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Comment by questime | Hacker News Reader

It's politically toxic to discuss but a ton of money goes to keeping people not dead (not really alive either). You could give a lot more people medicare/medicaid if we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.

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Yes, certainly people in medicine are aware.

> we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.

Often it's a 4 week old baby.

For every 1 sophisticated family member, there are 19 unsophisticated ones, who toss a weighted coin and, if it's heads, they decide they want their dying, non-responsive relative - possibly their baby, possibly their mom, etc. - to be kept alive at all costs. I don't know if this is politically toxic as much as it is cultural, and possibly globally cultural.

> Often it's a 4 week old baby.

You are stretching the word often, most people in the ICU are close to the end of their life. A lot of people don't realize but most of the time if you needed to spend weeks in an ICU you are probably not "living" in a dignified way. Almost all ICU doctors/nurses I've talked to would rather have a DNR in their old age than live like that.

Your human dignity is not predicated on how much pain you're in, how awake you are, or how able you are.

Uhh, yes it is to all three of those things.

If I'm in pain, am delirious, and am unable to operate in the world. I've lost my dignity.

Just because you feel undignified, or humiliated, or useless, does not mean that you are. Don't swallow the lies.

You mean yours.

My human dignity does depend on whether I have to endure the rest of my life pooping my pants, not remembering my own name, and hooked up to some noisy machine telling my lungs to breathe and my heart to beat.

Could you please stop creating accounts for every few comments you post? We ban accounts that do that. This is in the site guidelines: https://news.ycombinator.com/newsguidelines.html.

You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...

It's pretty well know and often discussed that up to 1/3 of Medicare spending is wasted. Being fee for service doesn't help but neither does spending 13-25% of all medicare dollars on end of life care[1].

What's worse is how much of Medicare's wasted spending goes to harmful treatments.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/#:~:tex....

Many of the top causes of death, per the CDC, are from diseases that can be prevented or naturally mitigated. We're all going to get old. We're all going to die. But carrying two or more "pre-existing conditions" into your later years is going to decrease your quality of life, as well as your use of healthcare.

My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy. But the USA wants to have its cake and eat it too, literally. That's not working out. It's not sustainable.

Finally, not to get off topic but over the last couple of weeks there's been a thread or two on HN based on acticles suggesting the GDP and similar "classics" economic metrics are hiding underlying social issues. That is, for example, healthcare care contributes to the GDP (or whatever) but that healthcare is for diabetes, opioids, faltering mental health, etc. We're falling apart but not to worry the economy is doing just fine.

It's complicated. But to your point, the fact that some important topics are ofc limits isn't helping. Until that changes the status quo will continue.

> My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy.

The recent push to try to re-frame obesity as healthy, fashionable and sexy seems particularly bizarre and unexplainable. It's the opposite of what happened with cigarettes, which started out as fashionable and healthy, then slowly became known as unhealthy and finally fell out of cultural fashion.

I think the root of it is recognition that mental health is as important as physical health, and that losing weight isn’t as easy as many people assume, and shouldn’t be done the way many people try - so actively shaming and criticizing fat people for being fat is of negative health utility overall.

> o actively shaming and criticizing fat people for being fat is of negative health utility overall.

Fair enough. But then what do you suggest we do as an alternative to normalizing diabetes and obesity?

To your point - kinda - about losing weight. Changing behavior isn't any easier when there are too few environmental signals to nudge behavior in a more healthy direction. As humans, we are wired to assume the norm we see around us. How do we reverse the tide when abnormal (and unhealthy) has been normalized? When everywhere you look, there are people just like you?

I do agree. Mental health is important. But a component of that is (dealing with) adversity. I'm certainly not condoning repetitive malicious bullying, but the current climate has outlawed any/all references to traits connected with being unhealthy. At this point there are no social deterrents, are we really better off?

Have we robbed Peter to over-feed Paul?

I think that it's also important to realize that maximizing "health" is not some kind of absolute goal. Not every aspect of life needs to be optimized to the highest level.

Of course, obesity is a huge issue (especially in the U.S. compared to many other "developed" countries) that can affect people's lives negatively and causes further medical issues such as diabetes, and ultimately can prevent people from leading a life that is as fulfilling and meaningful as they would have liked.

But we are still dealing with people here, not rats in a laboratory experiment, and I think the issues that directly follow from being obese are already bad enough that it does not help to pile on more shame by treating those people as being "weak-willed" or something of the sort, or denying them basic human dignity and respect for being outside the sacred norm. Do we really have to add artificial negative consequences for being overweight? Does that help those people have a more fulfilling and meaningful life?

I don't think people will just forget the direct negative physical/social consequences of being overweight by not being reminded of them all the time in a moralistic tone (and even just reminding people of such information can be moralizing, depending on the context in which the information is provided).

Any form of euthanasia runs into the legal and moral problem of who decides? And why?

You might think everyone wants to act in the best interests of their relatives, but of course that's not true. Some people will want to speed the natural process along because that inheritance looks really appealing, and no one is really going to miss the old guy/gal anyway.

Besides, that's not really the problem. The problem is profiteering by insurance companies and the hospitals they (effectively) run for profit, with patient wellbeing as a regrettable requirement they have to put some effort into.

I don't think its politically toxic, but rather, extremely humane that we care for our elderly. The real unfortunate part is that we, in the working class, have to make due with sharing slices of the pie so more money can go to our exploiters and owners - especially in the US, we are such a wealthy nation, and yet here we are bickering around who deserves care based on age. Sad.

> I don't think its politically toxic

Ever hear of the Obamacare death panels? The ones where doctors would decide if your loved one was too old and shouldn’t get treatment?

Yeah. That’s this.

What it really was that Medicare would pay for consultation with doctors (?) to discuss end of life care and setup living wills and DNRs and such if the person wanted.

That way if something happened and they were taken to the hospital they could be treated the way they wanted to be and not stuck in a coma on a vent for the rest of their life if that was against their wishes.

But the Republicans branded then “death panels” (which for political purposes was brilliant). So the choice of having help making those decisions was removed.

I disagree, spending on these things is growing at 2x GDP growth so yes more of the pie is going to this. What I'm suggesting is that at some point the pie isn't big enough for this. No matter what happens eventually standard of care will roll back/fewer people will be covered etc. Ideally we can innovate out of this situation but after spending 8 years working in healthcare I've gotten cynical about it.

We don't care for our elderly. We fear death.

If our society really cared for the elderly, they would be integrated and respected, not segregated and shunned. We do the latter because we fear age, sickness, and death. Fear isn't caring.

> We fear death

In the US. It's perhaps the most striking difference that hit me during my stay overseas. In the Old World we occasionally get people completely panicking about their own death. In the US, seemingly _everyone_ is like that.

I'd like to hear how elders are treated in these societies that don't fear death as much.

I'd wager: not very differently. But not out of fear. The social isolation of old age is the same everywhere. Young people have their own lives to live.

> The social isolation of old age is the same everywhere

That is certainly not true. Traditional societies and non-western societies have far different ways of relating to elders than we do, and even among western societies there are variations.

Well, yes I see what you mean. What I meant was: it's the same in the US and western Europe. But certainly if you go to more "old fashioned" places, the elderly usually live with the family and are taken care of. To be fair, this still happens even in "advanced" western societies. I seem to recall this also goes together with a lot of elderly abuse.

I wonder if elder abuse is correlated with younger people "having their lives to live".

Where do you draw the line? At what age, what illness do you refuse to treat a patient even though he may not want to die?

You could give a lot of people medical treatment with a proper healthcare and tax system. Why don't we try that first?

At some QALY/$.

QALYs are hardly non-controversial.

The original comment by questime literally said we should discuss the general topic even though it's controversial.

> Where do you draw the line? At what age

30? or 21, if you prefer the book ;p

I assume we start by getting more information from patients about their wishes, and then following them accordingly. A large number of elderly people don't want hopeless and unpleasant medical interventions, but end up having them anyway because no one asked them.

Canada is actually moving in that direction with their medical assistance in dying laws.

Is it the same dilemma if we can kill one to save more?

This is an oft-repeated piece of received wisdom that is empirically untrue.

https://www.statnews.com/2018/06/28/end-of-life-health-spend...

Wow: just sample bias! We need to also look at the old people who had expensive care and survived (95% of costs in that article). Money does gets spent on hospital care just before death (5%), but predicting how to avoid “wasting” that money is hard.

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