Putting a Price on Compassion

January 16, 2009
Doctor and Patient
Putting a Price on Compassion
By PAULINE W. CHEN

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.

http://www.nytimes.com/2009/01/16/health/15chen.html?_r=1