Medical Minimalism as an Alternative for the Elderly

Medical technology has undergone a very large growth in the past fifty years. There are now all kinds of enormously complicated devices and tests that can diagnose and treat a host of conditions. With such technology has come problems that have been called overdiagnosis and overtreatment.  Overdiagnosis is when large numbers of people end up with a diagnosis that does not correspond to any medical condition that needs to be treated.  Overtreatment is when unnecessary medical care occurs.  The table below shows some common cases where overdiagnosis often occurs.  The quotes are from Table 1 of this paper. 

Asthma	Very many given this diagnosis may need no treatment.
Attention deficit disorder	Many given this diagnosis may need no treatment.
Breast cancer	Up to one third of positive results in screening tests may be false alarms
Depression	There is substantial overdiagnosis, according to some experts
High blood pressure	A change in standards now classifies millions of new people as having high blood pressure, people who were previously said to have normal blood pressure
Lung cancer	25% of lung cancer diagnoses may be in error
Osteoporosis	“Expanded definitions – many treated low-risk women have net harm from treatment”
Prostate cancer	“About 40% of cases diagnosed by screening likely 'clinically insignificant' ”
Pulmonary embolism	“Increased diagnostic sensitivity – detection of small emboli. Many may not require anticoagulant treatment”
Thyroid cancer	“Much of the observed increase in incidence represent overdiagnosis”

The question of overtreatment arises most significantly when it comes to medical treatment of the elderly. In some cases doctors may be  making assumptions about treating the elderly which may not be valid. Let us consider some of the assumptions that a doctor might make when recommending medical treatment for an old person:

Assumption #1: "Once a person has died, they are gone forever." Probably a large fraction of all doctors habitually make this extremely dubious assumption. There are many strong reasons for doubting that this assumption is correct.  For example, there are very good reasons for doubting that the brain is the source of the human mind and the storage place of human memories, reasons discussed here and here. Scientists have never found a human memory by microscopically examining brain tissue, and scientists lack any credible theory of how human experience and learned knowledge could be translated into neural states or synapse states. Scientists are utterly lacking in a credible theory of how memories could persist for 50+ years in human brains which experience such very high synaptic turnover and protein turnover. Scientists are utterly lacking in any explanation of how instant recall could occur in the human brain which seems to have none of the characteristics (such as addressing and indexing) that enable instant recall in devices manufactured by humans. For some of their confessions about these topics, see my post here. Two centuries of literature in the field of psychical research and parapsychology (such as research into out-of-body experiences and near-death experiences) suggest that human beings are far more than their bodies, and will survive the death of the body. 

Assumption #2: "It's always best to proceed with any medical treatment that may extend the life of an elderly patient." This is a dubious assumption. There are no doubt very many cases when it is best to proceed with a medical treatment that may extend the life of an elderly patient. But it is easy to imagine some cases in which it might not be right to proceed with a medical treatment that may extend the life of an elderly patient. For example, imagine a patient at a hospital has just been diagnosed with a form of cancer that will cause him to suffer a slow very painful death within two months. Imagine that the day after getting this diagnosis, the patient has a cardiac arrest that will quickly and painlessly kill him if left untreated. Is it best in such a case to proceed with some cardiopulmonary resuscitation that may deprive the patient of a quick painless death, and lead him to two months of devastating pain? That is very doubtful. 

Assumption #3: "The worth of medical treatments can be simply assessed through simple 'survival curve' graphs that indicate how much longer elderly patients will live if a treatment is given." This is a very dubious assumption. Survival curve graphs are extremely simplistic things. They measure only one thing: how long a person lives. A survival curve graph does not tell us about quality of life that a patient will have if a treatment is given. Such a graph plots only "years of life" not "years of life that someone would want to have."  

Assumption #4: "The more the doctor and patient know about the patient's body, the better it is."

It is usually good for a doctor and patient to know about a patient's bodily state, but often it may not be good to have such a knowledge. For example, some prostate cancer test may show some tiny very slow-progressing cancer in an old man. Doing such a test and telling the result to the patient may have a bad effect. It may cause the patient to spend years worrying very much about dying of cancer, when it may be much more likely that the patient dies of something else that will not cause a slow and painful death. If there is no effective treatment or preventative for a disease, it may be harmful to the patient to do some genetic test that reveals he is at a risk of getting such a disease. 

Assumption #5: "Screening asymptomatic people saves many lives."  A 2015 meta-analysis found little evidence to back up this claim. It stated, "Among currently available screening tests for diseases where death is a common outcome, reductions in disease-specific mortality are uncommon and reductions in all-cause mortality are very rare or non-existent."

Assumption #6: "The worth of a medical treatment can be simply assessed by assessing a death risk that will be reduced." This assumption makes no sense. When dealing with elderly patients, every reduction in the chance of death by one cause  is essentially an increase in the chance of death by some other means, often some mode of death that is even less desirable. For example, did you decrease by 25% the chance of an old person dying by sudden cardiac death? Then you effectively increased the chance of such a person dying by cancer or dementia, by about the same 25%.

Now let us consider some of the assumptions typically made not by doctors but by elderly patients receiving treatment:

Assumption #1: "Once I die, I am gone forever." There are many strong reasons for doubting that this assumption is correct, some of which I mention above.  

Assumption #2: "It's always best to proceed with any medical treatment that may extend my life." This is a dubious assumption. Some medical procedure may cause you to linger on for years in some state that may be one you don't want to live in. Such a state may include painful cancer or dementia. 

Assumption #3: "When doctors give me medical advice, it is an impartial judgment, made purely for medical reasons." This is a very dubious assumption. Today's physicians often have strong conflicts of interest. A doctor giving you advice about whether to have an operation may be a co-owner or stock holder of some corporation with a financial interest in advising you to have a particular type of operation. The more such operations are performed, the more money such a doctor may make. There is also another huge reason why a doctor may give you advice that is not purely for medical reasons: the doctor may be trying to protect himself from a lawsuit. For example, if a doctor thinks there is merely 1 chance in 10 that you have some condition that might result in a negligence lawsuit if the doctor failed to detect, the doctor may recommend "exploratory surgery" to remove that chance of a lawsuit, even though the surgery will probably do you no good. 

Assumption #4: "My family will be better off if my life is extended as long as it can be." No doubt in very many cases  a person's family will be better off when an elderly person's life is extended. But it is also very possible that a person's family will not be better off when an elderly person's life is extended. For one thing, it is quite possible that the medical bills of the procedure and its related medications and the additional years of survival of the elderly person will result in very severe medical bills that will place a great financial burden on the family. In the United States there are Medicare policies that cover most medical bills, but there are many medical costs that are not covered by Plan A and Plan B of Medicare, which does not cover nursing home costs. Also, the additional years of survival of the elderly person may cause that person's savings to get used up, depriving his family of any inheritance. If the surviving elderly person requires years of home health care when very old, that may be a very severe expense that is not covered by Medicare. Some other expenses are also not covered by Medicare. It is also very common for hospitals to run up enormous treatment bills that may include things that Medicare does not cover.  An old person may run up a hospital bill of $250,000, with the hospital billing Medicare for $250,000, but only getting paid $210,000 from Medicare. The old person's family may be left to pay the shortfall. For extremely expensive treatments and long hospital stays, this shortfall may be much larger, and may be enough to cause a great financial burden on the old person's family. 

Assumption #5: "Once I get the recommended procedure done, my health problems will be over." Once a particular type of medical procedure is done, it can often be a kind of gateway to several additional procedures of the same type. For example, doctors may decide that a $70,000 procedure didn't go quite right, and that they need to fix it with some additional surgery costing $80,000. For old people, there are often multiple parts of the body that fail or need fixing during the same five-year period. 

Assumption #6: "My doctor has given me the best medical advice anyone could get in my situation." This may or may not be true. Maybe the doctor was encouraged to maximize recommendations that someone get an MRI or a CT scan because his hospital or clinic bought an incredibly expensive machine that needs to be paid off, or was told that such a device "needs to be more of a profit source." Or maybe the doctor gave you medical advice that was largely based on a desire to minimize his risk of being sued for not recommending something. 

Assumption #7: "I can get as much medical care as I want without having to pay for it, because I have health insurance." Nowadays hospital stays can lead to very high charges as much as $20,000 or more per day. For example, a heart valve replacement can cost $170,000, and a heart bypass operation can cost $120,000.  Your insurance might cover all of that, or it might cover only some of it, possibly leaving you with a very large hospital bill. A Time magazine article says this about a woman with a month-long hospital stay:

"That’s when she got the next surprise: Bills totaling more than $454,000 for the medical miracle that saved her life. Of that stunning amount, officials said, she owed nearly $227,000 after her health insurance paid its part."

Assumption #8: "I can get as much medical care as I want without having any impact on the medical care that other people receive."  This is a simplistic assumption that many people make. Such an assumption would hold true in an ideal world in which medical resources and medical were as unlimited as sunlight. But we don't live in such a world. Hospitals are often understaffed. There can be "crunch periods" when there are too many patients for all of the doctors to handle correctly. Emergency departments of hospitals  often have waiting rooms in which people wait at length for medical treatment, and people sometimes wait for hours to see a doctor. If you are an old person who uses up 100 hours of doctor time at a hospital, you may be decreasing the medical care that some younger person received. By getting more medical treatment, you may make it more likely that some younger person will get less medical treatment. In fact, in the worst case some younger person may die because he got inferior treatment resulting from you using up the time of doctors or ambulance drivers.

Assumption #9: "If I get very old, and live to an age greater than 80, I will be able to get medication that eliminates any pain I have." Very sadly, the United States is not a country that makes it easy for very old people to get pain relief medicine they may need. After so much concern was raised about people dying from overdoses of opiates, doctors began to become stingy about prescribing opiates, adopting policies such as requiring monthly office visits (or bi-monthly office visits) for a renewal of an opiate prescription. For very many very old people, such restrictions pretty much shut the door to the possibility of them getting the pain relief medication they need.  If you are a very old person in pain, you may have low mobility that may make it pretty much impossible for you to make frequent visits to doctor's offices.  You may not have any children living nearby who can drive you, and may not want to drive yourself, being afraid of some accident that you may cause because of slower reflexes and slower response times.  A very old person may not have the computer skills needed to do some video chat method that might be an alternative to a face-to-face visit with a doctor.  

Assumption #10: "When the doctor gave me medical advice, it was something he very carefully thought about after carefully reviewing my case and gathering all relevant information." Such an assumption is often correct, but often not correct. Very many people have had experiences in which a doctor seemed to hastily process them in a "car wash" fashion. A doctor with a waiting room full of patients or a busy hospital may have rushed his recommendation, without ever even asking you all the questions he should have asked, or without ever even having performed a good inspection of your body. 

Assumption #11: "It's always best for me to know exactly what is going on with my body or the exact state of my genes." In many cases, it may not be better for you to get such knowledge. Learning about some health risk may cast a dark cloud over your life which makes you less happy, and causes you to spend years worrying about a bad result that may never happen. 

The considerations above suggest a possible alternative to the "take all treatment recommended by doctors" policy that an old person will typically follow: an alternative policy we can call medical minimalism. The slogan of an old person who follows such a policy might be something like this: "When my old body wears out or fails, it's time for me to die." A person following a policy of medical minimalism might follow a principle of avoiding medical tests or medical treatments unless they are indisputably necessary, particularly tests or treatments that are complicated, time-consuming or expensive. 

Here is a possible dialog that might occur between a doctor and an old person following a policy of medical minimalism:

Doctor:  We have detected a condition that might put you at a risk of sudden cardiac death by arrythmia. I recommend that we insert a mechanical ICD defibrillator device inside you that will prevent this risk, and make sure that you don't die in such a way. 

Old patient: No dice, doc. When my old body fails or wears out, it will be time for me to die. I want to die only with my original equipment, not as some man/machine hybrid. 

I can think of quite a few reasons why an old person might choose a policy of medical minimalism:

• An old person might want to avoid the endless complications and hassles of long medical treatment, and might want to keep things as simple a possible. 
• An old person might be wary of causing great medical expenditures that he or his family might have to pay very much for. 
• An old person might want to stay away from hospitals and nursing homes for fear of catching an infectious disease in a hospital or nursing home, as very many people did (with lethal results) during the height of the COVID-19 pandemic. 
• An old person might wish to avoid the side effects that can occur from some type of medical treatments such as pacemakers or ICD devices. 
• An old person may be afraid that some fancy medical treatment path that extends his life may actually have the indirect side effect of increasing the number of years he has to spend in a state of pain, confusion or disability.
• An old person might wish to minimize his own medical expenses and use of the time and equipment of medical personnel, on the grounds that such time, resources and effort should be focused on younger people.
• Knowing how often very old people suffer from pain, and knowing that he lives in a country such as the United States that does not currently make it easy for very old people to get the pain medication that they need, particularly people with low mobility, an old person might think that medical procedures maximizing his lifespan may have the effect of buying him years of unnecessary pain. 
• An old person might hate spending time in hospital rooms, and may want to adhere to a policy minimizing his time in hospitals.
• An old person may feel disgusted by treatments that may make him feel like a man/machine hybrid or a man/animal hybrid (treatments such as heart valve replacements that often use parts from cows or pigs).  
• An old person might be skeptical of claims of medical benefits of some complicated procedure, and be worried about the small percentage of times in which such procedures go wrong, and result in death or injury to the patient, or cases in which people catch infectious diseases from being in hospitals. 
• Believing in life after death, an old person may have little interest in very complicated and expensive medical procedure programs that may give him no more than a few years more of earthly life. 
• An old person may not want to have tests which reveal risks to his health or happiness that he does not wish to worry about. He may realize that very great psychological harm can be done if he receives worrying medical information that he did not need to be told about. 
• An old person might be worried that some treatment that reduces his chance of dying one way will in effect be a treatment that increases his chance of dying in some other way that is even worse, such as death by Alzheimer's disease or a slow painful death by cancer. 
• An old person might very greatly prefer to quietly die at the familiar locale of his home, surrounded by his family members, pets, or personal possessions, rather than spending his last days or weeks in some noisy, unnatural and utterly unfamiliar hi-tech environment, hooked up to machines such as heart rate monitors.  
• An old person might wish to have nothing to do with the kind of futile care that a nurse describes in this article. 

Should you adopt such a policy of medical minimalism when you reach old age? I neither recommend nor discourage such a policy. No layman can advise someone else on such matters. Except for the one time I recommended getting a COVID-19 vaccine shot, I never give medical advice,  and nothing I ever write should be interpreted as medical advice. I discuss such a policy of medical minimalism merely as a way of familiarizing the reader with alternatives. I do think people are way too simplistic in making recommendations along the lines of "this is what you should do whenever such and such a situation arises." Decisions about medical treatment for the elderly are usually way too complex to be reduced to simplistic "do X whenever Y happens" kind of advice (with some exceptions such as the rule of applying a bandage whenever bleeding lightly, and calling an ambulance whenever someone is bleeding heavily).