July 30, 2008
You have probably heard a sick or dying person say, “What I wouldn’t give for one more day. . . .” Regardless of the setting, the meaning is the same: Life is priceless, something worth fighting for.
It turns out that “priceless” and “worth fighting for” may have their limits, at least measured in dollars and cents.
Some 30 percent of Medicare expenditures go to caring for people in the last year of their lives. Internationally, many countries and insurance companies explicitly ration health care based on cost effectiveness. Simply put, if a year of “quality life” costs more than a certain amount—usually $50,000—they simply will not pay for the care.
Medicare, in contrast, does not have a monetary threshold—at least not yet. Instead, Medicare makes a determination based on whether the treatment is “medically necessary and appropriate.”
A group of researchers at Stanford’s medical and business schools set out to determine if the $50,000 threshold was too low. They used kidney dialysis, which “typically has been used as a benchmark for evaluating the cost-effectiveness of all new technologies.”
In their new study, they conclude the $50,000 figure is much too low. They found that it costs $129,000 to provide a patient with what they called a “quality-adjusted” year of life—in their estimation, two years on dialysis was equivalent, quality wise, to one year off it.
To put it mildly, the implications of their findings are chilling. There is an obvious and disturbing question of how many people have died around the world because of the $50,000 threshold. While two years may not seem so long, it is priceless to those facing the end of life.
Even more frightening are the implications for the future: If Medicare were to follow the lead of other countries, how many Americans would be denied access to life-prolonging treatment?
To their credit, the authors of the study were aware of this and other ethical issues raised by their research. They also raised the prospect of the “sickest subgroups of patients” being “denied access to expensive treatments such as dialysis.”
It is not only the sickest who are at risk: When life is reduced to a cold calculation, the poor and marginalized are also at risk. We all are, as a matter of fact. Professor Peter Singer, for example, teaches packed classes at Princeton that funds should not be wasted on the terminally ill, or on abnormal babies—or who knows who is next, the severely disabled?
Few health care experts will go as far as the former governor of Colorado, who once famously said that the elderly have a “duty to die.” Showing how much it costs to keep people alive for another year or two, however, is the next-best-thing—the camel’s nose under the tent. It provides an economic rationale against prolonging life.
Now, there is a point at which we all must accept the inevitable. And that is why we should applaud efforts like hospice care that allow the terminally ill to die with true dignity.
But what we are talking about here is allowing people to die because we do not think their lives are worth $129,000 a year.
Whether they think the life is worth fighting for does not figure into the calculations—sorry.
