The Health Care Debate: What Price is Life? A Stranger’s Life? Your Child’s Life?

As we approach what hopefully will be a reasonable and humane outcome to the ongoing health care reform debate, some have become very emotional (including this author), some fall back on cold hard facts, cold statistics.

For those relying on cold, hard facts to either support their views or oppose others’ views on this issue, a brilliant article in this weekend’s New York Times Magazine is just loaded with them.

In “Why We Must Ration Health Care,” (Long title: “A Utilitarian Philosopher’s Argument for Placing a Dollar Value on Human Life”), Peter Singer gives us value for the buck.

Starting with the question, “You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?” Singer sets the scene for his own and others’ views on the value of human life and delves right into the concept of rationing health care.

In doing so, Singer looks at emotional, political, financial and ethical aspects of the issue.

We learn, for example, that Britain’s National Institute for Health and Clinical Excellence (NICE), “a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness” has in effect already set a general limit of about $49,000, on the cost of extending life for a year.

Singer provides a couple of dramatic examples of NICE “enforcing” such standards in the case of the drug Sutent. Examples that were immediately picked by both the British and U.S. media and by groups lobbying against health care reform in the U.S.

(Singer adds that “In March, NICE issued a final ruling on Sutent… it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer.”)

Before we start pointing fingers at the British health care system, Singer points out that in the U.S. we also ration health care, but “do so less visibly,” and also put a value on human life, but do so much more implicitly and subtly.

Singer gives a few examples on the latter—placing a dollar value on human life.

He cites how the Department of Transportation sets a limit on how much it is willing to spend on transportation safety to save one human life: “In 2008 that limit was $5.8 million.”

Singer says that other government agencies do the same and gives the example of how the Consumer Product Safety Commission decided that a $343 million project to make mattresses less likely to catch fire, was worth the cost because it would save 270 lives a year — and at $5 million per human life, it would get a good bang for the buck.

Then there is the famous case, twenty years ago, when the National Research Council decided that installing seat belts in all school buses at a cost of $40 million “would save, on average, one life per year…After that, support for the proposal faded away.”

Getting back to health care, and its “rationing,” Singer also provides several examples where we, in the United States of America, already implicitly or explicitly, directly or indirectly, ration health care through the high cost of drugs, because of inability to pay for insurance or for the actual cost of care, etc.

Singer tells us of a woman who came into an Atlanta emergency room “in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.”

But it is not only uninsured Americans who can’t afford medical care.

According to a recent Commonwealth Fund survey of adults with chronic illness in several European countries and in the United States:

Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.

Singer continues to discuss the complexities in setting a value on a human life, on how much we should spend to save or prolong a human life and on how to set that limit when it comes to health care.

He discusses a couple of theories filled with numbers, calculations, statistics, risk, life expectancies, etc., but those pesky variables related to social and religious issues and values, the relationship to the patient, the age of the patient, the love for the patient, or the desire by the patient himself or herself to live, seem to always get in the way.

But Singer does as good of a job in tackling this intractable issue as anyone could be expected to.

He concludes with the discussion of “QALY” (quality-adjusted life-year), “a unit designed to enable us to compare the benefits achieved by different forms of health care [that] has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money.”

Singer believes that if a reformed U.S. health care system explicitly accepted rationing, as he has argued it should, QALYs could play a similar role in the U.S.

I highly recommend the reader to study—and studying it needs—this part of Singer’s article.

In a “final comment,” Singer says:

It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get “socialized medicine.”…as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in “health care or medical systems” in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.

As my final comment, as a person and as a grandfather, and getting back to the initial question Singer posed on whether an extra six months of life would be worth $54,000, I just would like to modify that question into a two-part question:

Would an extra six months of life be worth $54,000

A. If the patient was a total stranger.

B. If the patient was your own child or grandchild.

And therein sits the Gordian Knot, that is not going to be untied, or sliced, anytime soon.

But, kudos to Peter Singer for trying.

Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia.