So I have to ask the question. Does this 92 year old have the right to consume the resources used to treat an incurable, fatal and futile disease if it means we wont have the money required to treat another disease that is neither incurable, neither fatal and neither futile?
Unsurprisingly, HHO treats this case as yet another flagrant example of the profligate waste we see in everyday medical practice in America. Health care dollars and resources are a limited commodity (like oil and soybeans?), he avers---we cannot afford to waste them on the extreme elderly.
Now I think his heart is in the right place. Happy isn't a preternaturally evil person. Most of what he writes is at least reasonable. Besides, when you are an anonymous blogger, sometimes you write things you don't necessarily mean, with a stridency that you wouldn't normally use in everyday discourse. Who knows, maybe in real life HHO is a giant softy, one of those docs who brings his patients warm blankets and a cup of hot tea every morning. But on this particular topic, I think he's way off the mark and a little out of his depth.
I'm going to veer of course for bit, if that's OK. Notice first the ponderous, pretentious title of this post--- "the meaning of life". What the hell is that all about? Is this going to be another rant about Baudrillard or Kundera or DFW, you ask? Well, sort of. Just bear with me. Much of what happens to us in life is unimportant and ultimately forgettable. The traffic jam on the way home from work. Saying hi to people you pass in the hall. Pumping gas. Watching television. Reading the sports section. The lost moments of time that slip through our fingers every day. But every once in a while moments arise that demand our attention. These are the moments that either force us to step up and make good on the ideal conception of the sort of person we think we are (adversity, ethical quandaries, etc) or force us to stop and re-evaluate the very foundations of our notion of being. No matter who you are, it's important to accept these challenges when they present themselves; otherwise life is a random, arbitrary mess that ends much too quickly. My 92 year old breast cancer patient was, for me, such a moment. As a physician, and this may come off as a bit arrogant, I think I am thrust into situations that demand this sort of introspection more often than the average Joe. This is both a privilege and a burden.
A physician's raison d'etre is arguably to alleviate suffering, to improve a patient's quality of life, and to, in some cases, work to extend the duration of the life of an ill patient. Life is the common denominator. Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?
Now this is purely my take and I'm just some yahoo like all the rest of you so don't get too upset if you disagree. I see our temporal time on Earth as having two distinct components. On the one hand is our contingent, a priori self that thrusts itself upon us, the part that deprives us of our autonomy. I was born in the late 20th century. I could not choose my parents. My genome is unalterable. I was raised a certain way by my mother. This is our contingent life. It didn't have to be like it is, but it is, and there isn't anything we can do about it. And it doesn't end at birth. The contingencies of life continue until we die. Events occur beyond our control that exert pressures upon our being. Wars. Economic depressions. Pestilence. The tragic untimely death of a loved one. A car that runs a redlight as you drive home from your daughter's wedding. We cannot control them. There is no escape from the weight that they bring to bear. But we are not condemned to let contingency define us. There is another side of Life, the side of free choice and alterability. Jean-Paul Sartre wrote about the being for itself (etre pour soi) that exists fleetingly in the instantaneous moment when we are free to decide, to choose to be, to push back against the weight of our contingencies, to create ourselves, fresh and new. Heidegger's dasein (being in time)is a similar concept. We aren't always doomed to serve out the sentences of our contingencies; every moment in time brings with it an opportunity to change, to rectify, to make better. We don't have to accept defeat. Those moments that interminably rush toward us with each waking second of consciousness afford us the chance to get back up off the canvas. And this is the aspect of Life that I find far more interesting.
Going back to my old lady with breast cancer. Her situation is fraught with contingency. She has incurable cancer. The chemotherapy may do more harm than good. She's old as hell. She's seemingly crushed by the cold hard weight of pure contingency. And she knows it. She knows she is going to die, that the cancer will ultimately vanquish her. But in that dark moment of impending, irrevocable mortality, she exercises her right to push back against death for the sake of her unmarried grandchildren and whatever else--- one more spring bloom, one more Thanksgiving, one last morning snow in December. Who are we to deny her that possibility?
This goes beyond charges of ageism. It's far more important than that. What we're talking about is a woman's dignity and free will. This was an intelligent, lucent, fully informed woman who has decided etre pour soi to mount one last counterattack against the ravages of time and human fallibility. It's as simple as that. To me, the succor of life is in those moments that challenge our preconceptions of who we really are, that force us to re-assess whom we wish to become. The full life, the life bursting at the seams with effervescence, is the one where one continues to make those big decisions as long as one can, independently, without meekly capitulating to the forces of time and contingency. To see it in a 92 year old woman is not grounds for condemnation; it's a reason to celebrate. To want to live so much, to have such appreciation for the rising of another sun, to thirst so much for the chance to make it all last just a little bit longer.... man it's just beautiful. The minute we start to ration care based simply on someone's age or some other convoluted bureaucratic formula, we start to lose something indispensable about what it means to be a human being, let alone for what it means to be a doctor.
Happy says: "Being 92 and functional is, in my opinion, not a good enough reason to abuse patients in their last few months of life, while we choose to ignore the economic realities all around us."
I feel bad for the guy. He's missing something crucial about being a physician. The "economic realities" of society will plague civilations long after we've all shuffled off this mortal coil. But if we cede the terms of our existence to pure contingency and ignore that powerful force of dasein that lurks deep within us all, then we might as well close up shop now because that's not the sort of world I want my grandchildren to live in.
Anyway, that's what a scrappy 92 year old lady, who will probably be dead this time next year no matter what she does, taught me last week....