August 18, 2009

On Medical Absurdity

Justin Katz

Wading through the self-defeating snideness of Ed Fitzpatrick's Sunday column on the healthcare debate (sorry to be harsh, Ed, but it oozes off the page), I wondered whether Fitzpatrick has heard the term "quality-adjusted life year." Here's the definition provided by

A year of life adjusted for its quality or its value. A year in perfect health is considered equal to 1.0 QALY. The value of a year in ill health would be discounted. For example, a year bedridden might have a value equal to 0.5 QALY.

As the Wall Street Journal describes, the measure is particularly popular among bureaucrats in the United Kingdom:

The [National Institute for Health and Clinical Excellence] NICE board even has a mathematical formula [to dictate limits on certain kinds of care to certain classes of patients], based on a "quality adjusted life year." While the guidelines are complex, NICE currently holds that, except in unusual cases, Britain cannot afford to spend more than about $22,000 to extend a life by six months. Why $22,000? It seems to be arbitrary, calculated mainly based on how much the government wants to spend on health care. That figure has remained fairly constant since NICE was established and doesn't adjust for either overall or medical inflation.

Proponents argue that such cost-benefit analysis has to figure into health-care decisions, and that any medical system rations care in some way. And it is true that U.S. private insurers also deny reimbursement for some kinds of care. The core issue is whether those decisions are going to be dictated by the brute force of politics (NICE) or by prices (a private insurance system).

The last six months of life are a particularly difficult moral issue because that is when most health-care spending occurs. But who would you rather have making decisions about whether a treatment is worth the price -- the combination of you, your doctor and a private insurer, or a government board that cuts everyone off at $22,000?

Attempting to impose objectivity on these decisions is clinically monstrous. A hugely successful British composer recently decided that a year of decline without his wife was actually worth paying to avoid. But what was the value — to himself and to society — of Stephen Ambrose's final days? Randy Pausch's? Me, far from a 50% detriment to my QALY, I'd see a bedridden year as an opportunity, probably to write a book, especially if I got to get out of bed and go on with my life afterwards.

Fitzpatrick winds up his essay with some powerful testimony from Rhode Island Medical Society President Dr. Diane Siedlecki, but she and he miss a key reality:

"I am the person you tell when you can no longer afford the medication prescribed, so you cut the doses in half or take [them] every other day, hoping at least for partial coverage," Siedlecki said. "I am the person patients call when they wish to be squeezed in for one last visit or for their annual physical exam because they are no longer covered after the end of the month. I am the person called when a patient loses his job and cannot afford to both come in and renew his medications. Or even when she has two jobs and still no has no insurance."

Involving government in healthcare does not alleviate these equations; it does not change the fact that a particular person has a certain amount of resources to contribute to the medical system and requires a certain amount of care. It merely offloads that judgment from the person him or her self. Rather than an individual's deciding whether the benefits of a given pill justify economizing in another area (whether food or the daily lottery ticket), a governing structure — a "death panel," if you will — decides whether one person's medication outweighs another person's cancer treatment or another person's contact lenses.

Whereas a free system allows patients to make their own quality-of-life adjustments, and advocate for themselves among friends, communities, and charities, a system manipulated through government regulation operates on a deceptive and presumptuous objectivity and political power.

The easy self-deception is that those folks calling up Dr. Siedlecki will no longer have to ration their own care, because the government will cover the expense. The other possibility is that they'll find a cold "system" making those decisions for them.

Comments, although monitored, are not necessarily representative of the views Anchor Rising's contributors or approved by them. We reserve the right to delete or modify comments for any reason.

Justin, I suppose that I shouldn't be surprised by your transparent pandering to the nuttiest elements of the fringe right anymore, but you never cease to amaze.

Let's start with this: any defense of Sarah Palin's claim that the President proposes a death panel to decide the fate of people like her child is pure sophistry of the worst kind. Why can't you simple suck it up, say that Palin is a nut case, and that the President never proposed a "death panel"? Then fire away about health care reform all you like.

But instead, you continue to pander to the crazies and cannot bring yourself to state what is obvious to anyone who is serious. Your post linking death panels -- which, absurdly enough, referred to government subsidies for end of life consultations with doctors -- with a bureaucratic structure to decide the fate of individuals based on their worth to society is absurd.

You say that: "a governing structure — a "death panel," if you will — decides whether one person's medication outweighs another person's cancer treatment or another person's contact lenses". What a remarkably dishonest linking of your fabrication to the health care debate.What you write bears no resemblance to anything that the grown ups are actually debating. But I admit, that as a talking point for people who carry assault rifles to presidential events, it is red meat.

On the larger issue raised by your post: do you not think that insurance companies are making all of those life and death decisions in the private market today? You fear government involvement in health care? Try and look up "Medicare". The overwhelming majority of those in that government-run health care plan are very happy with their care.

Posted by: Pragmatist at August 18, 2009 1:06 PM

When I hear the Palins of the world rail against "death panels" and link living wills to them, I have a big problem. I guess my family (including my pretty conservative sister-in-law) broke one of the Palin commandments when helping my mother-in-law set up a living will.

Posted by: rhody at August 18, 2009 1:32 PM

I know that it is a difficult concept to grasp - but a government panel declining to authorize a particular procedure or drug, the absence of which will accelerate death, operates as a de facto death panel.

Just ask the women with breast cancer in Great Britain.

Posted by: Tom W at August 18, 2009 2:50 PM

"Try and look up "Medicare". The overwhelming majority of those in that government-run health care plan are very happy with their care."

The overwhelming majority of people with private insurance are very happy with their care as well. Yet, somehow, those companies are making evil profits while Medicare is going bankrupt. What you need to ask is, if Medicare is such a great program, why is the President planning to undermine its foundation while simultaneously cutting hundreds of billions of dollars out of its budget? If Medicare is worth keeping, why would anyone support a plan that essentially destroys it?

Posted by: Mario at August 18, 2009 3:28 PM

Ruth Bader Ginsburg and Ted Kennedy both have terminal,incurable conditions.Both are of advanced age.
I'm sure Ginsburg never did drugs or booze,but Kennedy had a long history of alcohol abuse.
Does anyone seriously think they would be denied any extraordinary care,like they are undoubtedly getting now under the conditions of what some of Obama's advisers are suggesting as what people in their position should be getting?
People like them will never have to worry because they are part of the permanent power structure.Same goes for powerful conservative politicians.There are always going to be the anointed and then the rst of us.I have a better chance of having sex with Michelle Yeoh than of a politician telling me the plain truth about this.

Posted by: joe bernstein at August 18, 2009 4:56 PM

Well, Pragmatist, it's certainly pragmatic of you to try to force me to defend a divisive rather than address what I've written in the context in which it was written.

Nowhere do I claim that a specific provision creates death panel; clearly, I'm referring to longer-term trends likely to be set in motion by the principles on which the current legislation is being built, as I explain here.

Posted by: Justin Katz at August 18, 2009 8:10 PM

Ah, I see Justin: you simply created a hypothetical "death panel" as a necessary implication of the current health care reform effort. Funny thing about those hypotheticals: they can't really be refuted. I suppose health care reform might result in a great many things, none of which can be disputed today. And what's also interesting about hypotheticals is that they are particularly fun when you grab onto extremist language that incites your base and use that as a "hypothetical". Great contribution to the health care debate there. But, as I've said before, you are more interested in establishing your bona fides as the "icoloclast conservative" than you are at seriously debating the merits of anything.

Posted by: Pragmatist at August 19, 2009 9:59 AM
Post a comment

Remember personal info?

Important note: The text "http:" cannot appear anywhere in your comment.