Sunday, August 26, 2018

Rationing health care


An Ethical Musings’ reader sent me the following:

Our local newspaper had an article about a family that enjoys many of the local activities in our area. Their issue is the 34-year-old husband who survived pancreatic cancer as an eight-year-old child and now needs help. His cancer treatment removed 85 percent of his pancreas, 50 percent of his stomach, 50 percent of his small intestine, and 60 percent of his colon. Over the years he has had numerous bleeding issues that required over 100 units of blood and many hospital stays to stop the bleeding.

As a result of the cancer, he now needs a five organ transplants. He needs a new stomach, liver, pancreas, large intestine and small bowel. If he has the surgery, he has less than a 30 percent chance of surviving the surgery itself and a 40 percent chance of surviving for a year. If he gets the call, he goes to Georgetown University Hospital for the surgery. He remains in the hospital for six to nine months and will have to live near the hospital for another six months. The family is asking for donations as the surgery will cost one million dollars. This does not include living near the hospital.

Even with all of these health issues, the man married and has four children under the age of ten. He must decide whether to proceed with the transplants should they become available or living with the bleeding issues.

That scenario raises several important ethical issues.

First, the idea of rationing healthcare is, I suspect, anathema to most of us. Yet when we take a hard look at healthcare, the reality is that the United States, like every nation, rations healthcare:

·       Doctors choose where to live, with a disproportionate number preferring to live in urban and suburban areas. Consequently, rural areas and some inner-city areas have a shortage of physicians. This makes obtaining healthcare for residents in those areas inconvenient if not impossible.

·       Hospitals are closing in rural areas because of the lack of physicians and a lack of sufficient number of patients to justify a hospital’s operating costs. This rations healthcare, e.g., the patient who with emergency room will survive and will otherwise die.

·       The high cost of some prescription medicines forces some patients to choose whether to buy their medicine or other essentials (such as food or paying the rent).

·       The lack of healthcare insurance that includes preventive care leaves some persons unable to afford preventive care. Some of these people will develop serious medical conditions that receiving preventive care would have avoided.

·       And, of course, the affluent can buy all of the healthcare they need or desire in sharp contrast to what most people can afford.

Should our healthcare system provide the five transplants? Could those organs make a greater difference in the lives of five other individuals (the US has a shortage of transplantable organs, so organ transplants are a zero-sum game, i.e., what one person receives another will not)? Could the resources expended on the one patient if spent in smaller amounts on multiple patients, still totaling the same amount, do more good?

Second, do doctors have a moral responsibility to guide patients towards solution most likely to promote the patient’s quality of life? With only a 30% chance of surviving the surgery and a 40% chance of living for a year, the patient has only a 28% probability of surviving into the second year following surgery. Is allowing the patient to proceed with the surgery a good use of scarce healthcare resources? Is a doctor who fails to actively discourage the patient from proceeding with the surgery still honoring the Hippocratic oath to do no harm?

Third, the cost of healthcare for patients with multi-organ failure and chronic disease totals about 50% of US healthcare spending, yet achieves very limited increases in extending the patient’s lifespan or improving the patient’s quality of life. Redirecting that spending to benefit those with the least access to healthcare or simply eliminating that half of healthcare expenditures would arguably benefit society more. Should the US make that change?

Healthcare costs continue to skyrocket. Abandoning the myth that the US does not ration healthcare is an important step to improving healthcare for all while reducing the cost of that care.

Importantly, I write as a person who has a chronic disease. Thankfully, my treatment to date has restored me to a semblance of a normal life. I do feel obligated to serve society in partial repayment of care received. I also recognize that at some point in the future, I may need to decline further care when the cost of that care appears likely to exceed any real benefit to me while concurrently imposing an unfair cost on others. I wonder whether my care providers at that time will encourage me to act morally or to seek all of the care I can obtain regardless of potential benefits.

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