For those whose worldview picture is framed by biblical anthropology, the recent tenor of the healthcare reform debate should come as no surprise. When Americans have been forced to ration healthcare in the past—e.g., the early dialysis era, organ transplantation—social valuation explicitly and implicitly crept into decision-making.[1] Unfortunately, contemporary discussion, once again, is openly engaging the same wrong-headed direction. A sampling of three recent opinion pieces demonstrates the tendency to suggest cutting costs by placing devaluated people outside the pale of care.
The old debate resurfaced July 5th, 2009 with Charlotte Allen’s editorial in the Los Angeles Times.[2] She quotes the President’s discomfiture with his own grandmother’s hip replacement just prior to her diagnosis with cancer. The President suggested that maybe the Medicare money spent could have been put to better use elsewhere. He observed that decisions about whether to treat the elderly should no longer be made by patients or their families, but rather by a group of doctors, scientists, and ethicists who are not part of normal political channels. Will these decision-makers include bioethicists such as the one who was quoted in the same article as recommending “age cutoffs” or other “unpleasant solutions” as acceptable cost-cutting maneuvers?
Ms. Allen’s piece was followed by a critique penned by Ira Rosofsky in the July 14thL.A. Times.[3] He made a very tenuous leap of faith in the same Medicare arena as a response to her concerns. Spending for Medicare beneficiaries in their last year of life accounts for 30% of all Medicare monies. So, obviously, he concluded that we as a nation are “marginally extending” their lives. He then sets up a straw man. He looks at the costs of cetuximab, a cancer drug used for non-small cell lung cancer treatment, indexed against the time added to life. It costs $800,000 to prolong the life of a single patient for one year with the drug. This data led him to opine, “I might well choose to be put on that ice floe.”[4] This is a non sequitur, comparing apples to oranges. The data on cetuximab was not obtained only from the geriatric population. But that does not stop him extrapolating from the disappointing results to presenting a clarion call to cut medical expenditures for the elderly. If lack of benefit determines that cetuximab should be withheld from terminally ill patients with lung cancer and that care should comprise palliation, then that is one issue. It is categorically different, however, from withholding care in the last 6 months of life for all Medicare beneficiaries because cetuximab may be prohibitively expensive.
Is this all ethical hyperventilation? I think not. Some senators have decided recently that most readmissions of Medicare persons are “unnecessary.”[5] Their solution is to stop “rewarding” doctors and hospitals for not preventing them (as a physician, it is unclear to me that this is even feasible). It is no wonder that one commentator strongly recoils at the result of their conclusion: “government rationing and the denial of health care.”[6] Where will these elderly persons with pain, terminal diseases, and multiple comorbidities go for care? Who knows, but wouldn’t it be more efficient to just end their “unnecessary” hospitalizations with an updated, americanized version of an ice floe? Is it unreasonable to call that solution euthanasia?
Yes, the Dartmouth Atlas has suggested that there are bloated portions to healthcare spending, some specifically related to Medicare. Is the solution to stop caring for the elderly when they reach a magic age of no return? Social valuation sickened the generation by choosing who would live and die with or without dialysis over 40 years ago. If we have not learned from that generation’s terrible mistakes, we will once more sentence precious lives to the same misguided and unethical treatment.
[1] Gregory W. Rutecki and John Kilner, “Dialysis as a Resource Allocation Paradigm: Confronting Tragic Choices Once Again?” Seminars in Dialysis 12(1999): 38-43.
[2] Charlette Allen, “The Painful Side Effects of Obama’s Healthcare Reform.” Los Angeles Times July 5, 2009. http://articles.latimes.com/2009/jul/05/opinion/oe-allen5 accessed on August 13, 2009.
[3] Ira Rosofsky, “When I’m Really Old, Put Me on that Ice Floe.” Los Angeles Times July 14, 2009. http://www.latimes.com/news/opinion/opinionla/la-oew-rosofsky14-2009jul14,0,2375611.story accessed on August 13, 2009.
[4] Rosfosky.
[5] William Kristol, “Kennedy: Let’s Ration Health Care.” The Weekly Standard July 20, 2009. http://www.weeklystandard.com/Content/Public/Articles/000/000/016/755sqqdf.asp accessed on August 13, 2009.
[6] Kristol.
