Health Care Reform, Muriel Gillick’s The Denial of Aging

In addition to deciding whether to stop helping former automotive giants GM and Chrysler, working to restructure the deeply troubled economy and figuring out how to effectively end two wars, President Barack Obama is tackling our health care system. It is an ambitious task. At more than 15 percent, the United States spends the second highest percentage of its GDP on health care in the world, according to sources. The upward trend is expected to continue, approaching 20 percent by 2017, estimates say. Yet we also have a system in which more than 45 million people do not have health insurance-a number that has continued to grow during the past decades and shows little sign of abating. Statistics like these would appear to indicate the need for a change. Obama certainly thinks so. During his successful campaign, he sounded the call for universal health care. Since being elected, he has convened groups of “stakeholders” to Washington to initiate conversation; at this meeting, ailing Sen. Ted Kennedy, who has worked on this issue during much of his 50 years in office, received an emotional greeting. Just this week, Obama took up the issue again, saying the time for health care reform is now. He faces stiff opposition on a number of fronts, including some within his own party, powerful medical lobbying interests and conservatives who are painting Obama’s plan as yet another in a rapidly emerging long line of costly and long-lasting government mandates. If he has not done so already, Obama would do well to read Muriel Gillick’s The Denial of Aging: Perpetual Youth, Eternal Life and Other Dangerous Fantasies, a richly informative book that calls for both a confrontation with the inevitable decline accompanied by aging and health care policies and practices that reflect those realities. Thanks go out to my father, Ed Lowenstein, for lending me this book. An Associate Professor at Harvard Medical School, Gillick asserts in the book’s prelude that the baby boomers’ approaching senior citizen status will force the nation to ask “a question that in the past we have largely shied away from, insisting it’s all a matter of personal choice: What is the right approach to medical care for those near the end of life?” The question is particularly urgent both because of the sheer numbers of seniors and because of their increased life expectancy, according to Gillick. Peppering the book with examples from her clinical practice, the occasional quote from Ecclesiastes, and a fascinating section about her mother, a Holocaust survivor, Gillick calls for a re-envisioning of medical practice based both on the acceptance of people’s aging and eventual death and an acknowledgment of the extraordinary costs associated with end-of-life care. Estimates vary, but one source suggested that 40 percent of the entire Medicare budget is spent on patients’ final 30 days of life. Gillick suggests a different way, heavier on prevention and what she calls “evidence-based care” and taking intermediate, rather than extreme, measures toward the end of many people’s lives. In one chapter that was particularly helpful for an ongoing project at work, Gillick advocates for nursing home care to be based on quality of life, rather than quality of care. She also tackles difficulties with the Medicare system, assisted living and the combination of independence, dignity and connection that lead to seniors having meaningful retirement years. In short, Gillick calls for a dramatic reordering of our nation’s medical expenditures-a call that is underpinned by a shift away from what she describes as an overemphasis on the importance of individual choice. Gillick makes it clear in the book’s finale that the changes needed to achieve greater societal health relate to personal behavior, health care policy and our work force. While expressing confidence in our nation’s ability to meet the task it faces, she also does not back away from saying that drastic change is needed. The work has many strengths. Among the most noteworthy: Gillick’s clear and unflinching vision based on clinical practice, an informed critique of the current system and her own reflections; and her articulation of the present moment around this issue in American history. These positive attributes are compromised slightly by a comparatively thin analysis of how “our deep-seated faith in individualism” has become even more so during the past 30 years. Gillick cites a survey by Daniel Yankelovich and a finding from sociologist Robert Putnam’s Bowling Alone: The Collapse and Revival of American Community to buttress her point, but the effect is not particularly convincing. I have no doubt that Gillick had more personal, professional and academic resources at her disposal to make a stronger case about the rise of individualism and wish that she had used them because the point is so central to her work. That said, The Denial of Aging is an impressive and thought provoking book. The impact of Obama’s reading list has recently been compared to that of Oprah Winfrey. Public conversation and policy would be enlivened and enriched were he to read and endorse Gillick’s work.