I happened to be in the room, researching a book, when a group of doctors were debating what to do for an 86-year-old woman with breast cancer. If she had been thirty years younger, with the same early cancer, the regimen would have included a lumpectomy with radiation. Instead, a doctor who was a good forty years younger than the patient suggested that doing nothing might be the best course, not because it was compassionate to spare her the discomforts of recovery but, frankly, because she was eighty-six.
As in, there wasn't much life left to save.
One of the other doctors blew up at him. How dare he presume to decide when there was enough life left to matter and when there wasn't? It was the patient's choice -- and in that case, she opted for treatment.
I hadn't thought about her until I read about the slow-medicine movement, which encourages elderly patients to take charge of their medical care, to decide exactly what heroic measures they do and don't want as they age. As described, slow medicine sounds like a great idea, buoyed by statistics that show that most of the life-saving measures used on elderly patients don't live up to their advanced billing. The new smart move is a reasoned step away from big medicine; in fact, doctors come off in this scenario as the bad guys who suggest unnecessary treatments and procedures because that's how they make their profits.
Ah, but we forget the other two members of the power trio of institutional medicine -- the insurance companies and the government. Guess what? They'd much prefer slow medicine to fast medicine. They'd love us to chicken out on that new titanium hip because we think the physical therapy will be too arduous. They'd love us to turn down chemo and radiation, and whatever other pricey procedures the docs are offering to extend our pretty used-up lives. Expect them to endorse wholeheartedly the notion of slow medicine, because it means that we will ignore Dylan Thomas' advice, and instead go gentle -- and cheaply -- into that good night.
We're in no danger as long as these decisions reside with the patient, as they do now, in the fledgling days of the movement, but that rumbling sound you hear is the increasingly arthritic tread of the baby boomers, who are trundling into their golden years in sufficient numbers to make personal choice a social issue of monumental financial consequence. If we romanticize slow medicine into a movement, then we run the risk of the following backfire: The government and the insurance companies embrace it, codify it, turn it into policy, and, faster than you can say geriatric, somebody behind a desk is deciding whether you're too old to get reimbursed for a particular treatment.
You can still have it if they deny the request, of course, as long as you have six figures in your wallet that you don't need to spend on anything else. If that sounds suspiciously like the way health insurance too often works for those of us who are under 86, well, now you understand my concern.
Once slow medicine becomes public policy, someone, somewhere, has to figure out what's medically prudent at any given age, and that's the landslide, that's the end of a patient's right to choose. Your birthday was yesterday? So sorry; we would've given you a new hip on Tuesday, but not today. You feel like trying the treatment we'd give a younger patient because your granddaughter's getting married in a year and you'd like to be there? But we only do this procedure on people under 78; would she like to move up the wedding date? Be careful what you wish for. Every time you read an article about how Medicare's about to run out of funds, ask yourself: Will they urge me to forgo treatment because it's best for me, or because it's best for the bottom line?