Debating the r-word

The patient, age 97, needed expensive and risky open-heart surgery. He didn’t want the procedure, but after he sank into a coma, his family and surgeons decided to go ahead with it anyway. Although recovery was difficult, the patient ultimately did well and died two years later, at age 99.

Was surgery the right decision for someone this old? Was the cost justified? Was it worth it to society?

What if you knew the patient in this case was renowned cardiovascular surgeon Dr. Michael DeBakey?

As health care reform gathers momentum and the pressure mounts to rein in the cost of American health care, it’s inevitable that the discussion would turn to the r-word – rationing.

The United States arguably already rations health care on the basis of income and insurance status and, to a lesser extent, geography. We spend money on care that hasn’t been shown to be of any benefit, yet have failed to invest in primary care, rural health and mental health. Many are now starting to ask whether risk, cost, potential benefit, and even individual factors such as the patient’s age and health history also ought to become critical determinants in deciding whether to provide or withhold certain types of care.

This week the Philadelphia Inquirer devoted a story to this issue and asked the question: "For America’s aged, surgery at any price?"

An excerpt:

Age is no longer the deciding factor, even for invasive treatment such as open-heart surgery.

"You have to get out of the idea that there’s a threshold age where we think about this surgery differently," Charles Bridges, Pennsylvania Hospital’s chief of cardiothoracic surgery, said. "With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don’t?"

A more basic question is whether this never-too-old approach is an example of U.S. medical progress, or an example of why Medicare – federal health insurance for people over 65 – is headed for insolvency.

The answer, experts say, is both. Which is why the current debate over expanding federal coverage to all uninsured Americans is an ethical and economic minefield.

Should everyone have access to costly services and procedures? Or should these be reserved for the young or for those who have a reasonable chance of recovery? How do you define "young" or "reasonable chance" or "recovery"?

It’s by no means clear where the age line should be drawn, as one blogging physician explains. Some octogenarians are hale and hearty, Dr. Lucy Hornstein points out, while some people in late middle age are struggling with a raft of serious chronic conditions.

We shouldn’t be arguing about operating on healthy 90-year-olds. It’s the frail, fragile folk in their 70s and younger, bodies wrecked by years of abuse, who ought never to see the inside of an OR in the first place, but who all too often are whisked there without a second thought.

I would take issue with characterizing sick 70-somethings as having "bodies wrecked by years of abuse." Sometimes people just get unlucky, or draw the short genetic straw. But Dr. Hornstein makes a valid point. As she says, "Treatment needs to be individualized based on the clinical condition of the patient."

The bigger issue is how this could or should be applied across society. In a similar vein, here’s a recent article in Slate that explores whether medical students should learn about health care policy so they can incorporate it in the decision-making process for their patients. Harvard Medical School is already doing this with a required semester-long course that began in 2006.

The series of 13 lectures covers the different types of managed care, entitlement programs, the economics of insurance, medical malpractice, and even health care reform. In smaller discussion sessions, students confront tough decisions. Say you’ve got a drug that extends an elderly woman’s life for a few months but costs thousands of dollars. Do you prescribe it? "We want them to understand the trade-off," says professor Haiden Huskamp, who co-teaches the class.

Farther down in the article, Huskamp explains that medical students are trained to think about patients as individuals. "But we want people to think at the societal level, the health system level."

There’s a balance here between doing too much and not doing enough. The question is how to find that balance. Should it matter who’s paying the bill? Should it matter how much the procedure or the drug costs? Should it matter who the patient is?

Years ago, in a high school class we were given an ethics exercise to discuss. Five make-believe patients needed a life-saving procedure that was extremely expensive and available only on a limited basis. Our assignment was to choose the one person who would receive the procedure.

One of the patients, I recall, was a mother of two. One was a Nobel prize-winning writer in his 80s and one was a middle-aged blue-collar worker. I don’t remember what we decided. What I do remember is the agonizing sense of having to determine someone else’s fate, of having to decide who was worth saving and whose life was worth the most to society.

At the end of the class, the instructor explained to us that there was no right answer. What he wanted us to do was to think about and define the values that might guide such a decision. He wanted us to understand that hard choices often involve a trade-off.

All these years later, the questions have mounted, the complexity of the decisions has grown, and there’s an increasing urgency to try to address them. But there’s still no right answer on how we should deal with the r-word.

Update, July 8: Blogger Dr. Kevin Pho writes about the inevitability of rationing, and readers respond.

Update, July 16: Utilitarian philosopher Peter Singer writes about why health care rationing is necessary.

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