Saturday, December 19, 2009
Surgery For Life: How Romanticism and Religion Are Working With Science To Improve Medicine
Is medicine a life-saving endeavor? Is it the art of healing, combined with the science of life? Or is it a statistical exercise--just an offshoot of utilitarian economics, the most dismal branch of the dismal science? If it’s the former, then medicine should be celebrated. If it’s the latter, then “healthcare,” a concept borrowed mostly from social science, should dethrone medicine and all is lore, and we should all die at the most economically opportune time. The choice is ours. Unless, of course, Washington-based bean-counters make the choice for us. As they fully intend to do: cue up the current debate over Obamacare.
And as we shall see, the power of these reigning social-science bean-counters--these “sophists, economists, and calculators,” to use Edmund Burke’s famous phrase--is so strong that even the most heroic of doctors feel defensive about their life-saving work. And that’s a sad state of affairs.
On December 14, The New York Times’ Denise Grady published a genuinely inspiring chronicle of the heroic effort to save the life of one Robert Collison, a 59-year-old Wisconsin man of no great importance--except to his wife and family, his friends, and to God. Which is to say, Collison is, in fact, important. As are all of us.
But since he was suffering from a rare form of seemingly inoperable cancer that had surrounded his liver and other internal organs, Collison faced quick death earlier this month. But Dr. Tomoaki Kato, a surgeon at New York-Presbyterian Hospital/Columbia University Medical Center, was willing and able to perform an ex vivo resection--Collison’s cancer-strangled organs were removed, the tumor sliced away, and the organs restored to his body.
Here’s how reporter Grady described some of Kato’s efforts:
Surgery is a stunning blend of finesse and brute force. The incision was a huge, cross-shaped cut that ran from Mr. Collison’s breastbone to his pubic bone, then across his belly near the navel. Metal retractors needed to hold open the wound looked like tools from a hardware store, and it took three people to wrestle them into place. Electrocautery pens that did much of the cutting sparked, smoked and sent up a stench of burning flesh. Suction probes like bigger versions of the ones that dentists use gurgled as they vacuumed blood from the incisions.
The finesse is in the hands. Dr. Kato’s moved with confidence and grace that became all the more apparent when he worked across the operating table from someone less deft. An anesthesiologist said Dr. Kato had “soft hands,” reflected in the monitors tracking the patient’s pulse, breathing, electrocardiogram and blood pressure. When soft hands cut, stitched and moved organs around, the monitor readings held steady, but they spiked up and down when rough hands took over.
Surgeons tie knots in every single stitch. Dr. Kato said he made anywhere from 3 to 10 knots per stitch, depending on the type of suture material and the tissue being sewn. Nylon takes more knots than silk, arteries more than veins. Looking over his shoulder was like watching a magician: with a wave of his fingers, a knot would form, and it was possible to see the trick over and over without quite knowing how it was done. For Mr. Collison’s operation, he would ultimately tie 5,000 knots.
And they had to be tied just so. When a surgeon still in training pulled a knot too tight, Dr. Kato said, softly but insistent, “Don’t break the tissue, please.” At times, if helping hands fumbled, he would gently brush them away and say, “No, let me do it.”
When the liver finally came out, the tumor hanging from it was a dense, meaty-looking mass the size of a football. Embedded in the tumor were segments of Mr. Collison’s stomach, pancreas and intestines. Dr. Kato handed it to Dr. Jean C. Emond, the hospital’s director of transplantation, who cradled it in a purple towel like a grotesque baby. He estimated that the whole reddish-brown slab — tumor, liver and parts of other organs — weighed about 15 pounds. Ten of which were tumor.
Then Dr. Emond and Dr. Benjamin Samstein slid the grisly thing into a basin of icy salt water and went to work on it. The idea was to strip away the tumor, with minimal damage to the liver and its blood vessels and ducts, and then reimplant the liver.
And so Collison’s life was saved by Serious Medicine. Nobody knows for how long, but we know for sure that Collison would have had no chance were it not for Dr. Kato and his team.
But reporter Grady takes note of concerns that the New York City doctors harbor, even as they fulfill their Hippocratic duties:
A 43-hour operation inevitably raises questions about the best way to use medical resources.
Dr. Emond, who eagerly hired Dr. Kato as a rising star who could push the envelope in transplant surgery, said that even he was somewhat conflicted about operations that he called “extravaganzas.”
“What does this mean for medicine, doing these incredibly complex procedures to save individual lives?” Dr. Emond asked. “It’s an important philosophical question.”
He referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”
Another argument for the surgery is like the rationale for sending people to the Moon, Dr. Emond said: “Understanding things better or extending the limits of care in these extreme situations somehow moves the whole field of medicine forward.”
Both he and Dr. Kato likened ex vivo operations to the early days of liver transplants, which originally took twice as long as they do now and met with harsh criticism. Hopefully, we’ll get more efficient and make the surgery better,” Dr. Emond said. He noted that surgeons had a saying: “The great surgeon invents an operation that only he can do, and the truly great surgeon invents an operation that everyone can do.”
Thus we come to the ethical and political crux of the Times story: Was all this effort on behalf of Collison worth it? Was it a worthwhile expenditure compared to other possible priorities? Let’s take a second look at a key sentence from the passage above:
[Dr. Emond] referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”
Indeed, a 43-hour operation to save a single life is “not a very health-policy, quantitative way of looking it.” For one thing, such an operation is qualitative, not quantitative. It’s about the quality of mercy, and that’s hard, if not impossible, to quantify.
And yet it’s interesting, and revealing that Dr. Emond, a distinguished doctor, feels defensive about his own profession and what he does to save lives--that he feels that he has to explain himself to social science.
Medicine, from at least the time of Hippocrates, is naturally focused on the patient. And because of that personal focus, the overall romance and mystique of medicine is inherently qualitative--save one life, goes the Hippocratic argument, and you save the world. Saving people, one by one.
And that's why civilization has so revered medicine through most of human history. Not only is there the life-saving aspect, not only the religious element--do God's merciful work here on earth--but there's also a romantic element. That’s “romantic” with a small “r,” as in, say, “Magnificent Obsession,” but also romantic with a capital “r”: dueling with death, battling fate, taking on long odds, stealing Promethean fire. So yes, there are many good and valid reasons why medicine has been mostly privileged over the millennia, seen as a higher calling that ledgering and bean-counting.
But medicine has not been so privileged lately, at least among the dominant policy classes. These days, “healthcare policy” in Washington DC is seen mostly as a battle between social scientists, financiers and pseudo-financiers, waged not by doctors, but by ideologues--the sophists, economists, and calculators that Burke derided in an earlier era. And yet ironically, that policy battle, bitter as it is, is actually more of a conflation, because both "left" and "right" seem to agree that non-medical ideology and belief is more important than medicine. Thus the two disputant sides have disappeared into a ball, an indistinguishable blur of quant-talk that does nothing for, say, Robert Collison.
Picking up on Dr. Emond's comment, not only is “health care policy” the antonym of medicine--and to the idea that there’s a value in so many people working so hard to save a single life--but “healthcare policy” was, in fact, intended to be the antonym, or at least the antidote, to the exaltation of medicine. Back in the 70s and 80s, the chattering policy classes decided that “medicine” was too cold and technological; and besides, “medicine” was too closely associated with the American Medical Association, a leading bete noire of the left in those days. And so “medicine” beame “healthcare policy.” (And the AMA has been dethroned, shrunken, and substantially proletarianized.)
Yet even so, real people, as they live their lives, are reflexively romantic and qualitative. They'll drop everything, for example, to try to save the life of a child who falls down a well. Yes, from a Kennedy School point of view, such strenuous effort might be deemed a poor investment. But there's a reason why nobody gets elected to public office from the Kennedy School--the folks out there see these life-and-death issues differently.
Because ranged against every wonk is a Wordsworth. Indeed, those who think in the mode of William Wordsworth, rejecting “bottom line” thinking in favor of romantic thinking, vastly outnumbering the nerds. As the great English poet lyricized back in 1807: Getting and spending, we lay waste our powers...We have given our hearts away, a sordid boon!
Not everyone can quote Wordsworth, of course, but almost everyone thinks that morality matters more than money--we all have, or like to think we have, that spark of that celestial fire within us. And such instinctive romanticism is an ongoing rebuke to those who would smother and freeze personal feeling and compassion under the ice of cost/benefit analysis.
But there is another reason why medicine is celebrated: In addition to the romantic element, there’s also the religious dimension, which has inspired so many, over the ages, to go into the healing arts.
Having been reminded, above, about the Talmud, we are also reminded of the story about Jesus in Bethany, the House of Suffering, as recorded in Matthew 26:
6 Now when Jesus was in Bethany, in the house of Simon the leper,
7 There came unto him a woman having an alabaster box of very precious ointment, and poured it on his head, as he sat at meat.
8 But when his disciples saw it, they had indignation, saying, To what purpose is this waste?
9 For this ointment might have been sold for much, and given to the poor.
10 When Jesus understood it, he said unto them, Why trouble ye the woman? for she hath wrought a good work upon me.
11 For ye have the poor always with you; but me ye have not always.
12 For in that she hath poured this ointment on my body, she did it for my burial.
13 Verily I say unto you, Wheresoever this gospel shall be preached in the whole world, there shall also this, that this woman hath done, be told for a memorial of her.
One lesson to take away from these verses is that the Moment, if that’s the right word, can be more important than the broader Context. A single highly specific Good Work matters more than larger, vaguer Good Works. From a Christian point of view, it was more important to illustrate, for all time, in a vivid story, the importance of devotion to Jesus. By anointing Him in anticipation of His death, Christians were subsequently reminded that some things are even more important than aiding the poor. A controversial position, perhaps, but so be it. Religion is always controversial.
And speaking of controversy, one might note the role that conservative religion has played in reshaping the healthcare debate in the last 35 years. Religious conservatives have been at the forefront of the battle against “modernism” in healthcare--modernism defined as Benthamite utilitarianism, using numbers to justify “hard choices” about who lives and who dies.
In the middle of the last century, experts deemed it inevitable, as well as desirable, that we should all be moving toward a more secular calculus about life and death--just as we saw in Western Europe, where assisted suicide and euthanasia seemed to be the confident wave of the future. (In such a “progressive” intellectual context, the Supreme Court’s 1973 Roe v. Wade decision was regarded as just another milestone in the long march to social rationalization.)
From a “numbers” point of view, it makes little or no sense to preserve the life of a 90-year-old in a coma. But history suggests that if we concede that it doesn't make sense to protect the lives of the senescent elderly, then we soon find ourselves slippery-sloping our way to the point where “experts” assert that it's not worth doing too much to save the life of a one-year-old, or a 30-year-old. Medicine and healthcare are, after all, expensive.
So the Right To Lifers, and those who argue for a “seamless garment,” and for “a consistent ethic of life,” have played an historic and decisive role in turning around greatest-good-for-the-greatest-number-type arguments.
Indeed, in 2009, the Republican Party, historically associated with efforts to cut entitlements, found itself playing the role of chief defender of Medicare. An uncomfortable feeling for many libertarians, but nonetheless a decisive triumph for religious (and romantic) sentiment-- a victory for feeling over budget-consciousness.
But can we afford such heroic medicine? That’s one argument of the utilitarians that can’t just be waved away. Heroic medicine, critics say, is expensive medicine, especially when it is expended on “futile care” for “vegetables.” President Barack Obama himself said, just this week, that unchecked medical expenses would “bankrupt” the federal government.
No responsible policymaker can ignore fiscal concerns, and neither religious nor romantic sentiment should blind people to other realities, including economic realities. As Martin Luther declared, our lives must be lit by the light of faith, and by the light of reason.
But as Dr. Emond said to the Times, in the long run, doctors will find a way to streamline even ex vivo surgical “extravaganzas.” And yet history tells us that such streamlining can only occur as the result of repetition--doing the same procedure over and over again, until better and more efficient techniques are identified and applied. Through such a process, streamlining leads to assembly-lining. And assembly-lining is the key to making things better and cheaper.
It’s somewhat paradoxical that we would have to spend more to ultimately spend less, but that’s an obvious lesson of the industrial revolution over the last three centuries. You have to bear the expense of building the factory, and all the costs associated with climbing up the learning curve, before you can get the benefit of mass production. (And the jobs, and the wealth.)
But when you do reach the level of mass production, the expensive boutique item becomes the inexpensive routine item--and also, a much better item. Today, the humblest and cheapest cell phone is a vastly superior machine than the bulky portable phones that presidents and generals were using just a few decades ago.
That’s how Serious Medicine becomes Routine Medicine. And so, for example, if we put our minds to it, not only will ex vivo surgery get cheaper--performed, laparoscopically, perhaps, by robots--but one fine day, tumors will be eliminated non-invasively, through some new and better technique.
That's the story of technology, and it has its own kind of romance to it. The evidence on this score is so overwhelming that those who choose to ignore that evidence--pushing instead policies of scarcity and rationing--qualify as a category of Romantic themselves. As Luddites, peddling an alleged realism that is really pessimism, or even nihilism.
Luddites are entitled to their opinions, however wrong they might be. But when confronted by Luddism in the political and policy sphere, the rest of us are required, for our own sake, to vote against them and to keep them away from our medicine our healthcare, and our loved ones.
Posted by James P. Pinkerton at 8:51 AM