The need to control health care cost is a central challenge for health and economic policy. Other than the high prices we pay in the U.S., chronic illness is a main driver of cost escalation, especially for Medicare. Seventy-six percent of Medicare spending is on patients with five or more chronic diseases, including heart disease, metabolic syndrome, end-stage renal disease, and cancer. Treatment usually doesn’t lead to a cure, but it does tend to extend patients’ lives.
Prolonging life is one of the triumphs of medicine when the result is reasonably good health. But often costly treatments for chronic illnesses simply prolong the dying process, inevitably raising difficult questions about setting limits. “It is a great miracle that medicine can almost equal nature in forcing a man to remain in bed, to continue on pain of death the use of some drug.” That statement would not be out of place in current health policy debate, but it was written by Marcel Proust in 1923 in Remembrances of Things Past: Volume III – The Captive, The Fugitive, Time Regained. The rest of the passage, which follows, resonates today.
“I learned that a death had occurred during the day which distressed me greatly, that of Bergotte. It was known that he had been ill for a long time past. Not, of course, with the illness from which he had suffered originally and which was natural. Nature hardly seems capable of giving us any but quite short illnesses. But medicine has annexed to itself the art of prolonging them. Remedies, the respite that they procure, the relapses that a temporary cessation of them provokes, compose a sham illness to which the patient grows so accustomed that he ends by making it permanent, just as children continue to give way to fits of coughing long after they have been cured of the whooping cough. Then remedies begin to have less effect, the doses are increased, they cease to do any good, but they have begun to do harm thanks to that lasting indisposition. Nature would not have offered them so long a tenure. It is a great miracle that medicine can almost equal nature in forcing a man to remain in bed, to continue on pain of death the use of some drug. From that moment the illness artificially grated has taken root, has become a secondary but a genuine illness, with this difference only that natural illnesses are cured, but never those which medicine creates, for it knows not the secret of their cure.”