Could Versus Should, The Unasked Question


Last week, I was interviewing, and I was asked a question for which I should have been

prepared.  Of course saying this, I realize the question is one politicians, medical professionals

and the rest of the country have been trying to answer for years, so it’s not like I expect to have

the perfect answer.  After the interview, the question stuck with me to the point where I wrote

back to the interviewers thanking them for the interview and the question which had stuck with

me after the interview.  The question is one I still find myself mulling almost a week later.

“If you had a magic wand, how would you fix the healthcare system in America?” 


After thanking the interviewers, I wrote this:


As I was going home and then later putting my kids to bed, I was thinking about the question how would I use my magic wand to fix healthcare.  While I still stand by the answers of single payer and/or universal billing system as helpful to improve aggregate societal health, it occurs to me I failed to mention fixing a large part of the problem.  These are potential band aids, but they assume many decisions stay constant.  As a society we are loathe to talk about the beginning and ending of our lives.  Sex/birth control is a taboo topic and so is death.  With our reluctance to talk about these issues as a society, we all too often fail to ever come to grips with the questions of “should.”  We instead focus on the questions of “can.”  If we can, then we should is the assumption.


“Can we save this limb / life?” is the question we ask instead of “Should we save this life or limb and at what cost?”  I saw this when a 21 year old friend was pinned against a guard rail by a car.  She is at the 6-month post accident point, and it is still unknown whether she will ever regain use of the leg.  For less money and pain, she could be using a prosthetic and well on her way through rehab, but the assumption was they should try to save the leg because it may work.  That was how it was presented to her despite at least a 50/50 split amongst my medical friends who say they would have wanted their own leg removed.. 


As a society, we do not often ask what the costs will mean for our families or society.  I doubt any of my children’s birth parents ever gave a moments thought to how much the state of MD would pay to keep their children alive and later raised.  I am personally glad they did not.  However, with such a huge portion of the cost of healthcare being accrued in end of life care to prolong life for such short periods of time, at some point society will need to come to a point where we can at least acknowledge the costs and trade offs implicit in our choices or refusal to make choices.  At some point, we need to come to a point where “should” is not simply implied, and a conversation can take place.


I would never imply there is a universal correct answer or formula, but if I could wave my wand, I would at least get us to a point where we could talk about what our choices really imply in terms of trade offs.  Is saving my productivity for a year worth more than the cost of a college education?  Is keeping grandma alive in a coma from which she will never wake worth more than keeping a soup kitchen open for the same amount of time?  Should we use stem cells to prolong life?  Perhaps someday we will be able to bio-engineer our systems to be resistant to certain diseases, but should we do so?


As I think about the question of fixing our healthcare system, I am beginning to think my assumptions in our conversation were a bit misguided.  A lot of what is trending wrong happens well outside our traditional doctors’ offices and hospitals.  I also recognize much of this is outside the scope of the board except to say the presentation of the trade offs and respecting of patients views of their own trade offs is vital for any doctor.  When I think about what I like most in my neurologist, it is not just that he answers emails.  He has also never second guessed my willingness to take the riskier medications to prolong the time I can maximize my efforts to raise my kids.


In any event, thank you for giving me the questions to let me better phrase what I value from my doctors.