Thoughts on the Ethics of Health Care Reform

In a previous posting I commented on the recently-published study that suggested a radical shift in the conventional wisdom regarding the use of mammography as a "screening" examination for the early detection of breast cancer. My major point of concern was that such studies might somehow become an "official policy" in the hands of some petty bureaucrat that would probably have trouble spelling "mammography." In today's posting, I would like to expand on that topic by first introducing another "thought experiment." Consider the following hypothetical:

You are the Emergency Room physician on duty at Big Time Expensive General Hospital when you are presented with two patients, a 60 year-old male and a 6 month-old male, both of whom arrived at exactly the same time after being bitten at precisely the same time by a very rare snake whose venom is 100% lethal after exactly one hour. You immediately contact the hospital pharmacy and are given the following bit of "good news / bad news: the good news is that there is an antivenom serum available but the bad news is that 1) it works only 50% of the time and 2) there is only enough available to treat one patient but not both.

Considering all other factors to be equal, which patient will you give a 50-50 shot at living and which one will you let die?

While you take the above under consideration, let me share with you another tidbit on how I came to be writing all this.

A few months ago I sat down with my TI-83 calculator and a boxful of Medicare statements. After about a half-hour I discovered that, since May 1, 2005, the Social Security Administration had spent just under $1.2 million in order to keep me alive; although my mother assures me that a church-full of praying Southern Baptists is what did the trick while others assign credit for the save to the liberal application of the Last Rites. Me? I'm betting that a few months in the hospital was a big part of it, although I will credit an acquaintance that happens to be a Zuni medicine man for chipping in.

Is my life worth 1.2 million taxpayer provided bucks? Honestly, I don't know. All I can say is that it seems to beat the obvious alternative outcome. But first, let's get back to the two snakebites.

As you might have surmised, there is no "right" answer to the above because it requires making a decision based on your personal concepts of morality and how you would define ethical behavior. Would you base your decision on what the 60 year-old man had accomplished during his lifetime or on what the infant might accomplish in its lifetime? Does either patient have the right to live? If your answer is that both have a right to live, you are faced with how to justify your decision to hand down a death sentence to the other.

You could, of course, "kick the decision up the ladder" and let some anonymous business office type make the decision for you. But, on the other hand, the business office type isn't going to be the one that has to walk into a waiting room and tell someone that their husband, or maybe their father, or even that their child has died. Trust me on this one. In my almost 30 years as a PA, I had to walk into that waiting room more times than I care to remember. And it never got easier. Never!

Face it, people. The practice of medicine is as much about ethics as it is about science and technology, if not more so. I want decisions about my life made by the person who is most aware of what works, and not by some clown in an office a thousand miles away.

The point I'm trying to make here is that, in all the rhetoric and assorted flavors of hot air that are loosely described as "debate" on health care "reform," we must never lose sight of the simple fact that we are getting dangerously close to the point where decisions regarding human life could be seen as a matter of dollars and cents.

If we ever get to that point, we might as well get a number tattooed on our forearms and let our esteemed public servants help us onto the train.