Wednesday, February 27, 2002

This one really does justice to the theme of this blog:

Use a Gun, Get a Ticker
Why should taxpayers shell out a million bucks for a crook's transplant?

Thursday, February 28, 2002 12:01 a.m. EST
…. (an inmate in California) serving 14 years for armed robbery, last month received a $913,000 heart transplant at the top-flight Stanford medical center, paid for by the state's taxpayers. Statistically speaking, he now has a 74% chance of living through the next five years of his incarceration. Here's hoping he opts for the low-cholesterol meal plan on the prison menu.

This is something I’ve been thinking about for years, in one context or other. When I was an intern, I once had a patient who had been through five, (5), no that’s not a misprint, FIVE heart transplants. (Truth-in-blogging: this was well over a decade ago, so I can't remember whether this man had already had 5 transplants, or was on his fourth heading to his fifth. I am certain, however, that he'd had more than one transplant already) He was in my ICU with shortness of breath as his latest heart was failing. He probably would have had chest pains, except that he was working on a transplanted heart, and there were no pain fibers running from the heart to his brain. This man was (1) Obese and (2) just done with a cigarette when he rolled in. He also admitted to eating whatever he wanted (i.e. steak) when he was outside. Meanwhile, it’s a guarantee that the general public was paying for his care one way or another. Given the cost-shifting that goes on at major academic medical centers, either Medicare, healthy insurance customers, or the University Endowment was taking a major kick in the teeth for the benefit of a man who was making almost no effort to reduce his need for another transplant. I doubt it was the University Endowment.

I have a T-shirt from the Charity Hospital Emergency Medical Services in New Orleans. The T-shirt says “The life you save … may take your own.” That’s not just a slogan. Many of the patients at any urban medical center would, if they weren’t restrained, casually kill and rob the doctors who are loosing sleep to keep them alive. There was a mass shooting at the LA County ER in 1992 or 1993. Simple assault by people who are alive only because their victims kept them so, happens every day.

And now this case from the California Prison System. I have worked as a prison doc, and I spent a lot of my time behind the walls thinking about issues like this.

So here’s the common thread about which I’m trying to make sense: under what circumstances should “society” pay for the health care of people who are, through their own fault, a net drain or a net danger to society? How do we as a “society” make those decisions? I actually have an answer, and it’s one that the transplant surgeons are going to hate. Actually, I’m not too happy with my answer either, for reasons I’ll get to below.

My answer to the question about what we owe to the irresponsible and the dangerous? Nothing. Let them die. The irresponsible have already demonstrated that they don’t value their own lives enough to give up smoking or red meat.

The dangerous are even worse: they don’t value life enough even to give up shooting sprees and violent crime. I mean, I might be able to speculate that nicotine is physically addictive, so smokers might really value life, and yet be unable to stop smoking (though I doubt it). I am unable to concede that being willing to criminally fire off a gun into a crowd of strangers is in any way compatible with a respect for life. (note to hyper-critical readers: I said criminally fire a gun. I am not talking about acts of war, defense of life or property, or any justifiable, non-criminal shooting). Our bank robber, though he may not have actually killed anyone, probably demonstrated that he was willing to do so by waving a gun around and threatening everyone within earshot that he would kill them if they didn’t cooperate.

Meanwhile, it’s a good guess that the people who are paying for multiple heart transplants could find a use for that money that would buy them something they cared about, whether it be a college education for the kids or a kickin’ Fender Stratocaster. By taking money from people who might be a little happier with it, to pay for the extended life of someone who doesn’t value life anyway, we are making the general public a little worse off, and not making anyone really better off.

Well, someone is better off when we fund all sorts of transplants, and that brings me to why the transplant surgeons won’t be happy with what I just wrote. It’s an open secret among physicians that a plurality of transplant recipients, particularly on the West Coast, have blown out their own organs. Yes, I know, the CDC claims that hepatitis C is the largest reason for liver transplants, but I don’t think that tells the whole story. These people with hep C who develop liver failure tend to be exactly NOT the kind of person who developed hep C from some minor mistake, took care of himself, and then, unfortunately, got sick. Rather, the transplant recipients tend to be the ones who were alcoholics who happened to get hep C. As for kidney transplants, I have it on extremely good authority (i.e. a famous nephrologist) that approximately 85% of people on dialysis are on it because of "poor control" of hypertension or diabetes, i.e. (though this is NOT how the nephrologist put it) they just don't bother to take their pills. I’ve never seen a study that would prove or disprove what I just said, so feel free to take that with a grain of salt (though I did work in the ORs of two major liver-transplant programs, and I have anecdotal evidence from the UCLA liver transplant program for my belief. For those who don’t know, UCLA has been America’s largest liver transplant program, and may still be).

So why am I not happy with my “let ‘em all die” stance? There’s actually a very simple reason, and anyone who has read my earlier posts might have already guessed it. OK, here it is. The bottom line is that, particularly in trying to identify who is dangerous, I don’t trust the state to get it right. What if the “bank robber” who inspired this post was framed? What if he was just convicted by mistake? What if he was prosecuted on circumstantial evidence by a racist DA who was desperate to convict ANYONE, in order to cover up a previous wrongful prosecution? (see below for my very own take on what seems to be just such a case). If so, then we’ve taken away an innocent man’s ability to provide for his own healthcare. Under those circumstances, we (meaning, yes, you and me and all voters) really owe it to him to keep him alive at least until he can clear his name.

Well, as usual, you know the name of this blog. If you want to help me make sense of it, feel free to email.

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