Ordinary Medicine: Extraordinary Treatments, Longer Lives, and where to Draw the Line. Sharon R. Kaufman, Durham, NC: Duke University Press, 2015, 314 pp.
Medicine has changed dramatically over the past 15 years, medical anthropologist Sharon R. Kaufman argues in her path- breaking Ordinary Medicine. Some of these changes have produced obvious welcome benefits. Who would not want to choose a longer and healthier life, if that is what modern medicine’s miracles can offer? But other changes are the subject of widespread lament: too much life- sustaining but death-extending technology. The quandary we in the United States face is that “few know when that line between life-giving therapies and too much treatment is about to be crossed” (p. 2). The oldest generation is living longer but not always better. And we are failing to see the nearly invisible chain of social, economic, and bureaucratic forces that has made once-extraordinary treatments seem ordinary, necessary, and desirable.
This quandary—its origins, drivers, and impacts—is the focus of Ordinary Medicine. Kaufman investigates how patients, families, and physicians all find themselves caught up in a system in which “more and yes are so entrenched” (p. 15) that they hardly recognize nor stop to critically debate the options.
Is it okay, even discussable, to consider a path that may lead to death rather than pursue the next treatment that the patient is “eligible” for and thus “needs”? Patients, families, and doctors do not decide about treatments, Kaufman’s years of fieldwork in medical clinics expose, so much as they yield to procedures that the powerful chain of health care drivers has made normal and ordinary.
The central aims of Ordinary Medicine are not to offer any simple answers—such as for or against the use of any particular technologies at any age. Rather, the book aspires to unveil the hidden workings of our health care enterprise, its organizational drivers, underlying values, and reigning logic. As such, Kaufman’s project resonates with one of anthropology’s core missions—to open to critical scrutiny that which can be so part of ordinary common sense that it, like the air we breathe, remains mostly unnoticed.
At the heart of the book is Kaufman’s analysis of the powerful chain of health care drivers that shape a great deal about how people in the United States experience late life. These health care drivers include medicine’s institutions, forms of science, and industrial complexes—including evidence-based medicine, pharmaceutical and biomedical industries, insurance companies, and Medicare. The transformation of research findings into “best evidence” for treatment is one such player; another is industry’s growing influence on the biomedical research enterprise.
A third, and perhaps most important, force impacting the ways old age, medical treatments, and dying unfold in the United States is Medicare: Medicare’s coverage policies, Kaufman reveals, essentially determine which potentially life-extending therapies become standard, appropriate, and very quickly “needed” treatments for older citizens. Once the patient qualifies— according to evidence-based-medicine and reimbursement criteria—the “technology parade” that has become so normalized for persons in later life begins (p. 60). Physicians, patients, and policymakers, acting under the influence of this chain of drivers, largely ignore the realities of decline, assisted living, dementia, and suffering, while preferring to think of medicine as a series of progress-oriented “breakthroughs” (p. 110).
The specific medical technologies Ordinary Medicine explores include the implantable cardiac defibrillator, cancer therapies, dialysis, and kidney and liver transplantation, including living organ donation from an adult child to parent. Age is not a widely discussed criterion when considering the use of such treatments and devices, yet the reality today is that older adults are the major recipients of medicine’s life-extending treatments. To say no seems to fly in the face of the technological progress that is “an enduring feature and primary value in Western medicine” (p. 114). Kaufman articulates eloquently: “Because desire for life and for more life is so fundamental, the value of life has become strongly linked to the amount of it. Thus, the technical ability to intercede becomes the moral reason to proceed” (p. 164, emphases in the original).
One of the most compelling features of the book is the rich, poignant voices of patients and doctors woven throughout. Kaufman listened to hundreds of older patients, their physicians, and family members who expressed their hopes, fears, and reasoning as they faced the line between welcome and too much intervention. It becomes clear that one of the most powerful forces at play is the broader U.S. societal discomfort with death.
One 73-year-old patient on dialysis declared: “Now with death, there’s something you don’t talk about, you don’t want to think about, and we don’t know how to prepare or handle it” (p. 153). Another dialysis patient in the final stages of lung cancer told of how shocked and betrayed she felt when her oncologist raised the possibility of discontinuing dialysis if it was not still providing the benefits and quality of life she wanted. Her response reveals why discontinuing treatment is so difficult to bring up:
My doctor wants me to commit suicide! … I’m not an animal, I’m a human. Would the doctor recommend this to his wife, to his children? And then he asked if I were to have a heart attack and I was on dialysis, would I want them to revive me? What’s this about a heart attack?! [She begins crying.] I’m very hurt, very hurt. (p. 154)
Some physicians are ambivalent about recommending aggressive technologies to patients of advanced age: “It’s very tricky to sit down with an 88-year-old patient or their loving family—and by now they’ve heard about this technology—and to say, ‘You know, he does meet the clinical criteria, but, really, at his age, it may not be the right thing in this case” (p. 59). More doctors in today’s clinical settings seem to find it easier, as this one expressed, “not to sweat” difficult decisions and to “just go with what you know. … If they qualify, if they meet the criteria, let’s go” (p. 60).
In emphasizing the powerful role of medicine as shaper of ideas, Kaufman at times seems to downplay the role of broader social-cultural ideals as in turn shaping medicine. If “our medical practices define the kind of society we have” (p. 49), so do our social–cultural values and visions of personhood powerfully shape the kind of medicine we aspire to.
One solution to some dilemmas Ordinary Medicine exposes could simply be to talk willingly about death and the transience of the human condition. But such topics do not jibe well with prevailing contemporary U.S. ideals of ageless or permanent personhood. Many anthropologists cannot show as clearly as Kaufman does in Ordinary Medicine, however, what specific forces are at play in shaping ideas, experiences, and values in any cultural epoch. The clear focus in this work on medicine as a driving influence within U.S. society shines a powerful, illuminating lens onto one of the most important societal forces of our time.
This provocative, engrossing book will make a valuable addition to undergraduate and graduate courses in anthropology, sociology, public health, and public policy, including those in medical anthropology and sociology, science and technology studies, bioethics, the nature of U.S. health care, aging and dying, and visions of personhood and the life course. Beyond the classroom, the book should also be read by physicians, health care policymakers, medical ethicists, and an educated public wishing to rethink and renew medicine’s goals.