This weekend, doctors at Children's Medical Center of Dallas spent 34 hours separating Ahmed and Mohamed Ibrahim, conjoined twins. As the pictures demonstrate, they were joined at the tops of their heads, so they would have to spend their entire lives lying on their backs but for this surgery. So far, the twins are both in critical but stable condition, in a drug-induced coma. The surgeries, as of today, were successful.
They were also expensive and time-consuming, which has led to some questions. Dr. Joe Stirt, an anesthesiologist, rhetorically asks:
Oh, and did I mention that the current procedure, in Dallas at Children's Medical Center, involves five neurosurgeons, as many anesthesiologists, countless plastic surgeons, head and neck surgeons, orthopedic surgeons, vascular surgeons, nurses, intensive care unit nurses and respiratory therapists, all of whom are NOT taking care of hundreds, if not thousands, of poor kids in Dallas who could really benefit from this confluence of money and expertise?
Ken Womack lays out the issue starkly:
I'd hazard to guess there are plenty of children in Texas whose lives could be made significantly better if these medical resources were made available to them rather than devoted to making life better for two people from Egypt.
How about spending that "year of intense preparation" providing pre-natal care for poor women in the state? I bet there are plenty of poor pregnant women who could use "extensive diagnostic tests".
Why not use the 10 surgeons and support staff occupied by the twins to perform neurosurgery, craniofacial surgery, plastic surgery, general surgery and oral surgery for procedures for children who need those surgeries in Texas or elsewhere in the U.S.?
I live in Dallas, and yesterday at church we prayed together for the twins. I was glad to do so. I hope that they recover safely, and that they live long and healthy lives, unmarred by health problems related to their conjoinment. I hope that Dr. Stirt and Ken feel the same way, and they've given no indication that they do not. But they do raise an important question: Couldn't the $2 million spent on this procedure have gone to better use helping more than two kids?
The problem with the suggestion that the time and money could have been better spent on taking care of many children rather than just these two children is that it suggests an action. The action that is suggested by the question is to deliberately turn away these children because others could be better-helped with the time and money. The question suggests that each decision to treat or not treat any patient should be based in part on a financial equation, which is exactly the sort of thing I thought most of us hope would never be true. Aren't doctors supposed to provide the best possible care to all patients regardless of their ability to pay? Or does that only apply to certain kinds of insurance, or certain kinds of procedures?
Article comments
— go to most recent comments1 - Natalie Davis
Good job, Phillip. Thank you.
2 - Cap'n Ken
A good defense, Phillip, but I still have to disagree with your reasoning.
No, I don't think the time, money and other resources devoted to the twins took much if anything away from kids in Dallas who needed care. But the effort to separate the twins was a year-long project. And the key word there is "project."
This is not, as you say, a rich family who sought out the world's best medical care when the conjoined twins were born. So how, then, do poor Egyptian kids from a small town end up in Dallas?
Simple. They are a project.
They're a project for the Dallas hospital. They are a project for the individual doctors, nurses, support staff and everyone else who donated their time. They are a project for the individuals who donated the $125,000. And they are a project for the World Craniofacial Foundation.
A noble project? Absolutely.
But the hospital, the staff, the donors and the WCF all chose the twins as a project to undertake.
The hospital and staff could have chosen to undertake - for example - free pre-natal examinations for illegal immigrants as a project. And I'm sure Children's has many worthy projects they are involved in.
But there is a limited capacity for any organization, individual or donor to devote time, money and resources to these kinds of projects.
And I have to think there is some healthcare project in the state of Texas that would be more worthwile and benefit more people than a year-long project to separate these twins.
The Dallas twins project is compassionate, it's noble, it's a damn nice thing to do for the twins.
In my opinion, however, it is not anywhere near the best project a hospital such a Children's, a staff such as the one involved, the donors who showed their generosity or even the WCF - which also advocates the Romanian project you referenced - could have chosen.
3 - Eric Olsen
Very nice job Phillip, I agree with your conclusion although, again, I can understand Ken's consternation: "why this particular project?" Is "this project" the best use of time and money? I don't know, but it's pretty great for the twins. Every child who needs it deserves to be a "project" - let us always strive to reach more not resent those who do receive.
4 - ClubhouseCancer
Eric's right, as usual, and so is Phil. And may I add that a team of professionals from the fields of medicine and philanthropy determined that this project was worthwhile. One might assume they know better than us, esepcially since by Cap'n's own admission above, we don't know what other projects the good folks may have undertaken in the place of the twins.
5 - Eric Olsen
Thanks CC, and thanks to Ken for bringing the matter up
6 - Corinna Hasofferett
The relevant issue is not the amount of Time invested, neither is it the financial cost, or The Selection Criteria.
The real issue is moral.
Life is sacred.
A child, even one born to a poor family in a poor country, deserves a basic normal life.
The choice is not between one child or another but between one cause or another.
Is war a better cause?
Could some of the monies and energy invested in wars be more wisely used toward life saving goals and projects?
Instead of letting goverments and fanatics rule by division why not get together and demand the best for all humanity?
7 - ClubhouseCancer
Wow, Corinna. You've nailed it, and given us a lesson in perspective.
Your last sentence is especially juicy and correct.
8 - Natalie Davis
Brava! Amen to that.
9 - Mac Diva
Well done, Phillip.
Ken, a better operation to criticize would be the one on the adult Iranian twins. They did not meet the criteria for separation to most neurosurgeons. The operation failed because the pre-op research concentrated on the top and mid-head and a large blood vessel at the base of the skull was missed. That vessel bled them out -- much too fast for new blood to be pumped in. Even so, as I said on the other thread, the operation was a publicity and money bonanza for Raffles Hospital. It is the kind of case that should be taught at the Wharton, not U.Penn Med.
As I've mentioned on my blog, I have always been interested in twins. (I have sisters who are identical twins and just a year younger than I am, so my study of the topic started early.) I've read about everything there is about conjoined twins. The most interesting pair I am currently aware of have one body from the waist down and an arm each. That is a huge challenge. Though they move pretty well, they are never going to have any privacy.
10 - Cap'n Ken
Corinna: Nothing personal, but your comment is ridiculous.
Life not war? What a brilliant thought!
Every child deserves a basic, normal life? What a concept!
It's very easy to say these things - to talk about moral responsibilities, how life is sacred and whatnot. But how about spending some time in the real world?
A lot of kids and grownups get sick and otherwise have bad things happen to them. No matter how good the intentions of society are, there will always be people who suffer. Kids die. We can keep some kids from dying if we try hard enough. And maybe we could keep some more kids from dying if we didn't focus so hard on these twins.
And the world is full of bad people. War is, as they say, hell, but (sometimes) it's an ugly necessity of this world.
The two things are unrelated.
11 - Steve Rhodes
Well, there is a question of where do you focus your resources. Costa Rica which doens't have a military spends more on health care than other countries in Central America.
Everyone should get healthcare. That isn't the case now, but it should be goal.
But the bottom line is if they were your kids, you would think all of this time and money would be too much to invest in trying to make their lives better.
12 - Phillip Winn
No solutions, just desire...
Here's the thing: I grew up in a Republican family. They all consider me liberal, if you can believe that. I consider myself a libertarian or an independent, but tend to vote more conservatively than not.
So when I read statement like "Everyone should get healthcare," I agree completely with the stated words. But implicit in that statement is usually the understand that it really means, "The government should provide everyone with free healthcare," and that statement has a whole host of problems ranging from the moral to the practical.
As a practical man, the idea that so-and-so lives with a debilitating illness or that so-and-so can't afford a $1400 monthly prescription drug bill is just wrong. In the richest country on earth, we have the ability to solve this problem without bankrupting ourselves.
Of course, as a practical man, I'm also very aware of the probable abuses of any proposal I've ever seen thus far to involve the government in health care even more than it already is. In fact, government is in a certain sense the biggest part of the problem already, as drug costs are based largely on the $2 billion it takes to get a drug past the FDA to market, and doctors in small towns in Eastern Kentucky have to pay $80,000 each year in malpractice insurance.
It's a conflict. I cannot put my brain on hold to follow my heart any more than I can close off my heart to follow my brain. And I realize that the issue is not as simple as all that, either.
I believe that America has survived for as long as it has for more reasons than just a well-written set of founding documents or some decent choices in leaders over the years. I believe that you could put the same documents into place somewhere else and not have nearly as happy a result. It is the American people that have made America what it is today, and I fear that the increased polarization in this country is causing what external forces could not - America's destruction.
Instead of thinking of ourselves as Americans working together to build a better future, we are starting to believe that it is us against them, left against right, Democrat against Republican, rich against poor, dark skin against light skin, and on and on. These issues have always existed - we've had leaders killed in duels and an atrocious history of race-based slavery and robber barons and so on. And perhaps I'm guilty of longing for the "good old days" that never really existed.
But it is sad to me that all of the ways I can think of to try to meet the "everyone should get healthcare" goal runs smack up against a large segment of the population that will try to get for them and theirs and screw the rest of us.
Still, I believe that we can meet the needs of conjoined twins from wherever in the world they happen to be born and still meet the needs of kids in Dallas.
13 - Natalie Davis
Cap'n Ken: Some people will never support war. Their beliefs, morals, and principles won't permit such a thing. Deal with it: We are part of the real world too.
Phillip: "perhaps I'm guilty of longing for the "good old days" that never really existed."
I suspect so. And sadly, I fear good days -- old or new -- will never come to pass. Frankly, I don't give a hang about abuse: If people need help, help them. That people are forced to do without medical care is nothing less than a sin.
14 - Eric Olsen
All of this makes the health care debate very germane. Please reply to San per the email if you would like to participate. Thanks, EO
15 - Phillip Winn
Natalie, I'm about to bring up what seems to be the primary source of disagreement between us. I see shades of gray on this issue, as with most others, and you don't seem to, as with most others. Just as I believe that war and terrorism can both be bad but one is worse, so too I believe that the situation we have in American where people are without medical insurance is bad, but there are worse possibilities.
So again, I'm not denying that it would be better if everybody had access to perfect medical care, and that anything short of that is bad. Yet.
Yet. What is the solution? To eliminate FDA oversight of the drug approval process would be to reduce the development costs of medicines by anywhere between $400 million and $2 billion per drug. Reducing the length of patent protections granted to drug manufacturers would allow for increased competition on even newer drugs, bringing the prices down still more, but that can't happen unless the costs the manufacturer pays to get the drug approved goes down (see previous point), since the extended patent terms are largely there to provide a way for companies to make back the money they spent dicovering and developing the drug in the first place.
There is the minor downside that unsafe drugs might make it onto the market, but smarter people than I have suggested that rubber-stamp approval of drugs that have made it through the testing process in Canada or Europe or other countries with sufficiently stringent testing would be a good first start.
To not do those things is nothing less than a sin, right?
I really think that deep down we all agree on the problem. It's the solution on which we all differ, and it isn't cold-hearted or evil to suggest that some uses of money are more efficient or even "better" than others. Private citizens can donate to whatever cause they wish, as I said above, but government policy should be set on more practical grounds.
If two million dollars had actually been spent by the US government on separating conjoined twins when so many other children need important care around the country and the world, I think I would object — though I'd still be happy for these two.
16 - Steve Rhodes
The waste and added costs from insurance companies makes single-payer systems like in Canada where everyone is covered and costs aren't as high seem much better.
Yes, it should not be as costly to get FDA approval of drugs (and there have been reforms that have allowed drugs to reach marker faster which were pushed by ACT UP).
But it is hard for the drug companies to complain about the cost when they spend so much on marketing to doctors (my dad is a doctor, so I witnessed many visits by drug reps always with interesting gifts) and to the public (endless prilosec and viagra ads).
17 - Phillip Winn
Except that I met my wife because her family moved to the United States before they would allow a Canadian doctor to operate on their daughter (my wife's sister). My Canadian in-law that's a doctor practiced in Canada for a short time, got fed up with the bureaucracy, and moved to the States.
It's a complicated system, economics, and health insurance is a complex economic issue.
As an example, take your complaint about pharm advertising. I happen to think that the system is corrupt, so I won't argue at all on the visits to Doctors, except to say thanks once again for Wal-greens, who substitute generics whenever possible, resisting any and all pharmco pressure and kickbacks.
But on the advertising, consider this: ImClone spent $2 billion to try to get their drug approved, and then failed. Let's assume it had instead gone through. They've got a patent good for another 14 years, and they've got to try to make back the $2 billion spent. They've got to make $143 million each year for the next 14 years in profit to recoup their initial costs. That's over and above the ongoing manufacturing and distribution costs, legal costs, overhead, etc.
I don't know how much it costs to manufacture or distribute the average pill. Let's pretend it's twenty cents, which I think is probably very low. How many pills would the company need to sell at a dollar per pill to make back $143 million? Nearly 180 million.
You don't do that just hoping people read the business section last weekend and heard you were approved. You market to the doctors so that they're aware of your new drug. You market to the people so that they'll put pressure on the doctors to keep up on all the new drugs. And every batch of commercials you run adds a penny to the cost of each pill, but each extra pill you sell makes up for nearly 80 of those pennies, so you keep going.
And then, just to be sick, when your patent gets close to expiring, you make some incredibly minor change to the drug and market it anew as "Nexxium," so the generics don't kill your market.
Anyway, the system is awful, and there is plenty of blame to go around, but advertising isn't as foolish as it first seems. Not when you're talking about starting a billion dollars in the hole.
BTW, I am not a doctor, nor do I play one on TV, so for all I know Nexxium is just scads better than the original purple pill. Still, I have a past life in manipulative marketing, and I recognize attempted mental coercion when I see it.
18 - Phillip Winn
Sorry, I've been trying to back up statements with numbers in them, and I forgot to include this link about drug patents, and this link (among others), listing the amount ImClone spent on their failed attempt to get the drug onto the market.
19 - Chris Arabia
and last i checked, the torts system consumed $1.62 on top of every dollar it paid out in benefits. i mean the cost to society was $2.62 to confer $1.00 of benefits on Victim X.
that was a ways back, but i cant imagine its much better now.
you have to watch out for that victim x.
20 - Phillip Winn
Chris, I suggest that the problem there isn't usually Victim X, but the predatory lawyers who line their own pockets and manage to somehow convince their clients that getting only 38% is the bad guy's fault.
Of course, I've opened myself up for someone to list a few reasons why lawyers pocket what they do, as I've done for the pharmcos.
21 - Mac Diva
Uh . . . yea. Having worked for a firm that handled big personal injury and wrongful death cases, I know 'greedy lawyers' aren't the full story. In fact, in the area where I worked, PA/NJ/Delaware, there were caps on damages for many of the governmental defendants we sued. We were lucky to get a year's worth of actual costs for someone seriously injured, a quadriplegic, for example. Thirty percent of the total for cases settled or won at trial has to be weighed against the ones that wither away or are lost. Expenses are also high. Then there is the time factor -- years can pass before a case is settled or goes to trial. I think most claims made by people wanting tort reform are at the urging of big businesses. Their interest is in protecting their assets, not the fairness of the system.
22 - Steve Rhodes
Drug companies seemed to do fine without spending billions on advertising for many years.
And doctors say patients often come in asking for a certain drug or even complain when suggest a more appropriate drug that isn't as heavily advertised.
Plus I don't enjoy listening to the lists of side effects in the ads, but that is a minor matter. And they usually say the details are in some magazine I didn't even know still existed like the Saturday Evening Post.
23 - Phillip Winn
Steve, if you read this link, which I'll include for the third time on this page so far (<grin>), you might get a partial answer to the acceleration of advertising. The costs of "drug dicovery" have more than doubled in the last ten years. On average, the cost is estimated to be somewhere between 400 and 800 million (depending on how you count it), with obviously rare exceptions like ImClone's $2 billion lost gamble.
Of course, there is also this view, which is basically that pharmcos are greedy. That view doesn't necessarily take into account the high risk involved in the industry, but then, not many pharmcos actually go under, so high of a risk can it really be?
24 - Joe
Phillip, add to your point the fact that most governments place price controls on drugs, except for the US. So that means that the US ends up subsidizing the drug discovery costs while other countries are rewarded with the benefits (newer, better drugs).
25 - Natalie Davis
Phillip: "I believe that the situation we have in American where people are without medical insurance is bad, but there are worse possibilities."
For the person without insurance who is not sick, the only worse possibility is death. For the seriously sick person without insurance, death is the only better possibility.