On Medical Absurdity
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 MedicineNet.com:
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.