Listen to a discussion of this issue by the Ethics Center's Emerging Issues Group
[Ethical Decision Making in Health Care - Should Cost Play a Role?]
One thing that the health care debate has done, which has not received much serious reflection, is to introduce us—however briefly—to the elephant in the room: that is that health care from the gamma knife to allergy medication costs money. Many of us never see this elephant. Our health care is paid for by the government or our insurer. Yes, we may have a co-pay, but we are never confronted with the true cost of caring for our health.
The money elephant has caused many of us to consider whether or not there is a dollar limit to the value of human life. Is there a point when it is simply too expensive to keep heart pumping and lungs breathing? The statistic that we spend one third of our health care dollars during the last year of life has become a verbal prod, forcing us to consider, "Is it worth it?"
Now the trouble with this oft-quoted statistic is that we don't know when we begin our last year that it is indeed our last. We seek care in hopes of restoring health. It can take months or even years for us to discern that, in fact, a person is dying and even longer to accept that someone we love has slipped into the dying process.
All of this begs the question: Is it ever right to consider the cost of medical intervention—even life-saving intervention—in our decisions about how aggressively to treat a patient? Dying patients deserve to be treated with dignity and respect but that does not necessarily require—and sometimes mandates against—aggressive and expensive medical intervention, especially when of questionable or no benefit to the patient. We always have to care for patients, but that may mean offering pain relief and presence rather than the latest or costliest therapeutic.
The Ethical and Religious Directives of the Catholic Church can be very helpful to our thinking about the role of cost in our medical decision making. Directive 32 states:
- While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community.
In addressing those who are dying or seriously ill, Directives 56 and 57 state:
- A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community.
- A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.
On this line of reasoning, "excessive expense" is recognized as one of the important considerations in individual medical decision making, especially at the end of life, equivalent to considerations of medical benefit and burden. Of course, it is easier for us to reason about avoiding pain or avoiding devilish side effects than to reason about expensive interventions, but we need to take seriously the cost burden imposed on both individuals and communities by life-sustaining technologies, especially for the dying patient. Burdensome expense should never be our sole consideration, especially at the end of life, but in the current health care climate, it is best to bring the money elephant out of the shadows and deliberately and carefully consider the ever-increasing cost of health care and the burden it imposes on patients, families, and communities.
Margaret R. McLean is associate director of the Markkula Center for Applied Ethics and Center bioethics director.
April 2011