Medical Care in America … The Politics of Survival, Part II

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Fred Plum
Title: “Medical Care in America: The Politics of Survival”, Part II
VTR: 1/11/94

I’m Richard Heffner, your host on The Open Mind. And each year, because my wife is on the faculty at Cornell University Medical College, I learn first-hand about the impressive Women’s Health Symposium that the formidable, indefatigable Ellie Elliot, a governor of New York Hospital, conducts there. Well, at the 1993 Women’s Health Symposium, “The Politics of Survival” was the subject addressed by Dr. Fred Plum, neurologist-in-chief and Chairman of the Department of Neurology and Neuroscience at the New York Hospital Cornell Medical Center.

Last time, I asked Dr. Plum to examine this all important issue here on The Open Mind as well. And today we continue our discussion.

Dr. Plum, there were so many matters, issues raised last time that I don’t even known where to begin. But one point is, had to do with the certainty, it seemed to me, that you expressed concerning the neurologists’ ability to indicate when, in a very real sense, it’s all over, when consciousness is gone and a human being is in a vegetative state. Is that for sure, certain? Can’t there be any reversals?

PLUM: In anything living, one can never reach, simply by the nature of statistics, one can never reach 100 percent, because one can never know the total future. So that what one has is overwhelming probability with no evidence to the contrary when one reaches a certain point.

PLUM: Have you ever found something reversed that you thought irreversible?

PLUM: We have, I know the statistics, the world statistics on this, and they differ for different diseases. With, as we started to talk last time, with persons younger than 40 years, for example, and especially persons younger than 25 years, a severe head injury can be followed by four or five or six months of a vegetative state, yet recovery followed to the point that the individual was able to be independent. So that we’ve learned by data collection which has now gone on since April Fool’s Day 1972 when Brian Gianette and I put an article in Lancet magazine on the nature of the vegetative state, and we started then to do our prognostic study, Gianette in Europe on head injury, Plum and co-workers in this country and England, based on patients with medical, that is to say usually lack of oxygen, injury. And the numbers have increased to a very large degree by contributions from investigative neurosurgeons and neurologists around the world in the 20 years since. The data are very sturdy.

And why a neurologist? Why not just anybody? Two things. One, because the biggest risk is prematurely calling the shots. Prematurely saying that a body cannot survive. And this, at least in the early days, was a mistake often made, or potentially made on persons who had taken overdoses of sedative drugs with the intent of suicide. The other risk is making too early a decision simply because one doesn’t know all the facts. So that in the recommendations that have been drawn up by the National Neurological Societies, including the Child Neurology Societies, after a great deal of discussion and a panel which I was lucky enough to be present on and hear the opinions and the data from a variety of sources, guidelines are in effect as to when one can hopefully expect recovery to consciousness, and under what circumstances the situation becomes hopeless.

HEFFNER: Now, those guidelines are posited upon what we know now, and medical techniques that are available to us now. But over the past, in the years since you began to accumulate those statistics, certainly there have been changes in techniques, whether we’re talking about transplants or what have you that might make a difference. Is that not a fair observation?

PLUM: But, Mr. Heffner, the whole problem is based upon so-called advances in medicine. This wasn’t a problem before the end of, roughly the end of World War I when the extraordinary efficiency of the ventilators and drugs to maintain blood pressure became introduced, and the first step of the problem was to recognize that at times one was keeping dead persons alive by the simple business of maintaining their heart and pumping air into their lungs. And the new concept of brain death was established as an absolute in the early Eighties.

The second part of your question, “Isn’t it possible that tomorrow will show us something?” I don’t even know a turtle that’s gotten by with a brain transplant, much less any mammal.

HEFFNER: You know, you say that and you smile, and you say it with certainty. Would you not assume that at the beginning of this century, just as we’re coming to the end of it, that at the very beginning of the century there were eminently learned persons who assured us that they knew that there was as little chance for this to happen as for something totally, totally, totally ridiculous? Aren’t you flying in the face of everything that your own profession has demonstrated to us?

PLUM: Clearly none of us are endowed with the capacity to predict the future. If you’re going to talk about things such as brain transplants, one has to ask oneself as to how you’re going to do that. One has the precedent at the moment that we are in the stage of brain transplants. That by putting fetal cells in an area of the brain which naturally loses its cells in Parkinsonism and creates the increasing disability of that imprisoning disease in which consciousness remains, that one can at least stabilize the condition, it looks like an advance, and that possibly one may even be able to improve the condition if one is allowed access to enough fetal cells and they’re put in on both sides. And this is just now reaching the level of more widespread clinical testing in this country that was started in Sweden several years ago. But there’s a world of difference between transplanting and a whole brain to someone who’s lost it. First of all, who are you going to get to be wilting to give up his brain?

HEFFNER: You know, great question, but you’re talking now to a layperson, and not a terribly well educated, in medical terms, layperson. I’m simply raising the question with you as to whether we can, anyone can be quite so certain that tomorrow we’re not going to have to put a parenthesis around everything that we say today, because that’s happened again and again in man’s history.

PLUM: I think you can say that it won’t happen tomorrow.

HEFFNER: Next day?

PLUM: I think that you can say that it won’t happen in 25 years. And after 25 years, all bets are off.

HEFFNER: For you and for me.

PLUM: Well, no, no, no. I think in terms of the growth of…

HEFFNER: Oh, I see what you’re saying.

PLUM: …neuroscience. I’m not talking as a neuroscientist.

HEFFNER: Right.

PLUM: I’m not talking as a bedside clinician. I’m talking as a neuroscientist who knows the rate of advance in genetics, in cell survival. But we’re not talking about simple cell survival. We’re talking about the most complicated instrument in the universe. We’re talking about an instrument that probably contains something in the neighborhood of two billion – two billion – nerve cells with contact points on those two billion points that may be as much as 60,000 per cell. If you work out the probability mathematically of putting together that kind of a machine to think for somebody who simply has the housekeeping part of the brain still alive, I think that that’s, I think that that’s unreasonably hopeful for the next 25 years.

HEFFNER: Okay, Dr. Plum. Listen…

PLUM: That’s my answer.

HEFFNER: Listen, my feeling about this is that we should leave well enough alone, and probably it was well enough 20 years ago or 25 years ago. Which brings me back to the question…

PLUM: May I interrupt?

HEFFNER: Yeah, please.

PLUM: I can’t speak for you. But it’s quite likely that I would be as enthusiastically able to continue my job at my age 40 years ago. Because the health care provisions at that time simply didn’t have the same impact. It isn’t all genes. Its lack of smoking, it’s staying thin, it’s not eating too much meat, it’s not eating too much salt, it’s not doing, drinking too much alcohol. It’s the conjure which has put you and I, as lively as we are, at this table together. And I think those are not eradicable, nor would I want them to be. And if we can find anything else that will keep pushing that up five years, five years, five years, over the next century, that’s medicine’s gift. Immortality is not.

HEFFNER: But you really want it to be things that we can do for ourselves.

PLUM: Yes.

HEFFNER: Because that’s what you’ve been describing.

PLUM: Exactly.

HEFFNER: All right. The sensible things that we can do for ourselves. And yet, kind of needling you, both last time we sat at this table and right in this program, I come to the point that has been made that it is the notion that medical research will march on and on and on that puts us in the unhappy financial and perhaps moral pickle or psychological pickle that we’re in today. People like myself who keep saying, “Hey, maybe we’re going to find the way to make that transplant, because 25 years ago we didn’t believe we could do the things we’re doing today? Now, where do you draw the line? Where does medicine draw the line? At the beginning of the last program we were talking about Americans’ general feeling that we can live forever or we can live much longer. But isn’t that a function of the scientist? Is not the mad scientist. But isn’t it a function of the medical scientist who is constantly over these past two generations or more looked for the means of extending life? I mean, you’re the fellows who do it. We probably were willing to live and let die until you indicated to us that we could go on more and more, further and further.

PLUM: Discovery, and in this particular case, productivity, which is what one’s marking as essentially the center of a curve, hmm, of increased longevity and increased effectiveness, necessarily has costs. And the costs lie in the number of totally dependent, highly expensive sides to that ever rising hill of median age and ultimate age that one has at the present time And yes, there are more people aged over 80, percent wise, than ever previously existed in the history of the world. There are also more totally dependent people over the age of 80 than ever existed previously in the history of the world. And not to try to think through the ways to preserve and extend and enlarge that group which is in full possession of its faculties and can make life meaningful over the age of 80, it can’t be overlooked or for one second given up. But at the same time, one has to be sure that the residual cost to society does not become so overwhelming that we care more about people who are on the down slope of life than we do about children who are coming into life.

HEFFNER: Which raises the question, of course, what do we do about people like myself who are on the down slope? What do we do when we have to find extraordinary means, expensive means, of keeping me going, and not through great pain and not in a vegetative state? At what point do you think society should say, “Heffner, you’ve lived, not long enough, but we really can’t afford as a total society to invest all that much money in keeping you going after 68?”

PLUM: Well, you’re getting Swiftian.

HEFFNER: Nothing wrong with that. He’s lasted longer than we have.

PLUM: No, I say, you’re getting Swiftian at the horror of essentially having a population that never dies.

In terms of philosophical argument, I think it’s a potential absurdity in the sense that you are effective, you are contributing to yourself. I don’t ask that you work, I don’t ask that you pay taxes. I don’t ask anything but to honor you. I just don’t want to honor your remains at $175,000 a year.

HEFFNER: But let’s say I need dialysis…

PLUM: Yes.

HEFFNER: …if I am to continue to survive. But I’m 68. And continuing my survival means costs that, as you say, could, expenses that, as you say, could be directed toward education of the young, could be directed to many, many, many enormously needed social services. Are you willing for the medical profession or for the state to make the judgment, as I gather it is made in some places, that over a certain age, and I’m not talking about the 90’s or the 100’s, but over a certain age this facility simply isn’t available?

PLUM: Well, in fact, these are questions I should be asking you, aren’t they? Inasmuch as I’m your slave. I mean, I’m only a doctor. I cannot write the rules for the society.

HEFFNER: But I’m asking you as a doctor what rules you would write.

PLUM: I’m not the one to write the rules. I repeat, I’m the one to try to tell you what I understand about the biological nature of human capacity. And what one, what the costs are and what the benefits are as life moves forward. And you, as the society, have to make the rules as to how you’re going to allocate the resources. That’s not the doctor’s job. And many physicians would like to make it their job. But I’m keenly aware that I’m only a person in the social community. I’m only a person in the society. I can put problems in front of you which need a budget, and you can decide whether or not you wish to pay that budget. France, for example, had a law, and I think still has it, that one cannot be dialyzed over the age of 60. And a woman of a very prominent, perhaps the best-known prominent family of France elected to die in France because she had a congenital disease of the kidneys and could not be dialyzed in France. She refused to go and live elsewhere where she could have been dialyzed. And she couldn’t buy it in France because in France, whether you can buy it or not isn’t the issue.

HEFFNER: Is it, would it be enormously unfair of me to say, not Dr. Fred Plum, “Fred Plum, nice guy, Dartmouth graduate, tennis player, walker, etcetera, as a citizen, what decision would you make?”

PLUM: What decision would I make?

HEFFNER: About public policy toward dialysis.

PLUM: I would make the decision in favor of the children rather than the elderly.

HEFFNER: Now, you’ve got to put it more directly than that. You mean that you would prohibit dialysis over a certain age.

PLUM: I think we have to. I think we’re going to come to a stage whore we’re going to have to have judiciously applied rationing. We have it right now, It’s being self-imposed that the pressure – and I bless it – the pressure of the Clinton principles during the campaign and the early enunciation of the requirement for a health bill has dropped health care prices by – I only know general figures – but what I understand to be approximately 1.2 percent below what they were expected to be this year already. How has this happened? The number of laboratory tests have gone down, the number of repeated uses of CT scanning and MR scanning and other highly expensive technologies have gone down. I don’t know to what degree the transplantation or cardiac surgery and so forth has gone down. Always there’s been a certain reluctance to open heart surgery on octogenarians because of the costs-versus-survival ratio. And different surgeons have faced it in different ways. But I think it’s increasingly clear to the nation that the state of schools is reprehensibly bad, to the people of this city that if we continue to neglect an underclass, our life won’t be worth living, and that those might be issues which are as important to the payment of our tax dollars as is the indefinite maintenance of elderly bodies which have lost their capacity to know themselves or the world.

HEFFNER: Wait a minute. You’re talking only about elderly bodies that have lost the capacity to know themselves or the world. Suppose we agree, and we lock them out, we take that state of consciousness that you spoke about and make that a criterion. We’re not going to push to lead to their survival. But suppose we take, we go back – and you were very frank and I appreciate that, and I know I put you on the spot – this question of dialysis and the option you as a citizen would make. How many more of those options, which have nothing to do with consciousness, which do have to do with enabling someone who otherwise is perfectly conscious, is functioning perfectly well, but happens to be 61 rather than 59? Do you think we’re going to be able to make those choices?

PLUM: I’m not trying to duck. I think these are going to be the major discussions for the next decade. I don’t think I…

HEFFNER: Do you think we’ll engage in that discussion?

PLUM: Oh, I think it’s coming now. It’s already come in Oregon. It’s already had partial acceptance at least in Oregon that there are some things you treat and there are some things you don’t treat. Diseases of habit, for example, are falling low on the priority for reimbursement.

HEFFNER: What do you mean by diseases of habit?” Smoking…

PLUM: Smoking, intoxication, so on and so on.

HEFFNER: Kind of censorship all of its own.

PLUM: Yeah, but a…

HEFFNER: Social control.

PLUM: A rationing all of its own. These are social decisions. Slippery-slope decisions are sometimes held up to us as threatening Nazi principles. That’s absurd.

HEFFNER: Why is it absurd?

PLUM: Because we have slippery-slope decisions and they haven’t pushed us an inch toward Naziism. We set a speed limit at 55 miles an hour, which is actually about 60 miles an hour. At 60 miles an hour we can expect to lose casualties of somewhere between 35,000 and 40,000 people per year. If we drop the speed limit down to 20 miles an hour, that number would probably drop by two-thirds. At the same time, truckers would lose their living, commercial operations would slow to people being out of goods a large part of the time because of the slowness of the transportation system, an enormous people would be deprived of the privilege of going to grandmothers for Thanksgiving or Christmas. I’m just giving you examples. This is a slippery-slope decision. One decides to build a high building. It’s my understanding that the insurance rating for accidents on the job is apportioned to the height of the building with an expectation that one will severely injure or lose one worker per X floors. That’s slippery slope. We could build two-story buildings and none of this would be true.

HEFFNER: Yeah, but now look…

PLUM: (Laughter)

HEFFNER: …there is a certain crucial point at which the slippery slope becomes much more threatening, much more meaningful. And you and I agree, okay, you’re right, we’re on the slippery slope all the time because we make decisions.

PLUM: Of course.

HEFFNER: Okay. But we make decisions of a certain magnitude, or we have made decisions of a certain magnitude. And now we’re talking about making decisions about life and death, making decisions about the availability of medical treatment that are of a nature far different from what we have done before. And that’s where I ask you now not for your personal opinion as a citizen, but for your judgment as to whether we’re able, given what we’ve experienced in our national history for decades now, we’re willing to engage in that kind of discussion, serious, serious, serious. I know you cite Oregon. Can we do it generally?

PLUM: Can you engage in a discussion as to whether to spend a dollar to send a child to school whether to spend a dollar to keep somebody forever in a nursing home on dialysis?

HEFFNER: I guess, and we have 20 seconds left, my answer is, I don’t know? And I just wondered whether you, in your experience, think we are capable of doing that?

PLUM: I’m glad we both joined together with not knowing. (Laughter)

HEFFNER: (Laughter) Dr. Plum, thank you so much for joining me today. It’s clear there are so many more issues to be discussed here in this framework of medical activity. And I hope you come back many times to discuss them with me.

PLUM: You’re very generous. Thank you.

HEFFNER: And thanks too, to you in the audience. I hope you’ll join us again next time. And if you’d like to share your thoughts about our program today, our intriguing guest, please write: The Open Mind, P0 Box 7977, FDR Station, New York, NY 10150. For transcripts, send $2 in check or money order.

Meanwhile, as an old friend used to say, “Good night, and good luck?