Living better and the costs of getting old – hard moral choices ahead

It’s fun to play this thought game: If you could go back in time, when would it be?

The answer for me depends upon the rules of the game. If I could return only as an observer, then I have a hard time choosing between, say, watching Jesus do his work or Mohammed receiving messages delivered by the angel Gabriel.

But if I had to live like one of the people from the period, I would decline to play the game. I only need to read the book, The Worst Jobs in History: Two Thousand Years of Miserable Employment, to be reminded that for most of humankind, life was nasty, short and brutish. Work was misery and even for nobility life was dirty, smelly and disease-ridden. The idea of comfort didn’t even exist.

Women died in childbirth, most children died before adulthood and those that did make it into the upper reaches of age were afflicted with injuries that never healed correctly or suffered from illnesses that took their toll in countless ways.

Dentures were commonplace for my parents’ generation and I had friends who had had polio (a disease, which when I mention it in my classes, draws an unknowing stare) and I remember the unnerving hack of a child who had whooping-cough.

In Kenya, I saw what a paucity of modern medicine means. I knew many who were in and out of hospitals for recurring bouts of malaria and saw people waddle along streets with gigantic legs (elephantiasis) and those whose limbs were so thin that they couldn’t support themselves and propelled themselves along sidewalks with their hands.

Perhaps these thoughts about the virtues of modern medicine are more prevalent in my mind now that I am a Social Security beneficiary. My ailments are more frequent and, I expect sometime in the near future, more serious.

I was reminded of my recent CAT scan when I read about the furor in the State of Washington as health care panels hold public meetings to determine which medical devices and procedures will be covered for state employees, Medicaid patients and injured workers. The panelists listened to the testimony of people who, like that of a carpenter, pleaded with the committee to authorize a particular treatment, in his case, spinal injections. “My life would be a living hell without these injections,” he said. “I don’t deserve to be sentenced by a committee to a life of agony.”

No one’s life should be lived in agony and I would like the panel to approve every procedure, but can each agony be covered by health insurance? Every insurer, whether private or public, has to decide what to cover. Not every procedure can be approved; not every desperate patient’s complaint can be medically addressed. All compassionate people wish otherwise, but wishing isn’t a viable policy or a sustainable model for non-for-profits or for-profit organizations.

Washington State’s approach is unique in that the committee meets in public and the proceedings are for all to witness. What disturbs many people is learning that the cost and efficacy of treatments is taken into consideration. An absurd hypothetical makes the point: If there is one and only one person who is terminally ill and the only potential treatment is unproven to be effective and costs tens of millions of dollars to administer, everyone can agree that such a procedure shouldn’t be approved.

Manufacturers of medical devices, doctors and patients are critical of the approach, claiming that this is rationing health care. The panel responds by saying that their decisions are based in evidence-based medicine. Does the procedure work? Are there other procedures that work just as well but are cheaper?

One of the most contentious areas discussed by the panel concerned spinal injections that are commonly used by pain specialists. In 2009, the state spent $15 million on the procedure. Some doctors acknowledged that specialists sometimes overused injections in order to generate income. After reviewing the medical literature regarding spinal injections, the panel concluded that there was no evidence that they did reduced pain or improved physical functioning compared to placebos. They therefore denied coverage for spinal cord stimulation and pumps that delivered medication to the spinal cord. The testifying carpenter was obviously distraught by the decision.

I don’t know if the panel made the right decision about spinal injections or anything else during their deliberations. I am not familiar with the reports they read or know the medical literature. But what is certain is that society can’t cover the costs for every procedure irrespective of cost or efficacy. In the US, as people like me grow older and need more care, it will be increasingly clear that not all our illnesses or ailments can or should be treated. There are limits and one of those limits is the price tag. By labeling this “rationing,” it puts a stop to a necessary discussion about how we are going to care for the medical problems of an aging population while at the same time technology develops more and more expensive procedures to deal with them.

I’m glad that my life has been made better and easier by advances in modern medicine and public health. But I’m not entitled to have society pay for my care without limit. This is a hard fact to accept. Our society isn’t very good at admitting that not everything can be made better. Society will have to deal with a huge aging population. And that population will have to decide whether they deserve at outsized portion of the national treasury or whether our money is better invested in making the future better for those we inevitably leave behind.






5 thoughts on “Living better and the costs of getting old – hard moral choices ahead

  1. Wow! Very honest and thought-provoking post–certainly one that implies the deep moral responsibility we all have when considering our own mortality and the treatments we will want to ease our passage out of life. The problem I see is that certain folks will not have to make this decision due to wealth–then it boils down to those who can’t afford healthcare who are made to choose between the present and the future, treatment or not. Certain parts of the population will not have to struggle at all with such a tough conundrum.

  2. As long as there is wealth disparity, there will be those who can buy a better life. But things don’t have to be so unfair if society decides that justice and equality are as important as individual freedom and unfettered capitalism.

  3. The difficulty in distributing medical care in an equitable fashion underlies Arthur and Coleen’s comments. It is an accurate and very important observation that our resources are sometimes wasted in futile efforts, and are often not available where those resources could do more good. The reasons for this go far beyond financial resources per se, although wherewithal is probably the largest factor.

    Attacking the problem with evidence based medical decisions may be helpful, but many decsions are made empirically, in the sense that practical experience, rather than or in addition to, objective evidence enters decision making; you can’t make everything objective.

    The problem has to do with the wish to exert control of the medical situation by all the people involved in decision making. This means the patient, the family, the doctor(s) and other health care personnel and facilities, the insurance companies, the legal profession, and official bodies dealing with ethical and financial distribution decisions.

    It seems to me that the inability of our society to distribute medical care equitably comes from a disregard for fairness and compassion, not necessarily as individuals, but institutionally. Why does the principal “separate and unequal” apply to educational facilities but not to health care?

    We need to have a system of health care where everybody’s in and nobody’s out and decisions are made to apply resources rationally. Perhaps, if we can attain universal health insurance, we can more readily apply priorities in our decision making. In my opinion, it is not morally justifiable to exclude any age group in medical care but it is justifiable to exclude care which is futile, misapplied or wasteful of resouces. That doesn’t constitute “rationing” but restricts forces which squander our resources.

  4. Milt makes a strong point about not excluding any age group in medical care except if that care is futile, misapplied, or wasteful. There does seem to be an heightened sense of “futility” in treatments for, say, those who are in their 80s or 90s because we tend to think of the number of potential years left to live as valuable. But this doesn’t necessarily have to be the case! To put it in a crude example, giving someone who makes tremendous positive impact in whatever forum alive (say, the Dalai Lama) for one year might have a greater influence than keeping me, for example, alive for a 10 years in spite of my relative youthfulness. The quality of the life and relationships matters, but this is tremendously subjective, of course! So many issues!

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