Last Thursday, The New England Journal of Medicine published an
opinion piece titled “Money and the Changing Culture of Medicine.” The
authors, Dr. Pamela Hartzband and Dr. Jerome Groopman, argue that the
current drive to fit health care into a business framework has resulted
in a loss of medicine’s communal and compassionate aspects.
It struck me as more than a little ironic that on the same day last
week — and perhaps to greater fanfare — the saga of Dr. Richard Batista
and his kidney made the national news. The Long Island surgeon is suing
his estranged wife for either the kidney he donated to her or the $1.5
million dollars he believes it is worth.
In interviews,
bioethicists and transplant experts have characterized the Batista case
as “soap opera,” “an entertainment blip,” and “impossible.” But I think
the discussions surrounding Dr. Batista’s troubles are more than light
tabloid fodder; they are representative of the problem Drs. Hartzband
and Groopman describe — the extent to which money has become enmeshed
with medicine.
Twelve years ago I participated in my first kidney
transplant from a living donor; the experience was nothing short of
extraordinary. And like the very act of donating an organ, the kidney
itself was hardly glamorous, demanding nothing in return for its
miraculous work. It was a sturdy organ — pink, firm as a small rubber
ball, and shaped much like the kidney beans you’d find at a restaurant
salad bar. Other than the vessels that emerged from the pucker on its
side, the kidney was smooth; its only bid for my attention came from a
translucent capsule that gave it an unmistakable sheen under the
operating room lights.
I watched the “bean,” as it is sometimes
lovingly called by transplant surgeons, go from brother to sister. In
one operating room, a brother lay sideways on a table, split along the
flank to expose his healthy kidney. In the operating room next door was
his sister. Another team of surgeons had made an incision the shape of
a hockey stick over her right hip and had created a small “pocket” in
her pelvis just large enough to hold a functioning kidney.
As
with other living donor transplants I would witness in the future, the
brother’s kidney began to function in his sister’s body within minutes
of connecting the vessels. Clear yellow fluid squirted out against our
instruments as we tried to suture the ureter to the bladder.
It was, I remember thinking that morning, a gift of life.
But it’s a gift, according to some, that can be assessed for as much as $1.5 million or as little as $20,000 or less.
Since
the 1984 passage of the National Organ Transplant Act, or NOTA, it has
been illegal to buy and sell organs. Nonetheless, there was no
mistaking the assumption underlying the coverage of the Batista case:
an organ is a commodity.
It is hardly headline news anymore that
kidneys and livers are available for a price. But what has been
particularly worrisome about the Batista case is the ease with which
that topic has gone from black market alleyways to local courthouses
and national media. What should have been outrage over putting a dollar
value on a human organ became curiosity over the accusations and the
pictures of those involved. Many of us reading, listening to and even
writing about the story — myself included — accepted the premise long
enough to wonder how Dr. Batista and his “medical expert” came up with
that high a figure or if it was even physiologically possible for him
to take back the kidney.
In the 25 years since NOTA was passed,
all of us, doctor and patient, have become more comfortable with
money’s role in medicine. It is routine now to assess the quality of
health care by parameters like cost containment, increased efficiency
and relative value units, or R.V.U.’s (the widget-equivalent of a
doctor’s time and effort). Increasingly, we refer to patients as
“clients” and “cases,” to doctors and clinicians as “service
providers,” and to the very act of giving care as a commodity that can
be graded, rated and quantified.
There’s no question that some of
these business metrics are good for medicine and for patient care. But
perhaps, as the Batista case has revealed, we have become so
comfortable with money in medicine that we have downgraded once
horrifying taboos to fodder for entertaining chatter and calculations.
In
order to restore medicine’s compassion, doctors and patients need to
reestablish the balance between cost containment and compassionate
care, profit-and-loss tabulations and patient-centered partnerships. We
need to give money its proper due but remember that our work, and our
worth, is and can be more than the monetary sum of parts. We need to
begin, as the Batista case has shown us, by looking critically at our
own assumptions about what we value and how we value it. Or else we
risk putting even our most priceless gifts at peril.
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