Obama's Grandmother and End-of-Life Care Choices

Recently at Pajamas Media, philosophy professor Edward Halper used remarks by Obama from an interview with David Leonhardt published May 3, 2009, in the New York Times Magazine, plus an experience with his own father, to charge that health care practitioners and hospitals have "an agenda that they pursue aggressively: the speedy demise of the severely demented" and that hospitals are "practicing or urging euthanasia."

Prof. Halper approvingly cited hip replacement surgery performed on Obama's 86-year-old grandmother, Madelyn Dunham, as an example of the aggressive care that everyone should receive (apparently without regard to their individual health history or their own wishes), care that Obama coveted for his own grandmother but may deny to others under his health care plan.

Halper is wrong to say that if Obama's grandmother had been refused hip replacement surgery it would have been tantamount to euthanasia, or even just really mean.

In the interview, Obama explained that his grandmother was diagnosed with terminal cancer, apparently in September 2008, and told she could last anywhere from three to nine months, i.e., long enough to see the outcome of the election and maybe even the inauguration. Then two or three weeks later, in mid-October, she had a stroke, which caused her to fall and break her hip.

Obama said his grandmother was told, "Because of the weakness of your heart, if you have an operation on your hip there are certain risks that -- you know, your heart can't take it. On the other hand, if you just sit there with your hip like this, you're just going to waste away and your quality of life will be terrible."

"And she elected to get the hip replacement," Obama told the Times reporter, "and was fine for about two weeks after the hip replacement, and then suddenly just -- you know, things fell apart."

Let me explain that another way. Dunham was told the surgery could kill her immediately. She was told that her end-stage cancer would cause cachexia, which is weight loss and wasting due to a disease process that causes the sick person to reject food and/or fluids, due to being sickened by them. (The difference between cachexia and starvation is that in cachexia, the person does not want food, can't handle it, and rejects it. With starvation, the person wants food, can handle it, but does not get it.)

I don't know why Dunham was told her quality of life would be terrible. Was it really attributed to being bed-bound from the hip fracture if she refused the hip replacement surgery or becoming cachectic due to the cancer, or both? Or something else like feeling lonely, abandoned, powerless, and frightened of the future?

Madelyn Dunham was offered the choice of surgery because our medical system still supports the autonomy of the individual to determine their own medical treatment, if they are able to do so. For end-of-life care, this includes the autonomy to decide whether to stay in the acute care system or enter hospice care.

In the acute care system, you continue to receive aggressive treatment to the end of life, regardless of side effects that may shorten your life or make life hard to endure, and when you die heroic measures are used to try to bring you back to life. (For example, CPR is a heroic measure. The EMT or nurse who performs CPR generally breaks the sternum and some ribs in the person receiving it -- when the recipient is osteoporotic, all of the ribs may be broken. Survival rates after resuscitation are in the 1.4 to 5 percent range.)

In the hospice care system, your pain and anxiety are managed, appetite stimulants are given if needed, and you receive the food and fluids you enjoy and that your body can handle. The treatments and medications with side effects that you can't stand and which no longer can save your life are withdrawn -- ironically, this is the measure most likely to prolong your life and improve its quality. Also, in hospice care, you can die peacefully without the trauma of heroic measures.

Dunham may have seen her surgery choice as win-win: if she lived she could regain some of her walking and independence; if she died she escaped the slow death of cancer. Offering her surgery with such a small chance of success was not euthanasia because Dunham's doctors all intended to save her life. It was not assisted suicide because Dunham probably intended to live.

However, Dunham was gambling with other people's money against long odds for a small payout when the option to forgo surgery and enter hospice care had almost a 100 percent guarantee of longer and reasonably pleasant life.

Therefore Obama is right that we need to have a conversation among our medical experts and as a nation on whether to change the standard of care for the dying to have public monies pay only for hospice care.

In terms of conservative respect for individual liberty, Prof. Halper is wrong to force his values of requiring aggressive acute care for the dying on everyone because that violates the individual's autonomy to choose between acute care or hospice care.

Personally, I hope we decide that we should pay whatever it takes to preserve the right of the dying to choose between acute care and hospice care, but bring costs down by improving the hospice care system and doing a much better job of explaining why and when to choose it. This satisfies the requirements of conservatism to protect individual liberty and to reduce the cost of government.