I’ve spoken of how medicine is the victim of its own success. The ability to ever more successfully manage chronic illness has contributed mightily to the financial stresses of the institution, and this is likely to continue into the foreseeable (and not so foreseeable) future. Two recent events, diametrically opposite in nature, one personal, illustrate the paradox of efforts to save and prolong life.

It was recently reported that the Northeast rapist, active since 1996, was imprisoned when he was arrested on a larceny charge, and a tip led authorities to run a DNA sample which confirmed his status as the long-sought serial rapist. He attempted to hang himself but was discovered and the act interrupted. We are now in the position to provide him with psychological testing so that he can stand trial and eventually be incarcerated for decades to come.

On a more personal front, a sixty-year-old patient of mine with a serious heart ailment that had been remarkably stable for years who I’ll call John Smith presented the hospital over a week ago after being resuscitated from a cardiac arrest. He was at risk for this but had repeatedly declined an implantable defibrillator, having experienced sudden death at the time of his heart attack years earlier that had left him fearless at the prospect of an early, sudden demise. Fortunately, or unfortunately, depending on your viewpoint, no one who knew his wishes was with him when the second event occurred, and paramedics were called. He not only survived, but his neurologic function rapidly improved over a matter of days to close to normal. In view of the delay prior to resuscitation, this is a remarkable outcome, and is likely the result of a new cooling device that is being pressed into service in a growing number of hospitals throughout the country. With a supportive wife at his side, he had a change of heart (no pun intended) and decided to have the defibrillator placed. Had he died, the cost to the system would have been nil. As it stands, he spent almost a week in intensive care, had his device placed, and will require ongoing medical treatment which will ultimately end in refractory heart failure, although it’s possible he will continue to have years of reasonable quality of life with his loved ones.

I present these two disparate examples not because I have answers, only to illustrate the uphill battle we’ll be facing. It is difficult to turn a blind eye to the act of even a despicable human being hanging himself, even if it is in society’s best interest. However, I still maintain we can take a much more passive stance when it comes to the ongoing management of disease in these individuals (the paradigm of “letting nature take its course”). As for John Smith, he’s a fine, upstanding citizen and, other than being headstrong, a delight to care for. Money spent here is well spent; the problem is that there are many more John Smiths in the system, many more cooling units being deployed, and a shrinking piggy-bank. There is also the concern that we’ll swell the ranks of people with severe, incurable brain damage that would have otherwise have had a quick, merciful death. And we have no way to predict this on an individual basis in advance.

I said I have no answers. That’s not entirely true—we need to clean up the system to free up funds where they’ll do the most good, and stop wasting them where they won’t. For those of you who tuned in late, turn to my earliest posts where I lay out how.



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