Knocking on Heaven's Door: The Path to a Better Way of Death (26 page)

side in the creek. My face softened like melting wax. My lips let

go of their habitual tight line. Instead of coping with the debris

on the surface of my mind, I was reveling in the peace below:

the gentle rhythm of my breathing, the beating of my heart. It

was as though I’d dropped down a dark well.

A man behind me cleared his throat. I stayed calm. In my

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right shoulder, nerves fired and faded in response, like a bright

lace of phosphorescence stirred up by an oar in night water.

Earlier that day, our meditation teacher had suggested we

avoid what she called the “Second Arrow.” In a classic sutra,

the Buddha had said that if someone shoots you in the foot,

don’t pick up the bow and shoot yourself in the foot again. Don’t

make your suffering worse by arguing with what’s so. That’s a

Second Arrow. Accept pain. Don’t criticize yourself, or others,

for feeling pain: that is a Second Arrow. Don’t regret what can-

not be changed, or try to predict what cannot be known. By

throwing their complex machinery into the path of death, my

father’s doctors had shot my parents with a Second Arrow. And

by trying too hard to shield my parents from suffering, I might

be shooting myself—and them—with a Second Arrow as well.

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of Lifesaving

On the idealistic and hopeful day in 1958 when the forty-

three-year-old Swedish ice-skater and businessman Arne

Larsson was given the world’s first fully implantable pacemaker,

few in the worlds of business, engineering, or medicine foresaw

a time when there would be a need or a market for hundreds

of thousands more. Potential customers seemed at first glance

few: a handful of “blue babies” and adults emerging from pio-

neering heart surgeries with unintended cardiac damage, and

another handful of fatally ill people like Larsson who got dizzy

and fainted multiple times a day because their hearts failed to

maintain normal beats.

Things were about to change. Two years after Larsson’s sur-

gery, the pacemaker moved out of the hands of tinkerers and onto

small assembly lines. By the end of December 1960, Medtronic’s

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cofounder, Earl Bakken—who’d been persuaded by a Lutheran

minister when he was a teenager to turn his inventiveness away

from tasers and toward helping people and did not even mention

“profit” in his company’s original mission statement—had taken

orders for fifty of his pacemakers, priced at $375 each.

In 1961, Bakken bought the licensing rights to a fully

implantable pacemaker similar to Arne Larsson’s, designed by

the American inventor Wilson Greatbatch in a converted barn

behind his house in Buffalo, New York. Sales were slow at first.

In 1962, Medtronic lost $144,000. The next year, when U.S.

health care spending was 5.3 percent of gross domestic product

(GDP), and the average American life span was close to seventy,

Medtronic sold only 1,200 pacemakers and edged barely into

the black. The start-up was so starved for capital that Bakken

considered selling it to the Mallory Battery Company, but the

deal fell through after the Arthur D. Little consulting company

estimated that only ten thousand people worldwide would ever

need a pacemaker. Then, in 1965, Medicare—the Great Soci-

ety insurance program bitterly opposed by the American Medi-

cal Association (AMA) and championed, like the 911 system,

by the heart attack survivor President Lyndon B. Johnson—was

established. It approved the pacemaker for reimbursement the

following year for any American over the age of sixty-five with a

medical need for one, and Earl Bakken’s world changed.

In the first full year of Medicare reimbursement, when health

care consumed only 5.9 percent of GDP, Medtronic sold 7,400

pacemakers, six times as many as it had three years before. It

made a profit of nearly $308,000. Two years later, in 1968, it

reported annual sales of ten million dollars and profits of more

than a million. By 1970, health care spending was consuming 7.2

percent of GDP, and Medtronic’s annual sales had doubled again,

to $22 million. Pacemakers had become the company’s cash cow.

The atmosphere in what would later be nicknamed “Medical

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Alley”—Minnesota’s cluster of high-tech medical start-ups—

soon rivaled that of the nascent semiconductor industry near

Stanford University in northern California’s Santa Clara Valley.

In small towns on the outskirts of Minneapolis and St. Paul,

engineers, visionaries, and salespeople rented offices, wooed

venture capitalists, invented, borrowed, and stole innovative

technologies, and sued each other for patent infringement and

theft of intellectual property. Members of a new breed of sales-

man—part electrical engineer, part medical paraprofessional,

and part Willy Loman—fanned out across the country, enter-

ing operating rooms dressed in scrubs just like doctors, to show

eager but ignorant physicians how to implant the new devices.

Big corporations bought out small companies. Initial public

offerings showcased shares that doubled in price within hours

of hitting the stock market and stayed high.

Four Medtronic engineers and salesmen, frustrated with Earl

Bakken’s cautious approach to technological innovation, left his

company to manufacture a slimmer pacemaker also designed

by Wilson Greatbatch but powered by a longer-lasting, hermeti-

cally sealed lithium battery. (The earlier models had mercury-

zinc batteries, which released small amounts of hydrogen gas

and lasted only a year or two before needing replacement.) The

start-up, Cardiac Pacemakers, Inc., was financed with $50,000

in bank loans and $450,000 in venture capital. Its pacemaker

was barely more than a prototype, and at first its salesmen had

nothing to show doctors but a wooden mockup. It had almost

no sales in 1972, its first year.

Four years later, with health care now consuming 8.4 per-

cent of GDP, and the average American life span creeping up

toward seventy-three, Cardiac Pacemakers had $47 million in

sales. “The profit margins were beautiful in those days,” said

one of the company’s founders, Manuel Villafaña, a colorful for-

mer Medtronic salesman born in the South Bronx who’d earlier

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introduced Medtronic pacemakers to doctors in South Amer-

ica and Europe. Cardiac Pacemakers’ after-tax profits were 20

percent. Two years later, its founders sold the company to the

Eli Lilly pharmaceutical company for $127 million. Renamed

Guidant, it would later branch into coronary stents and other

cardiac hardware and become the world’s third-largest manu-

facturer of cardiac surgery devices—and would employ Katrina

Bramstedt, who later became a bioethicist. In 2004, it was sold

to Boston Scientific and Abbott Laboratories for $27.2 billion.

Spin-offs begat spin-offs. Manuel Villafaña left Cardiac

Pacemakers to found St. Jude Medical, Inc., which developed

and promoted a new heart valve made of stone-hard pyrolytic

carbon, a major advance over the bulkier metal and plastic ball-

and-ring models, prone to clotting, then being used by surgeons

like Dwight Harken at Peter Bent Brigham Hospital in Boston.

The St. Jude valve became the most commonly used in the

world; in one of its early years, after-tax profits hit 48 percent. St.

Jude would use those accumulated profits a couple of decades

later to buy a thriving international pacemaker company called

Pacesetter, part of the German industrial and health behemoth

Siemens, which had earlier swallowed Elema-Schönander, the

Swedish company whose inventors saved Arne Larsson’s life.

The secret to success from the first was a guaranteed market

and close-to-guaranteed prices. Unlike the tightly controlled,

government-run variants of universal health care then being pio-

neered in many European countries, Medicare functioned more

like a government-funded insurance company. Thanks to intense

lobbying from the AMA, it was never given authority to negoti-

ate bulk discounts, to request bids for standardized models, to

second-guess a doctor’s decision, to control prices, or otherwise

to interfere with what the AMA called the “doctor-patient rela-

tionship.” In the United States, a handful of pacemaker compa-

nies, enjoying a near monopoly, essentially set prices. Individual

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doctors decided independently who needed the devices and

billed Medicare their “usual and customary” fees. Hospitals

provided operating rooms and ancillary services, exercised little

control over the doctors who used them, and billed Medicare

separately. Medicare simply paid. Thanks to this unique finan-

cial structure—a griffin-like hybrid with neither the marketplace

checks and balances of capitalism nor the top-down government

controls of socialism—pacemakers and other emerging medical

technologies were delivered practically cost-free to the hospital,

surgeon, and patient. The system had no brakes.

As profits grew and sales forces expanded in Medical Alley,

the thinking and practice of many cardiologists across the

country changed. In its pioneering days, the pacemaker was

regarded as a specialized lifesaver for a handful of otherwise

healthy people with fatal disturbances in heart rhythm. After

Medicare, as the devices improved technologically and insert-

ing them became simple and profitable, the rationale changed.

Doctors began inserting them to improve “quality of life” in a

much larger pool of older people with minor heart arrhythmias.

They next began inserting them on a “just in case” basis in rela-

tively healthy people whose hearts were slowing down naturally

with age but who had no symptoms at all. People like my father.

In 1974, a Columbia Medical School cardiologist named

Irene Ferrer, a sister of the actor Mel Ferrer, argued that “peri-

odic or sustained sinus bradycardia [that is, a slow heartbeat] can

no longer go unchallenged, even if asymptomatic.” Pacemakers,

she said, should be implanted on a “prophylactic” [preventive]

basis, particularly in patients in a broad, new, diagnostic cat-

egory called “sick sinus syndrome,” characterized by a variety of

modest disturbances in the heart rhythm revealing themselves

on newer, ever more sensitive diagnostic machines. Pacemaker

implantations doubled year by year. The guiding principles of

the day were maximum promotion and maximum treatment.

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Behind the scenes, meanwhile, Medicare—which paid for

about 85 percent of pacemaker insertions and thus was primar-

ily responsible for the explosive growth of the industry—was

changing the shape of American medicine. Medicare’s fram-

ers had hoped to provide better medical care for the elderly.

They did. The average life span increased from sixty-five in

1940 to seventy-one in 1970. Deaths from heart disease fell.

But because Medicare mimicked the fee-for-service structure

of existing private insurance plans, it paid better for procedures

than for time. It starved doctors who provided hands-on primary

care and overrewarded specialists who churned out procedures.

Doctors peddled their wares on a piecework basis; communica-

tion among them became haphazard; thinking was often short

term; nobody made money when medical interventions were

declined; and nobody was in charge except the marketplace.

Fueled not only by Medicare but by private health insurance,

doctors’ average incomes quintupled—from $50,000 a year in 1940

in 2011 dollars to nearly $250,000 in 1970. Most of the increase

went to specialists. Pay for primary care doctors was so poor that

some of them refused to take Medicare patients at all. Doctors

flocked to where the money was: by 1969, there were nearly three

specialists for each primary care doctor in America. When Medi-

care approved coverage for routine colonoscopies, gastroenterology

incomes rose, and so did the number of gastroenterologists.

Newly enlarged high-rise hospitals—technological palaces

fueled by private insurance and by federal dollars for research,

construction, and patient care—rose in cities across the coun-

try. In their shadows often lay neighborhoods of the impover-

ished and the working poor, served, if at all, by a dwindling pool

of underpaid and low-status internists and family doctors who

maintained close emotional relationships with their patients