Many of the problems with health-care financing in our country come about as a result of difficulty with line-drawing. I’m not talking about geometry, but about making hard decisions.
This difficulty with line-drawing is not new. In 1971, while Congress was debating national health insurance (!), a man named Shep Glazer testified in dramatic fashion before the House Ways and Means Committee about funding for renal dialysis — while hooked up to a dialysis machine. “Gentlemen,” he said, “what should I do? End it all and die? . . . If your kidneys failed tomorrow, wouldn’t you want the opportunity to live? Wouldn’t you want to see your children grow up?” After thirty minutes of debate in the Senate and ten minutes in a House-Senate conference committee, Congress voted to extend Medicare coverage to any and all who need dialysis. The uncharacteristically short amount of time spent considering this action, one that should have raised some very hard questions about things like the just distribution of limited resources, suggests that the hard questions were ignored in favor of doing something that feels on the surface very good — paying for everybody’s dialysis — but that has far-reaching, unexamined consequences.
An excellent article in the Chicago Tribune last week described a recent iteration of the old problem. Through medical advances, increasing numbers of our oldest citizens are being made healthier by procedures that were once reserved only for younger people: it is not unusual for people in their 90s to have hip replacements or a 102-year-old to have a heart valve replacement. Now, these are good things! These people are living more fruitful lives through medical procedures. But they are living under a system, Medicare, that does not consider price, but only benefit to the patient, in making decisions about what medical procedures it will cover. And as the proportion of the population receiving Medicare expands, and as expensive medical techniques proliferate, the demand for such procedures will be virtually infinite. Unfortunately ,the resources to pay for them will be all-too finite.
At some point we have to go beyond emotional appeals, beyond doing the thing that feels the best but which bankrupts the country (covering everything for everybody at any cost). At some point we have to draw lines, to make hard decisions about who will get what — and who won’t.
What is the most ethical, most just way to make this decision? The Tribune article mentions one solution put forth by Daniel Callahan and Sherwin Nuland: set a cutoff age (they suggest 80) beyond which people will not be covered for anything beyond “good basic health care.”
Callahan said, “If you want to save all lives, you’re in trouble. And if you want to save all lives at any cost, you’re really in trouble. . . We need to stop thinking of medicine as an all-out war against death, because death always wins.”
Callahan’s perspective in that last statement is a good corrective to distorted expectations of medicine. I don’t agree with how and where he draws the line on providing medical care; but if it gets the discussion going, it’s at least a place from which to start.