Human Dignity on the Cancer Cost Curve

I apologize for the grandiose title…
If medical care simply must cost less than it does now, and if one is concerned that the goals and values of sick patients will be steamrollered by opinions of small groups of experts, where might things be headed? One view that the experts—i.e., doctors—may do some things to keep outstanding care affordable and in the best interest of the patient was proffered in May 2011 by Drs. Thomas Smith and Bruce Hillner, in their article, “Bending the Cost Curve in Cancer Care,” in the New England Journal of Medicine.
Drs. Smith and Hillner proposed that oncologists change their attitudes and practices in 10 ways. I condense and summarize them here; while all seem eminently reasonable to me on their face, some may raise tensions for human dignity, if that is understood from the perspective of patient choice. The condensed list:
1) Test cancer patients who are in remission less frequently for recurrence.
2) For most advanced cancers, use less chemotherapy—fewer cocktails of several drugs, at lower doses (rather than toxic doses with expensive other drugs to mitigate the toxic effects), stop giving chemotherapy after 3 rounds of failure, and don’t give chemotherapy to bedridden patients.
3) Integrate supportive care, of the sort usually identified with hospice in the last days of life, earlier on, with active treatment.
4) Pay doctors more for end-of-life conversations and other treatment planning, and reduce their financial incentives to overtreat. (Many cancer doctors make half of their incomes giving chemotherapy.)
5) Accept that cost-effective analysis and limits on availability/allocation of some treatments are here to stay.
6) Both doctors and patients should adopt more realistic expectations (we tend to be over-optimistic about how well active treatments will work).
7) Patients with [advanced] cancer should have end-of-life discussions with their doctors fairly early on in treatment.
Of this list, the first three are supported by a growing corpus of medical evidence. The next two are policy matters that raise ethical issues (doctors’ values, rationing). I think all 5 are coming, regardless of whether our government’s policies are more “Democrat” or “Republican” going forward. Policy questions in particular demand the broadest public discussion, as Dr. Dan Sulmasy and others have argued elsewhere.
The last two are the most poignant, because they sound sort of defeatist but they go to how we think about, and how much we cling to, our earthly lives. They demand intimate conversations in relationships characterized by trust and the covenantal role of the physician. Our medicines can often do much, but they can’t do everything. Of course, the Christian’s eternal hope provides critical context for these concerns.
Any affront to the dignity of “do everything” autonomy can be more than offset by the dignity of physicians wisely providing the best care they can to their patients, and guiding their patients through the necessary decisions. But those decisions must remain as individualized as possible. A list of broad principles does not distill into an easy formula or blanket rule. And setting appropriate expectations need not collapse into “rationing at the bedside.” Still, it may be critical to remember—to turn around Dr. Robert Orr’s statement—that “we never withhold care, but we may withhold treatment.”

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