Sunday, September 7, 2008

POSTER CHILDREN?

In a previous blog (Life and Death in the Great Northwest – Part I) I wrote about Oregon’s successful Death With Dignity law and the upcoming election in Washington state where something nearly identical is on the ballot. I also mentioned political opposition to the Washington measure in the form of millions of dollars from religious conservatives, particularly the Catholic Church. Even the Portland Archdiocese has contributed a hefty sum, notwith- standing its struggle to pay for past child sexual abuse cases.

Now Fox News and the right-wing blogosphere have chimed in big as well. Since this is a campaign, and every campaign needs a poster, the search seems to be on for poster children. The leading candidate at the moment may be Randy Stroup, 53 years old, from Dexter, Oregon, who is afflicted with a recurrent prostate cancer judged to be terminal. A second Oregonian, 64 year-old Barbara Wagner, terminally ill with recurrent lung cancer, has made news as well, though not at the national level.

Without actually interviewing Mr. Stroup or Ms. Wagner, I’ve done my best to learn the facts. But first, we should express sympathy for them and acknowledge the cruel situations they face. Both, as noted, are terminally ill, with Stroup still a rela- tively young man, and both receive their health care through a public Oregon program coordinated with Medicaid, because neither could afford care otherwise. They both have received the full range of standard treatments, but both are now on the wrong side of Oregon’s long-standing and perfectly legal "5 in 5 rule"—no treatments exist that offer a 5% or greater chance of ensuring their survival for 5 or more years.

In both cases there are expensive new chemotherapy agents that might postpone their deaths by two to six months, with some possible gain in quality of life, but the costs are beyond what Oregon’s plan will pay. When the "5 in 5 rule" can’t be met, it covers only hospice care, palliative care—i.e. intervention for comfort and pain reduction—or access to lethal drugs under the state’s Death With Dignity law. Both Stroup and Wagner have received coverage denials in writing, yet the letters were so inartfully written that a nudging by the state toward the last of those options could be inferred. It was this that Fox News, et al seized upon to allege that Oregon is headed down the slippery slope to forced euthanasia, just as Death With Dignity opponents had predicted all along. Sadly, Stroup may believe that himself.

Maybe he’s at least enjoying the attention, and I don’t begrudge him, nor do I know how he got on Fox News’s radar, but the timing of the blowup in view of the election in nearby Washington hardly seems coincidental. Meanwhile, Ms. Wagner has actually benefited. Sensing a PR coup, Big Pharma, in this instance Genentech, has gifted her a one-year supply of erlotinib, the $4,000-per-month pills in question. All to the good, of course, so let’s hope the treatment works spectacularly and she beats the odds. Stroup hasn’t yet been as lucky, and it would be great if something broke in his favor too.

But what about the underlying argument. Is Oregon forcing people into euthanasia? No, not even close, though were that true, it would certainly be worth getting excited about. The fact is, Stroup and Wagner, by any measure, are better off under the health plan they have than with nothing, and in my opinion, better off in Oregon than they would be elsewhere.

Without health coverage, as President Bush said in discussing the uninsured, "you can always go to the ER." But does anyone ima-gine an ER would provide and pay for these kinds of treatments? Or would Medicaid in some other state? Slim chance. Or if Stroup and Wagner had private insurance, would their coverage extend that far? Not in 99% of the policies out there. So medically, in terms of what’s available to them at affordable cost, the Oregon Health Plan is it. And Oregon is also better, because the usual options of hospice or palliative care are delivered in a manner found by a recent University of Wisconsin study to rank Oregon with three other states as best in the nation. Moreover, uniquely in Oregon, patients can decide if and when to end their own suffering in the future should they choose.

Fox News was aflame with the horrors of medical rationing and the sinister presence of euthanasia. As if we don’t have rampant medical rationing now throughout the US that goes all but un- remarked. Under our so-called health care system, you get the treatment you can pay for, or some bedrock minimum, varying state-by-state, through public assistance when you’re out of money. For anything beyond that, tough luck. A better designed, more efficient and more universal system would undoubtedly raise the level of that bedrock minimum in many places, which I wholeheartedly support, but no system, public or private, would or could meet every imaginable need for every patient.

That happens only when you’re the one writing the checks, after which you still may die, sometimes in even greater pain, on the schedule originally forecast. In cancer we’re fighting a not fully understood disease with remedies that are at best only approxi- mately equal to the job. That’s why Stroup and Wagner had re- currences.

As a result, Genentech, not Oregon taxpayers, ought to be footing the bill for Ms. Wagner’s treatment. She’s in a fashion serving as their guinea pig, and if their brand of erlotinib proves more ef- fective than previous clinical trials have demonstrated, they’ll be handsomely rewarded with future profits. Fox News and other political opponents of Washington State’s Death With Dignity initiative seem bent on working up outrage over Stroup and Wagner, but sorry, I don’t see it. All I see is that the wording of Oregon’s treatment denial letters badly needs to be revised.

1 comment:

Last one standing said...

Visit http://www.ItsMyDecision.org to learn more about YES on 1000, Washington's Death with Dignity initiative