Commentary

Get more care for health buck

Thoughtful, self-imposed rationing can make health reform more just than status quo

Leonard M. Fleck

What does it mean to be a "just" and "caring" society when America has limited resources in the form of tax and insurance premium dollars to meet virtually unlimited health care needs?

We spent $2.4 trillion on health care in the United States in 2008, about 17 percent of gross domestic product or national output, and projections call for that rising to $4.4 trillion in 2018, or 20.5 percent of likely GDP. A torrent of expensive new medical technologies drives costs upward.

As we discuss health reform, Americans ought to be able to talk to one another about excessively costly medical care yielding too little real benefit.

Having some level of health insurance does not assure unlimited access to needed health care. About 62 percent of personal bankruptcies last year were precipitated by medical bills and about 75 percent of those individuals had some level of health insurance (obviously inadequate).

Since these numbers are large and impersonal, consider two personal stories.

"Ginny" was born in West Virginia with a heart defect surgically repaired at age 5, paid for by Medicaid. At 16, she developed a life-threatening heart arrhythmia that required an expensive medication paid for by Medicaid.

At 19, she was no longer eligible for Medicaid, but no one would hire her because of her health problems. She died at 19 of a fatal arrhythmia because she couldn't afford her medications.

Was her death merely "unfortunate" or "unjust and "uncaring"?

In another case, Michael DeBakey was a famous heart surgeon who, at 97, diagnosed in himself a life-threatening aortic aneurysm. He had successful surgery, but it required an eight-month hospital stay costing $1 million. He died a year later. If he had been denied that surgery for economic reasons and died at 98, would his death be unfortunate or unjust?

The Institute of Medicine estimates that 22,000 uninsured Americans, just like Ginny, die prematurely because they cannot afford health care. This ought to motivate and justify major health reform. But it will be costly.

Proponents of health reform contend costs can be controlled by getting rid of health care waste and inefficiency. But one person's "waste and inefficiency" is another person's "life-sustaining health care."

The Terri Schiavo case illustrates this. She was in a vegetative state for 14 years with no hope of recovering. Her care cost at least $100,000 per year. Was that wasteful health care?

Does a just and caring society owe DeBakey unlimited life-prolonging care? Do we owe a comparable level of life-prolonging medical care to every American faced with a terminal illness?

If yes, are we willing to pay the additional taxes and insurance premiums required to meet that moral obligation for the insured and uninsured?

Many Americans assert that human life is priceless (and rationing is morally objectionable), yet some criticize health reform, especially if it requires raising taxes. If the need for health care rationing is inescapable, then the real moral challenge is to determine how rationing can be done fairly and openly.

Patients legitimately fear two things: the denial of costly but effective care, and denial by uncaring insurance managers or bureaucrats. These forms of rationing are unjust and uncaring. But there are alternatives.

We should be able to engage the public in deliberative forums. Many new cancer drugs cost $100,000 for a course of treatment and yield only extra weeks or months of life. Is that worth the cost?

If we can agree which health care interventions are not worth it, morally or economically, we will have made rationing decisions. These are self-imposed rationing decisions, not rulings imposed by uncaring bureaucrats. These are decisions made openly, thoughtfully and fairly, not decisions determined by interest groups advancing their narrow concerns at the expense of public interests.

Such decisions require moral and political courage. They also require respectful public deliberation.

If we cannot have civil conversations about morally and politically controversial policy matters, more than health reform will fail. The noble political experiment that has been American democracy will fail as well.

Leonard M. Fleck is a professor of philosophy and medical ethics at Michigan State University and the author of "Just Caring: Health Care Rationing and Democratic Deliberation" from Oxford University Press. E-mail letters to letters@detnews.com. Mail letters to The Detroit News, Editorial Page, 615 W. Lafayette, Detroit, MI 48226.