernia repair. My legal position becomes even more precarious if I knew that the patient had risk factors and I made no effort to ameliorate them. The hernia surgery could be done using local anesthesia, but there would still be non-trivial risk.

    There is no piece of paper that you can sign that would prevent you or your heirs from suing me. Even if I’m not sued I still have to suffer through the psychic pain of the unnecessary death of my patient. If you sue me I will be publicly labeled as an incompetent and a killer and your attorney will attempt to destroy my good name. I have $1,000,000 in malpractice insurance but there’s a non-trivial risk that a sympathetic jury might blow through that threatening my home, my childrens’ education and my savings. Regardless of the outcome I will be reported to the National Practitioner Data Bank which will raise my malpractice premiums and put my ability to retain my license and get privileges at another hospital at risk.

    So the question becomes, how badly do you want that hernia fixed? Maybe Mr. Butler could live with that discomfort. By extension you’d also be willing to tolerate a high risk of death if he developed a strangulated hernia and required emergency surgery.

    1. Katniss Everdeen

      Good, succinct explanation, Doc. Five paragraphs, give or take.

      The problem is, most of it is about YOU and how the death of the patient would/could affect YOU. And you hit that pretty hard–homelessness, uneducated children, inability to make a living. The only thing you didn’t mention is traumatic erectile dysfunction. (Or the female equivalent.)

      So the question becomes, what would your recommendation be if you could see your way clear to putting the PATIENT and his family first? It wouldn’t seem to be too much of a stretch to mention to them that the “pacer” would not only see him through the surgery, but could keep him alive far longer as his dementia inexorably progressed. Hell, you could have even discussed the fact that “pacer” batteries have different life spans. Or, god forbid, that the hernia could be repaired under local anesthesia OR NOT AT ALL.

      While it isn’t true for all patients, most don’t sue when they feel you’ve done your best to cover all the bases. Most don’t sue unless they somehow get the idea that it’s more about you, your house and your children than it is about them. Most know that you’re not superhuman, though many in your profession act like they are.

      I’d go so far as to say that your best defense against a malpractice lawsuit would be a good, honest, thorough pre-treatment consult during which you laid out every detail and consideration you could think of. From the patient’s point of view. Even though insurance doesn’t “cover” that. But it’s kind of hard to get your thoughts together when you’re going stratospheric about not being able to send your kids to college unless…

      In case you don’t realize it, your comment illustrates the problem this article attempts to tackle. Unfortunately for patients seeking medical care in America today, your comment comes as no surprise.

      1. Maggie Mahar

        Katriss–

        I tend to agree that Dr. Duh seems to see this as all about him.

        But I would add that he doesn’t represent the entire profession. There are many doctors out there who do their best to put the patient first.
        See Flora’s comment below.

      2. Brian M

        Katniss: Did you even read what he said? I think he has a better understanding of the risks in today’s litigous society. If he does not protect himself, yes himself, and his family, who will? Certainly not an Internet Social Justice Warrior eager to lay blame and look for nefarious motives.

        And no…I am in no way part of the medical field, so I am not “biased”. I just thought your attack was…highly inappropriate.

      3. Vj

        Your point is that seeking to avoid malpractice lawsuits is somehow selfish ? Surely you don’t mean that but that is how it comes across.

        Maybe you mean that the threat of malpractice litigation is resulting in procedures that are a tad perverse in their impact. Maybe so but it is good to remember that the cause is excessive litigation in the first place.
        This phenomenon is pervasive across our society – take another profession with fiduciary obligations say the audit or Company directorship profession for instance. They would rather be seen as stupid rather than negligent so a lot of meaningless form or over substance seems to result.
        And this seems to be an acceptable defense in our legal system. Over a period of time we have become a society where we have created a world perhaps unintentionally where if only one out of substance or form are possible your best bet is to choose form.
        In this situation it bears thinking how can you isolate one person or profession and expect them to fly against the direction that the environment has created.
        When you essentially make it appear that somehow the previous commentator should have essentially gambled that a particular case would not sue ( “While it isn’t true for all patients, most don’t sue when they feel you’ve done your best to cover all the bases. ” ). And incidentally in effect was the procedure not a case of ‘covering all bases” ?
        I agree something is not working. Just not sure if it can be solved without a larger change of societal paradigm.

        1. Maggie Mahar

          Vj-

          When a doctor performs a surgery (or prescribes a medication) that he is pretty certain is not necessary– and probably will provide no benefit–he exposes the patient to risk without benefit. All treatments carry some risks–even tests, which expose patients to “false positives” which then lead to unncessary treatments and the side effects and unnecessary suffering that come with those treatments.

          When a doctor does this to protect himself against a possible suit he is
          violating the oath he took which said he will put his patients’ interests ahead of his own interests–including his financial interests.

          Being a doctor is unlike any other professoin–he has your life in his hands.

          If someone is not comfortable with the oath, they shouldn’t become a doctor.
          They might consider becoming a stock-broker–or a real estate broker.

      4. run75441

        Katniss:

        In support of what you have said, hospitals such as Univ. of Michigan and Stanford University have begun to admit to making mistakes which has resulted in reduced malpractice suits. People appear to accept apologies over the truth being hidden from them.

    2. flora

      Dr Duh, thanks for pointing out that even good and caring doctors and nurses can be ring-fenced by the current system. My parents’ primary doctor was a great guy, cared about my parents as well as for them. For both mom and dad, he was nearly in tears when he told us there was no hope of recovery. When the time came to honor my parents wishes and we had to say, “turn off the machines” (hardest thing I’ve ever done), the hospital had to be assured that the entire nuclear family was present and that no other family member would come zooming in from the outside to disagree and sue the hospital.

      1. Maggie Mahar

        Flora–

        Yes hospitals are terribly afraid of being sued–and too often put that fear ahead of the welfare of the patient.

        This is why the Butler’s family doctor told them: try to avoid putting him in the hospital. Don’t call 911.

        When seriously ill, you want to be in a hospice, or at home with palliative car–if at all possible.

        It’s good that you had a good family physician to help protect the family..

    3. Maggie Mahar

      Dr. Duh–

      Too many docs claim “fear of malpractice” when they are in no danger.

      As the post makes clear, the cardiologist could have protected the patient by calling for an “external pace-maker” that would not have to be implanted and could very easily be turned off when the operation was over.

      He just didn’t want to do that. But it would have been (and still is) perfectly legal.
      No one could sue him.

      Secondly, he never told the patient or the family about the options–or that the implanted pacemaker could keep the patient alive for 10 years.
      Did he have a legal obligation do do that? Not under today’s laws.
      But he did have an ethical obligation.

      I look foward to the day when the law says that doctors like this cardiologist must “share decision-making” with patients, using the approved videos and pamphlets that explain
      risks and benefits. (They should be paid for the time it takes to do this.)

      The state of Washington now has a law that says if a doctor can shows that he followed “shared decision-making protocols” he is, to a large degree, protected form malpractice suits.
      When docs share decision-making, they do fewer procedures (and make less money) but
      they know they are doing the right thing.

  8. impermanence

    The fear of death drives a great deal of human behavior. Using this fear to exploit individuals is the the polar opposite to the other side of marketing, pandering to desires that distract people from the very same.

    With Western culture obsessed with happiness and all of it accoutrements, it seems unlikely that people will begin to embrace the reality that death is simply the beginning of the next life.

    1. Maggie Mahar

      Impermanence–

      This fear of death is particularly strong in the U.S.

      Talk to people and doctors and Europe, and you will find that attitudes are very different.
      Perhaps this is because it is an older, more philosophical civilization, maybe it is
      because “American in individualism” makes us feel that the death of any individual (ME!) is a great tragedy.

      By contrast, toward the end of her life, the British novelist George Eliot wrote “I am glad to know that the sunlight will be here when I no longer am.” She understood that the world would not stop, that nature would continue and generations would continue to unfold.

      My husband’s best friend was an Italian (Roman) who died of liver cancer. When he was diagnosed, the doctor explained that there was nothing he could do. Filipo and his wife
      accepted this. The doctor sent them home, with morphine, and came to the house to show Filipo’s wife how to administer it. The doctor made house visits every week until F. died, and spoke to the wife on the phone.

      They were, of course, very sad, but there was no Denial, no Anger. F. had a very full, rich and successful life. They moved to
      acceptance quite quickly.

      1. Banger

        The key to it is philosophy in the broadest sense of the word. We in the US hate depth and thus everything stays on the surface. Those of us who swim in deeper waters feel like aliens in our own land–yet we exist and live interesting lives. Unless we engage in a dialogue about the meaning of life we cannot have anything to say about death that is meaningful.

      2. Lambert Strether

        “I don’t want to achieve immortality through my work. I want to achieve it by not dying.” — Woody Allen

        Except for me being immortal through work would be fine! For me, it’s not the endpoint — although I expect to blog ’til I drop and have stuff I want to do up to the last minute! — but the process, the horror of being tied to a machine or stashed in a urine-soaked home.

        So it’s good to hear about palliative care.

        However, since these machines and these homes are also, whatever else they may be, extremely efficient rental extraction devices :-), there are a lot of people who are incentivized, one way or another, to “hook me up” in the system.

  9. KFritz

    DDD(Dear Dr Duh):

    I think that one big part of the malpractice insurance and lawsuit problem is the decades, maybe even centuries, old PR campaign by American doctors and the medical establishment to present them(your)selves as supremely competent, nearly omniscient guardians of health and, especially, enemies of death. That and our unrealistic attitudes about health and death (mea culpa), set doctors and the establishment up for lots of anger and subsequent lawsuits when things go wrong. And the medical establisment has helped to foster the unrealistic attitudes.

    Weak regulation of doctors and the medical establishment also leave civil lawsuit as the only recourse when things go wrong as a result of medical mistakes.

    And since medicine is organized as a for-profit, capitalist enterprise here in the US, it’s legally, and even ethically, fair game for civil litigation.

    Yes, irresponsible ‘patients’ and rapacious attorneys are a problem, but the character and structure of medicine in these parts are much more responsible for the dysfunction nature of medical malpractice law in the US. In my opinion, as I said.

    1. James Levy

      KFritz, I think the anger that you and Ms. Everdeen evince is irreconcilable with Dr. Duh’s fear of humiliation and desire for financial security. I have no idea what percentage of people who lose a loved one in surgery actually sue, but Dr. Duh seems to believe it is every other person. Katniss points out, cruelly but fairly, that he views this as all about him–his pain, his reputation, his wallet. Could it be otherwise? Perhaps, but we’d need a completely different culture (as Banger likes to point out) for that to be the case. So I think that this problem will only be solved when the money dries up. And that day is coming. The sad thing is that it will replace one set of lousy conditions for the average person with an even worse set.

      1. Maggie Mahar

        James —

        When phsycians at Harvard reviewed patient records (in a huge study) they found that in the vast majority of cases where the doctor and/or hospital Were guilty of malpractice (in the view of the docs reviewing) the patients Did not sue.
        People really don’t want to believe that their doctor made a mistake. They want to trust their doctors. And many are able to accept the fact that even very good doctors make mistakes.
        They are most likely to sue only when they always thought that the doctor was a “cold, arrogant SOB”).
        The fact is that hospitals are beginning to adopt the “full disclosure, say “Im sorry” and settle” approach.
        And the best medical schools are teaching doctors that practicing medicine is not all about “I, the doctor.” It’s a team sport. Doctors are now expected to listen to suggestions and criticism from other doctors–and nurses.
        There is less money in medicine than there was in the 1980s, and this means that
        the type of people going to med school has changed.
        Of course there are still SOB ‘s, but people who went to med school in the 1990s were more apt to be woman, more apt to be people who saw medicine, not as a business, but as a healing profession.
        Of course, we still have a long ways to go in changing the culture and the climate in our medical schools. But we have made a beginning.

        1. Kokuanani

          “teaching doctors that practicing medicine is not all about “I, the doctor.”

          That’s “Me Doctor,” as in “MD.”

    2. McMike

      There is, in reality, no mechanism to remove corrupt. negligent, and incompetent doctors, besides civil recourse.

      Self-regulation is non-existent; bad doctors are passed around like pedophile priests, with a lot of crossed fingers and hushed tones.

      Government regulation, meanwhile, is, well. just guess.

      1. Maggie Mahar

        McMike–

        “Bad doctors are passed around like pedophile priests” made me smile.

        But there is an answer: much better legal protection for whistle-blowing docs and nurses so that they cannot be sued or fired.

        Also, in our med schools, we need to tech that a doctor’s loyalty to other docs should take a back seat to loyalty to patients.

        1. McMike

          I am not sure it’s about whistle-blowers. My view is it was more about professional courtesy, unwillingness to make waves, and lack of financial incentives for exposing and drumming out bad docs.

          In fact, if you expose a bad doc, it usually exposes you and your practice to adverse consequences collectively, in terms of PR if not financial exposure and client defection.

          So, instead of self policing, they leave us malpractice suits as the only recourse. We all wait for the docs to majorly screw up, then we sue their insurance company.

          if you know a doc ask them: I guarantee every single one can name a peer that they would strongly, um, suggest you ask to see someone else.

          The connection good docs need to make is until they can self-police, they will find themselves lumped in with the bad docs in the malpractice game.

          1. Maggie Mahar

            McMike–

            It’s not just that medical professionals don’t want to make waves.
            Nurses, in particular, are terrified of being fired.
            When I wrote my book, a great many docs talked to me –though often they said “please don’t use my name.At my hospital they would crucify me..
            Nurses see everything. They know which docs are sloppy, which ones are too smug and arrogant to question themselves, which ones drink and which ones do drugs.
            But they don’t dare talk.

    3. Maggie Mahar

      KFrtz–

      I agree.

      The best soultion to malpratice suits (which some hospitals are now following) is:
      full disclosue (let doctors and nurses explain exactly what happened)
      Apology– not just saying “I’m sorry,” but explaining how the hospital and staff plan to do
      things differently in the future to minimize the danger that this will happen again
      and
      Settling (rather than dragging out Discovery and litigation.
      Hospitals finds this works very well. Families and patients are much more willing to settle.

      Research shows that people are most likely to sue doctors who they perceived as “arrogant”, didn’t listen to the patient, etc.

      1. McMike

        One way to guarantee a suit from me is to treat me like a potential litigant – and clam up and clamp down, lawyer up, and get evasive or arrogant – immediately after you just presided over a high cost procedure with major adverse consequences.

  10. kevinearick

    Pledge of Allegiance, to the flag…

    New World Order, same as the old world order, boldly going nowhere, faster and faster, issuing debt as income to support misappropriated real estate, in stupid peer pressure groups designed for the purpose. The 99% is completely dependent upon the 1%, but the 1% is not Bill Gates, Warren Buffet, or Hillary Clinton. They did not build anything in their garages, or design any economies on the back of an envelope, but they do have moron slogans on their business cards.

    Surprise, surprise, the Germans played last to lose, hoping that the pressure on its global slave labor population would produce the necessary technology to further exploit the countryside, so all the morons had to do was finance it, with an artificial sur. Biofuel, solar, NatGas, wind and all the other proffered solutions have failed, as did nuclear and the Internet. The world doesn’t need another catalog for consumers.

    If you want to see just how stupid the S&P is, look at capital gains variability by peer pressure group collecting debt as money. The hedge fund managers are welcome to all they can choke down. Now, the Swiss are throwing their own under the bus, and California is squeezing its own tax advantaged to make room for more global embezzlers. Never saw that coming.

    You might want to back and look at CAN/US, silver and US Treasuries…

    When the majority lives within the means provided, labor makes one set of decisions, another when it exceeds the limits, and another when it begins to pay interest on interest. The empire majority does not appreciate the universe it has been given, so it builds artificial boxes to suit itself, becoming more self-absorbed with each iteration, measuring growth as control over its box, brilliant.

    The empire participants compete to join a peer pressure group most suited to their individual stupidity, at which point they learn the secret, that the nation/state is all about extortion, saying one thing and doing another. The children of legacy have the advantage because they are bred to exploit stupidity, and the various layers of the middle class assume they are brilliant as well, until they get crushed. Labor is that which is distilled, which recognizes tyranny for all the patriotism, and acts accordingly, from the beginning.

    How dare you not pledge allegiance, to stupidity.

    The economy is rebooted when the majority DNA is flushed, which you are watching, and not before. The majority is welcome to abortion, feminism, chauvinism, Immaculate Conception and all the other breeding contrivances it employs to suit itself, to replace marriage, with greater control of increasingly shrinking boxes. If you look, you will see that the government unions are decimating their own economies, of which civil marriage, a contract for divorce, is the primary culprit. Flushing DNA down the toilet in exchange for an entitlement promise in a debt ponzi isn’t much of a bargain.

    Empires are quite simple. They eliminate talent and issue debt as income in hopes of exploiting what talent remains, which they efficiently distribute for a price, until no talent remains, within the empire, and then change the name of the empire. War, over artificially scarce resources, is the only possible outcome, which is why America produces nothing but extortion, military hardware and software, selling others derivatives of derivatives. The hospitals are collapsing and the elderly majority is psychologically addicted to their care. Good luck with that.

    You might want to cultivate your talent in privacy developed for the purpose, choose a spouse with talent, and cultivate each other’s talent in privacy, or not. The majority has simply distilled talent out of its banking system, which is why its credit is worthless, and its money is rapidly being discounted, leaving its assets stranded off-sheet, to be managed by morons who still think debt slavery is wealth, expecting to win in an artificially closed system.

    The cartel may appear to be a hydra, to the middle class selling itself out to itself, but for labor it’s just a virus, and the upper middle class only mimics an economy, for the purpose. Children choose to lead, follow or get out of the way by age two. You can’t choose your parents or your children, but you can choose your assumptions.

    If the upper middle class wants to ‘fix’ the economy, it might want to get the F out of the way, or not, before its DNA gets prematurely flushed. Breaking windows to learn how to fix them more efficiently is not an economy. Critters killing each other in a sh-show is no emergency to labor. It happens all the time, for a reason.

    Marriage is between a man and a woman, seeking the unknown, becoming one in the process. Everything else gets distilled away, sooner or later.

    The only future you are going to find in the Big Apple is the past, heroin or hopium, it’s all the same. We give them global communication and all they can think to do with it is attack each other. Labor doesn’t care who the majority chooses to lead it further into the past, but someone is going to sell out the feminists next. Take another look at demographics, and QEInfinity outcomes in Japan.

    So, the prim and proper appearing old lady says,” I bet you are glad not to be working in that sh-hole Safeway any longer. I don’t blame you. I would rather work in hell than Safeway.”

    Don’t an old-timer bullsh- and expect the gate to open, closing the circuit in your favor. You are following a hundred salesman that have already tried that approach, in one form or another.

  11. McMike

    In light of this series of stories about pathological health care corporations, arrogant doctors, self-perpetuating bureaucracies, and massive over-treatment of patients who meekly do whatever they are told, or meet major push back, disregard and bullying if they don’t – particularly in the context of the fact that every major corporate/government institution is apparently thoroughly corrupt and broken – I’d like to hear someone explain by what mechanisms the scorched-earth, ever-increasing vaccine paradigm is immune from this corrosive phenomena.

  12. ambrit

    McMike;
    The present system depends on a continuing revenue stream for survival. The Law of Diminishing Returns begins to bite when the societal resources degrade. Stupidity and greed guarantee the degradation of the resources: ecological, infrastructural, educational, financial. In short; nothing is immune.

    1. Maggie Mahar

      ambrit–

      True. The greed of the 20s led to the Great Depression–and ultimately, to
      FDR and the New Deal.

      The New Deal represented progress. Beginning in about 1980, we reversed course.
      (As James Galbraith Jr. once said: “Sometime around 1982 Americans lost interest in the poor.”

      But now, we seem to be once again striking out in a new direction that will call for some
      redistribution of wealth and social progress in many areas. I look forward to seeing what happens over the next 15 years.

      Human history is cyclical, but over time we do make progress.
      Anyone who doubts this should remember that at one time, people really believed that
      slavery was necessary and would never end.
      I realize that there are many types of slavery, but at least we can no longer buy and sell people, break up families, and treating people as chattel.
      I see this as proof that progress is always possible.

      1. Jerry

        I’m afraid I do not see society as progressing in many areas…..we do buy and sell people..human trafficking; so many people hungry; so many wars; so many living in desperate circumstances. People have to be taught to care about and consideration of others, to care about community, instead of consuming self-interest and self- idolatry. That is where people find joy as well instead of seeking elusive happiness.

  13. mellon

    A number of years ago it was observed that people of Indian descent rarely if ever got Alzheimers. That led to a series of discoveries involving curcumin, the active constituent of turmeric.

    Evidently curcuminoids seem to prevent Alzheimers and may even help to reverse it.

    So now US and foreign drug companies are scrambling to find synthetic variants which they can patent, monopolize, and turn into million dollar drugs.

    1. Banger

      This is the tragedy of American medicine–it is an industry not a calling–the main consideration is material gain–sorry docs–I know many of you and even more nurses aren’t all in it for the money but the system demands you genuflect to the dollar or you’re out.

      1. Maggie Mahar

        Banger–this is not true.

        Docs on salary at places like Group Health Cooperative, Kaiser, Mayo Clinic are under no pressure to geneuflect to the dollar–or o
        vertreat in order to hike revenues.
        Unfortunately, doctors are some of our most esteemed academic medical centers
        (which charge fee for service) are. .

  14. bad_patient

    I found the reference to “fast medicine” and “fixing rather than healing” particularly resonant. Unfortunately, I’m a regular consumer of medical services. It’s always an unpleasant experience and I find myself doing lots of work before every visit to stay on top of these technicians. I don’t trust these guys, they are not healers and my personal health and life take a back seat to their protocols and systems. Luckily I have the energy and mental dexterity to manage my care. I feel bad for the elderly who are herded and corralled by the medical industrial complex. I watched my father-in-law and father die terrible deaths at the hands doctors and nurses entrenched in the system. I read Mr dr duh’s comment and quickly pegged him for one of these guys that would last about 60 seconds with me.

    1. Maggie Mahar

      Bad patient–

      Being a “non-compliant patient” can be wise.

      I’m very wary of docs who complain about “non-compliant patients” These are the docs
      you think they are God. (The nice thing about God is that he doesn’t think he’s a doc.)

  15. sharonsj

    I am 70 and so far in good health, but I plan to do whatever it takes to keep me away from hospitals and doctors. Maybe the best idea is to save up whatever pills you can while you’re still in your right mind and, when you start to slip, have a good-bye party where you wash down those pills with a few bottles of great wine. It’s more fun than going in search of an ice floe.

    1. Banger

      Less painful is the helium and plastic bag–painless, quick–a good friend of mine is promoting that method through his organization–we were just discussing it today. Materials are freely available.

      1. OIFVet

        It is sad that the state claims the power to kill people who want to live but denies people who do want to go the ability to do so in a humane way.

  16. mellon

    Its clear that if we had SINGLE payer, we would save so much money that they wouldn’t be trying to get people to commit suicide to preserve assets for their families because healthcare would have to be free to the end users.

    There may still be enough ambiguity in the free trade agreements that we could prevent their stealing our ability to have affordable, but its quite possible that they have already or are in the process of stealing that freedom, NOW..

  17. Jacob

    Anti-psychotic drugs are widely used in nursing homes to “sedate” elderly patients and reduce the number of personnel needed to attend to the patients. Although it’s been about 25 years since I researched the available information on the psychotic drugs that were most-prescribed at that time, I’m pretty sure the latest ones have potentially fatal side effects just like the old ones did. Back then, the two most aggressively promoted ones in geriatric medical magazine drug ads were Mellaril and Haldol. Ads for both drugs were accompanied by a huge list of side effects, including heart attacks, so I’ve suspected for a long time that many nursing home deaths are not from “natural” causes.

  18. Kate

    http://www.nybooks.com/articles/archives/2005/jun/09/the-case-of-theresa-schiavo/

    I reread the Joan D article on Schiavo.

    James–the article was published at the beginning of June 2005. Her daughter died Aug. 26, 2005.

    Maggie–Joan overwrought? lashing out? I’ve searched her essay high and low for that and can’t find it.

    “James Levy
    May 20, 2014 at 10:11 am
    I thought the Terry Schiavo case was very interesting in this regard. I am a great admirer of Joan Didion, but after losing her own daughter she wrote a long essay in the NYRB basically calling Schiavo’s husband a creep, a cad, and coward for not keeping her alive so long as there was any chance she might, in some way, “recover….”

    1.Maggie Mahar
    May 20, 2014 at 3:36 pm

    I too like much of Dideon’s writing, but in this particular case she was simply overwrought and lashing out.

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