I remember a while back two articles were released in the New Yorker and the New York Magazine about reproductive medicine and the impact it has on our nation’s overall health care budget. Both articles approached the idea of aging mothers, fertility clinics, and premature birth sensitively and though different, both equally eloquent.
What struck me most about each article was the element of choice, especially in premature birth. With medical advancements, a “viable” pregnancy (limit of viability) has shifted to 24 weeks gestation. Yet the survival rate, and then the complications and resulting disability rates are high. The expecting family is asked during the time of early delivery what they would like the doctor to do. In Europe, the decision is made for them. Pre-24 weeks, the fetus is not rescusitated and put onto ventilators to help their undeveloped lungs breath. There’s a threshold, alleviated the decision from the parents, as well as from the doctor.
In the US, this decision is made by the patients, with advice from their physicians, where advice includes risks, complications, likelihood of survival, etc. It is up to the parents to choose, to take the risk of survival, complications, or even death. Should they say yes to ventilators, they might end up with an extremely disabled child. Cerebral Palsy is a common result. However, full recovery is also a possibility. How does one decide?
Though this is an extreme case of the burden of choice, it’s not far off from what our health care system as a whole is grappling with.
Health care is a new consumer-driven industry. Technological solutions to improving access and patient-control are slowly moving into the folds of our everyday lives. People are being asked to be more engaged and more accountable for maintaining their health. An overwhelming onslaught of new gadgets and smartphone applications promise to drive behavior change by improving people’s awareness. People are provided with the ability to choose an insurer, a provider, a schedule; they are also able to dive deep into medication through companies like iodine, or treatment regimens for chronic conditions. Much of this isn’t entirely new, but the technology enabling more personalized and useful information to the individual certainly is.
There of course remains the challenge of education, where technological innovation and iteration is moving at such rapid clips that regulatory or assimilating bodies cannot possibly keep up. Which brings us back to the burden of choice and to the challenges within. Though it’s tempting to say that it is all good that health care is turning into a consumer-driven industry, there is still that wonky element that Atul Guwande examines in his book Complications. Often decisions are made with combinations of fact, feeling, intuition, or personal experience. For this and so many other reasons, patients and health care providers must be co-pilots or collaborative co-operators. The burden to choose should lie on both sets of shoulders, and the responsibility to respectfully listen and provide useful information while also being critical must equally be ingrained into that interaction.