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(2020)National Health Expenditure Projections, 2019-28
Health Affairs, 39
(1978)citation_author=Calabresi G.; citation_author=Bobbitt P.; citation_publisher=W.W. Norton & Company, New York; Tragic Choices: The Conflicts Society Confronts in the Allocation of Tragically Scarce Resources
Sean Keehan, Gigi Cuckler, J. Poisal, Andrea Sisko, Sheila Smith, Andrew Madison, Kathryn Rennie, Jacqueline Fiore, James Hardesty (2020)National Health Expenditure Projections, 2019-28: Expected Rebound In Prices Drives Rising Spending Growth.
(2009)citation_author=Fleck L. M.; citation_publisher=Oxford University Press, Oxford; Just Caring: Health Care Rationing and Democratic Deliberation
It is a serious understatement to say that this is a thought-provoking volume. The author identifies and analyses numerous ethical and policy issues regarding the ways in which we in the United States effectively establish invisible prices for saving and prolonging lives at the same time that we assert publicly the pricelessness of human life. An alternative sub-title for this volume could be: Tragic Choices, Wicked Problems, Impossible Ethical Imponderables. Friedman identifies four main points he intends to defend in this volume. (1) Price tags are routinely placed on human lives. (2) These price tags have major ramifications for these individuals. (3) Typically, these price tags are neither transparent nor fair. (4) The lack of fairness is critical because undervalued lives are unprotected and more vulnerable to risk than highly valued lives. I would add a fifth point of my own. As a society, we in the United States are unwilling to discuss these issues openly and respectfully, most often because any choice we make will be seen as violating some fundamental ethical and social values (Calabresi and Bobbitt, 1978). This is why the language of tragic choices and wicked problems is appropriate. Friedman’s second chapter, “When the Towers Fell,” is an attention grabber. He explores the follow-up from the attack on the World Trade Center in 2001. Specifically, he analyzes from an ethical perspective the challenges faced by Kenneth Feinberg, who was appointed to administer the Victim Compensation Fund. Almost three thousand lives were lost. Most of those individuals had families that were economically dependent upon them. What would be fair compensation to those survivors? By 2004 the fund paid out $7 billion in federal funds. The range of awards was vast. The minimum was $250,000 and the highest award was $7 million. Those differences reflected the earning power of an individual in the present and for what could have been their future. To make things as concrete and compelling as possible, Friedman imagines the lives of Rick, Jim, Anitha and Sebastian; a firefighter, a seven-figure financial analyst, a hostess in the North Tower and a six-year old. Feinberg struggled to get these awards right, to make them as fair as possible. He was criticized from all sides, in part, I suspect, because there was no social agreement as to what would count as fair. Freidman, however, goes on to ask the harder question. Why was there a compensation fund to begin with? The victims of the mass shooter from a tower in Las Vegas received no compensation. The same was true for the victims at Sandy Hook and the gay bar in Atlanta. What justifies such selective compassion with public funds? Friedman suggests there is no justification. Friedman finds similar problems in the US court system with civil cases where awards must be made for death, or damage to health and resulting disability. These awards vary enormously, in spite of great similarities among cases. Friedman’s concern is that such differences reflect the skills of lawyers trying these cases with top notch lawyers hired by affluent individuals and companies. Again, the results have no relationship to any shared social understanding of fairness, which makes it impossible to critically assess those awards. How much pollution should we in the US tolerate in our air or water? This will strike many as a terrible question to ask, especially if there are serious risks to life or health for individuals who might be especially sensitive to various pollutants. In saintly moments, we might be motivated to say that zero pollution should be tolerated. However, those saintly intentions seem to dissipate when we get into our cars, or when we are informed how much our taxes must increase in order to address effectively some range of environmental pollutants. Moreover, if some individuals suffer significant ill health or premature death as a result of elevated sensitivity to some pollutant, that will not make news headlines. Those are consequences that are invisible to all of us. Hence, no opportunity is generated for social criticism. We in the US might imagine a world in which these consequences were brought intensely to consciousness for all Americans. What would we do? Consider ALL the threats in the world to human health and safety. We could not possibly fund the efforts needed to remove completely all those threats. What would a social conversation look like that was aimed at determining as fairly as possible which threats we could afford to diminish, and which ones would be (regretfully) tolerated? To illustrate, forty years ago, I was reading some Sunday news essay about the pricelessness of human life. It noted that 1200 Americans die each year at grade level railroad crossings (mostly as a result of impatience and trying to drive around gates). We could save all those lives if we were willing to spend several hundred billion dollars to separate all such crossings with overpasses or underpasses. Has anyone noticed over the past forty years a groundswell of political enthusiasm for such a project by all who assert the pricelessness of human life? We quietly accept those deaths and soothe our conscience (if somehow awakened) with the thought that these were irresponsible individuals anyway. Friedman reminds us of the Ford Pinto case. The gas tank was poorly positioned and vulnerable to exploding in a rear end collision. The car was already designed and being built. An $11 [$66 inflation-adjusted 2020 $] fix could correct the problem, though that would delay the introduction of the car and risk market share. Economic analysts at Ford figured that it was less expensive to pay off some relatively small number of likely lawsuits rather than correcting that problem now. Friedman denounces such corporate behavior for the “brutal pursuit of profits, unfettered by moral or legal restraints” (p. 94). However, to my mind, that is only half the story. Americans have denounced vigorously the addition of mandatory seat belts and air bags for adding to the cost of the car for consumers. They have insisted instead on their right to be ejected from the car in a rollover crash with an 80% chance of death (including passengers who might have made a different choice). Many readers will recall from 2010 the 33 Chilean miners who were trapped underground for 69 days before being rescued at a cost of $20 million. There was worldwide cheering when that rescue was accomplished. However, Friedman points out that hundreds of American miners died in that same year as a result of indifference to mine safety, though barely a public peep was uttered in outrage, in part because these deaths were not publicly visible, in part because, even if visible, the deaths are excused as part of the risk of the job. Investing in mine safety could reduce those deaths. However, the lives saved would be entirely invisible and anonymous. Consequently, no worldwide cheering. If there is any one place where saving and sustaining lives would be very visible and publicly supported, it would be the US health care system. In 2020, we will spend more than $4 trillion on health care in the US, roughly 18% of our GDP (Keehan et al., 2020). Many will see this as a clear public affirmation by Americans of the pricelessness of human life. We will spend $250,000 for a left ventricular assist device [LVAD] for patients in end-stage heart failure, which will give them one to three extra years of life. We will spend $475,000 for CAR T-cell therapy for patients with advanced blood cancers as a “last chance” therapy. Roughly 30% of those patients will fail to survive one year with that therapy; the remainder will survive one to three additional years. Is this a good use of limited health care resources? Friedman calls attention to the case of Terri Schiavo, who spent the last fifteen years of her life in a permanent vegetative state [PVS] at a cost of about $1.5 million. Friedman asks whether that money could have been better used to save the lives of others who would have the capacity to appreciate the fact that they were alive. “If so, he asks, whose life should have been saved instead” (p.131)? However, before we could answer that question, we would have to withdraw life-sustaining care from Terri, i.e., the feeding tubes that sustained her life. We are then choosing to end her life because we can readily imagine a better use for the money being used to sustain her life. This is not a thought that many Americans are willing to entertain, perhaps because we can see her in that bed, unlike the anonymous people who die at railroad crossings. What makes this even harder is that there might be 25,000 Americans in PVS, just like Terri Schiavo. If we assert with conviction that human life is priceless, then the thought of such a tradeoff cannot take root in our thought. That will seem noble. However, these noble sentiments are tainted by the 30 million uninsured Americans and the additional 40 million who are underinsured. Most Americans say they are opposed to rationing access to needed health care. Many will say they are opposed because that represents putting a price on human life. What they are really opposed to is explicit rationing, the visible denial of expensive life-prolonging care by either a private or public entity. However, we do ration access to needed life-prolonging health care by ability to pay. Underinsured Americans may have to pay the first $5000 toward the cost of health care incurred in a year, which is a barrier to seeking primary care in a timely way. In addition, they may have to pay personally as much as 30% of the costs of very expensive drugs. Targeted cancer therapies and immunotherapies, for example, have annual costs of $100,000–$200,000 or more for treating metastatic cancer. Fully insured Americans will have their health plans pay that full cost, often at a discounted rate. Someone who is underinsured and earning $50,000 per year with metastatic melanoma will not be able to afford the targeted therapies that might yield a few extra years of life. They will die prematurely (relative to what contemporary medicine could have provided to them). These premature deaths reflect a price we silently permit to be placed on these lives. Here is another thought-provoking question: If there are 25,000 patients in PVS whose care is funded by Medicaid, would it be fairer to fund instead these very expensive cancer drugs for the underinsured and allow these PVS patients to die (the rest of the way)? How should all these questions regarding the pricing of human life be answered? Friedman is an economist by training and considers in this volume the various economic formulas that could provide an answer to these questions. However, he rejects all these proposed economic answers as flawed, sometimes for methodologic reasons, more often for their failure to give due weight to considerations of fairness and equity. As a philosopher, however, I can affirm that no philosophic theory of justice will yield the clear and certain answers we seek. Our theories of justice are too abstract to address effectively relevant real-world details. The answers, instead, will have to be crafted by us through fair and mutually respectful rational democratic deliberation (Fleck, 2009). These will necessarily be painful social conversations that our politicians are too prone to avoid. We will have to make tradeoffs among fundamental values in setting health care priorities. Our public response to COVID in this regard is disheartening. The most rigid ideological thinking and disrespect for the best scientific information is corrupting our capacity for rational democratic deliberation. Protecting our collective deliberative capacities must be seen as critical to protecting fairly the lives of all. Friedman’s book is a step in the right direction. He calls our attention to the problems we ought not ignore. Furthermore, he makes clear that no political slogans or economic formulas or ethical theories will yield clear and simple answers. This will be true, I will suggest, with regard to the widely endorsed norm of solidarity in many parts of Europe. References Calabresi G. , Bobbitt P. ( 1978 ). Tragic Choices: The Conflicts Society Confronts in the Allocation of Tragically Scarce Resources . New York : W.W. Norton & Company . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Fleck L. M. ( 2009 ). Just Caring: Health Care Rationing and Democratic Deliberation . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Keehan S. P. , Cuckler G. A. , Poisal J. A. , Sisko A. M. , Smith S. D. , Madison A. J. , Rennie K. E. , Fiore J. A. , Hardesty J. C. ( 2020 ). National Health Expenditure Projections, 2019-28; Expected Rebound in Prices Drives Rising Spending Growth . Health Affairs , 39 , 704 – 714 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Public Health Ethics – Oxford University Press
Published: Feb 28, 2021
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