The New York Times published a thought-provoking article today about the opioid crisis and the healthcare industry's evolving response to it, but also about second chances and human nature.
Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?
By Abby Goodnough, April 29, 2018I highly recommend reading the full article. A few thoughts below.
OAK RIDGE, Tenn. — Jerika Whitefield's memories of the infection that almost killed her are muddled, except for a few. Her young children peering at her in the hospital bed. Her stepfather wrapping her limp arms around the baby. Her whispered appeal to a skeptical nurse: "Please don't let me die. I promise, I won't ever do it again."
Ms. Whitefield, 28, had developed endocarditis, an infection of the heart valves caused by bacteria that entered her blood when she injected methamphetamine one morning in 2016. Doctors saved her life with open-heart surgery, but before operating, they gave her a jolting warning: If she continued shooting up and got reinfected, they would not operate again.
With meth resurgent and the opioid crisis showing no sign of abating, a growing number of people are getting endocarditis from injecting the drugs — sometimes repeatedly if they continue shooting up. Many are uninsured, and the care they need is expensive, intensive and often lasts months. All of this has doctors grappling with an ethically fraught question: Is a heart ever not worth fixing?
The various hospital systems' focus on antibiotics and surgery seems to be short-sighted. In these cases, endocarditis is only a symptom – addiction is the underlying disease. Ms. Whitefield, Dr. Pollard, and Ms. Stringfield are right to think about what happens after surgery, and it's certainly plausible that funding addiction treatment programs would save the hospitals money in the long run.
The issue is who pays for that treatment in the short term. This quote struck me:
"Everybody has sympathy for babies and children," [Dr. Pollard] said. "No one wants to help the adult drug addict because the thought is they did this to themselves."Cause and effect, action and consequence: people who shoot up bring their misfortune on themselves. I suppose it's human nature to think this way, but the world isn't that deterministic. These days it's fairly widely recognized that addiction has genetic and environmental components in addition to behavioral ones, just like practically every other disease.
Take sun exposure, a risk factor for skin cancer. If a light-skinned person never uses sunblock and spends a lot of time outdoors, how responsible are they if a skin cancer ultimately develops? One could argue that they should've done more to protect themselves, but external factors and randomness play a huge role. Believing bad outcomes can always be anticipated and avoided is magical thinking. I suspect most people would be uncomfortable with the assertion that a person with skin cancer should be denied surgery1 if they didn't use sunblock.
Addiction and skin cancer? It's a difference of degree, not of kind2. In any case, false certainty and judgment don't help solve these problems.
1 Maybe that's what happens anyway when people don't have insurance, but that's another blog post. (back)
2 In the sense that behavior isn't the only, and perhaps not even the primary, risk factor. (back)
Thanks for recommending this article, Paul. Thought provoking indeed. Another thought I had, aside from the issues you comment on, is whether the author's choice of such a sympathetic primary subject--a young mother who might not live long enough to see her children grow up--could be considered unduly manipulative.
ReplyDeleteI agree with your focus on addiction as the underlying problem, treatment of which might be more cost effective in the long run. When it comes to sun exposure and skin cancer, though, I don't see how it's unreasonable to judge that someone who spent a lot of time in the sun should have used sunblock. I don't think that kind of judgment amounts to "believing bad outcomes can always be anticipated and avoided," which is "magical thinking." Isn't it reasonable to expect people to make basic efforts to take care of themselves in well-known ways that don't cost much but significantly reduce risk, such as applying sunblock at the beach, fastening the seat belt, etc? That sort of expectation doesn't seem like "false certainty" that the bad outcome won't sometimes happen anyway. But you are right, I think, in saying most of us, despite our tsk-tsk and tut-tut judgmental inclination, wouldn't go so far as to deny medical treatment to the un-sublocked skin cancer patient or the un-seatbelted victim of a car crash.
So, moving back to addiction, I think that considering someone to be at least partly responsible is not only natural but can be helpful, in that it implies the person has some degree of agency, some degree of control. I think the addicted person needs to feel some degree of agency in order to feel she has a chance to deal with the problems and manage if not always overcome them, as opposed to feeling like a hopeless powerless victim. There is a lot of nuance here, of course. My use of the term "judgment" as "holding one to be at least partly responsible" is meant to be a vote of confidence in the addicted person, because it says you have the ability to do otherwise, though it may need awakening and some coaching (and may possibly require medication as well). This is probably not the "judgmentalism" the subject in the article complained about, which I think is meant not to instill hope but rather shame, and which then excuses those doing the judging from any obligation to help, because she "did it to herself" and so doesn't deserve help. The fact that the help can be extremely expensive, as with heart valve replacement, thus doesn't have to be confronted.
But wait. Isn't the cost of a treatment relevant after all? We can't afford as a society to perform every kind of medical procedure on everyone who might possibly benefit from it. So isn't some kind of "judgment" needed as to which patients should be denied, which is inevitably a decision about which patients are more "deserving"--more deserving, say, of the liver transplant (someone who contracted hepatitis C from a tainted blood transfusion before blood was routinely tested vs someone who destroyed his liver through alcohol consumption?), or which patient is more "deserving" of the first or second heart valve replacement (the mother who swears she will stop using vs the young man on whom Dr Pollard declined to operate because he continued using?).
Wouldn't virtually all of us choose the young mother, as the author of the article most certainly assumed we would? So yes, thought provoking.
Thanks for the comment. Yes, I meant judgment in the sense of self-righteous tut-tutting, not as in exercising judgment.
DeleteSunblock is actually an interesting case. The articles I've seen (e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4399380/) suggest that typical use – slather on a bunch before going on a hike or to the beach – isn't sufficient to protect against the more serious forms of skin cancer. Daily use has been shown to reduce risk, but I've never met anyone who applies the stuff every morning. I wonder if any of the major moisturizer or skin cream brands include SPF-15+ in their product?
As far as magical thinking goes, I've observed the typical thought process to be something like "If they had/hadn't X, then Y would/wouldn't have happened." I see this constantly in the reader comments of news articles that're at least somewhat controversial. The implication seems to be that the virtuous X-aware (like the commenter) would never experience/ignore Y, without acknowledging that in the absence of X, Y could've been pinned on X', X'', X*....
From a statistical point of view, the effect size of the intervention (sunblock) is much smaller than the natural variability wrapped up in environmental factors (e.g. freckles, living in the tropics) and the error term (unmeasurables, randomness, bad luck). That doesn't mean the intervention isn't worthwhile, or that ignoring it isn't irresponsible, but it does mean that we're kidding ourselves when we make deterministic statements. People can and do have some responsibility for outcomes, but based on Ms. Whitefield's account, the health system's judgmentalism seems not to differentiate between those who have accepted responsibility and those who haven't, which is a problem.
Cost absolutely matters. I think the "homo economicus" (https://en.wikipedia.org/wiki/Homo_economicus) formulation would involve expected return on investment (let's call this EROI), where the investment is the cumulative cost of all the interventions or surgeries someone receives, plus secondary effects. The EROI of a second heart valve surgery on the 25-year-old could well be a third heart surgery down the road, at which point the surgeon has to make hard decisions about limited resources. But maybe the EROI of adding addiction treatment and counseling to the first heart surgery would have been enough lifetime earnings to pay back Medicaid for the heart surgery and the additional counseling. Reading between the lines, the issue seems to be that the area's health systems each view being the first to pilot such an initiative as a competitive disadvantage, which, again, is a problem.
I think the 2017 tax bill included some funding for researching the opioid crisis. I wonder how much of an impact this will have.
Definitely a thought provoking article. I will also note that Oak Ridge, TN is one of the towns I grew up in (and I would say was center of gravity of my childhood moves since that was where my dad always worked). All my family on my dad's side still lives there or within a few miles of there, and my niece and nephew go to Oak Ridge schools.
ReplyDeleteThat's right - I'd forgotten that you grew up around Oak Ridge. Does it change the tone of the article for you?
Delete