Justice Scalia's Death: Three Lessons for the Healthcare Community

John Mandrola, MD


February 16, 2016

When I heard Justice Antonin Scalia had died suddenly, presumably of cardiac causes, I spent time reading and thinking about the famous judge. Three themes seemed worth putting down in writing.

The first is obvious: this is a great loss. By all accounts, and despite being a month short of his 80th birthday, Judge Scalia was living life to the fullest. Right before his death, he heard cases in the highest court, wrote strong opinions, and he died on a hunting trip. Clearly, this sudden death resulted in a significant loss of quality time.

Extending quality years is the ultimate goal of medicine, cardiology in particular.

Yet one of my first lessons in cardiology, one that remains today, is that the first presentation of heart disease can be sudden death. Although recent data[1] suggest many of those who suffered cardiac arrest had warning signs, many do not.

Dr Robert Myerburg (University of Miami Miller School of Medicine, Florida) calls this the low-risk/high-number dilemma of sudden death.[2] The great majority of sudden death comes from the segment of the general population with either undiagnosed heart disease or disease considered low risk by conventional markers, such as ejection fraction.

The future of cardiology, perhaps the promise of genomics and digital health, lies in better ways to predict sudden events. At the risk of sounding nihilistic, I don't see it happening anytime soon.

The second theme that comes to mind about the judge's sudden death was captured in a tweet: "Do we always want to prevent [sudden death]? It seems like a good way to go."

Indeed, Judge Scalia lived a productive life; on his last night, he had dinner with friends at a luxury resort. He died without any loss of dignity. He avoided time in an ICU or nursing home.

Judge Scalia enjoyed what Dr James Fries of Stanford University calls compression of morbidity.[3] He had essentially no time of infirmity before his death. That's not the case for the majority of people now. Dr Fries noted in his 1980 essay that chronic disease has superseded acute disease in the United States. I need no reference to say chronic disease and debility are even more prevalent in 2016.

Therein lies the dilemma of medical care for the elderly. Take, for example, an implantable cardioverter-defibrillator (ICD). (You could also substitute heart-valve surgery or chemotherapy.) An appropriate ICD shock brings both good news and bad news. The good news is death avoidance. The bad news is that shocks usually herald declining organ function. And that means extending the time one lives with infirmity. Make no mistake: that is a trade-off.

When all we explain to patients is that an ICD (or chemotherapy or surgery) has a certain probability of preventing death, we don't tell the whole story. I've said this before: it's not morbid to talk with patients about their last part of life and mode of death. It's our job.

The third theme worth mentioning about Judge Scalia was his friendship with Ruth Bader Ginsburg. This famous kinship is notable because he was the court's most outspoken conservative and she its most outspoken liberal. Their mutual respect and friendship in the face of deep disagreement on ideas is a shining example for all of us.

In Letters to a Young Contrarian[4], Christopher Hitchens says that "we make progress by conflict." No doubt this is true. But Scalia and Ginsburg teach us the important lesson that we should disagree with ideas, not people.


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