Sunday, September 20, 2009

Ethical Health Care Reform

With the publication of the Baucus proposal for health reform, we may be entering the “end game” of negotiations about a final bill.  My intent today is not to review that bill because, while I believe it is the most realistic of all proposals in play, it is unlikely to be the final agreed upon version.  Rather it seems that with its publication, we now have at least two starting points for the final push towards legislation, the Baucus bill and the House bill.  The debate has played out thus far on financial and ethical terms and there are significant ethical dilemmas to consider.   Reform of a health care system, that no matter how confusing and flawed, still gives excellent care to those in need who access the care will not be easy or straightforward.  The debate cannot, however continue to be the cartoon caricatures that each side seems compelled to present.  I believe that the ethical issues are between two positive ethical visions and not between two opposing visions, one from the devil and one from the angels (pick which is which depending on which side you are on). 

The Proposal To Kill Grandma

Obviously there is no proposal on the table to develop death panels.  However, in the White House’s own words “the President’s plan will create an independent Commission, made up of doctors and medical experts, to make recommendations to Congress each year on how to promote greater efficiency and higher quality in Medicare”.  If we follow that proposal to one potential result, it could easily include proposals to shift spending from complex cancer treatment to prenatal services.  That is certainly good and ethical.  However if you are the 80 year old who is now not getting new cancer treatment because of that shift in resources, you may not believe it is ethical towards you.  The fact is that in a classic article written in 1995, it was found that the United States statistics on survival at age 80 is the highest in the world.  Part of the reason for that is that we, in the United States have far better survival rates for cancer than anywhere else in the world including other western democracies.  We do exceptionally well in finding people with breast and prostate cancers and treating them aggressively.  That, according to statistics from the American Cancer Society.  Would that change under some of the proposals being considered?  It could.

The Un-American Racist Proposals

On the other hand, the opponents of the Presidents plan are not liars, un-American or racist on the basis of their opposition to the reform proposals.  They are honestly worried about the high financial burden to be placed and the loss of ready access to high tech, costly care if you have a cancer or other catastrophic illness.  However they also cannot just ignore the findings as outlined by the Institute of Medicine that people without insurance are less likely to get adequate care for stroke, cancer, heart disease and diabetes among other conditions. 

The Greater Good or the Individual Good

As a nation of people who believe strongly in the Horatio Alger story that stresses individual initiative and individual responsibilities and rewards, we tend to lean towards programs and policies that allows for unique decisions in health care which includes the right to get whatever care they and their doctor believe to be appropriate for their individual predicament.  The greater good, from both a population health and a financial health point of view may involve limiting that individual decision making to some extent.  Many of the proposals currently on the table can take us down that path.  That is either a reason for celebration or a reason for caution.  Does the ethics support allowing that person to get the care that they and their physician deem to give them the best chance of life, even if the odds are low, or does the ethics support a process to determine on a population basis that, if the odds are low, the resources should be spent elsewhere.  The answer will require balance and careful discussion, not demonizing the opposition.