Another reader question, and open thread

This is one of those topics I’ve always sort of avoided, and I’m still avoiding it for now. But that doesn’t mean you have to remain silent. Here’s the reader comment/question:

This is off-topic, but I wanted some doctorly input to a discussion that I am having over at another blog.

This lady is hyperventillating about the “sinister” (her word) policy of the Oregon Public Health Plan.

They won’t cover curative treatment for people who have a “less than 5% chance of surviving five or more years”

Instead, they cover palliative treatment, hospice, and Doctor-Assisted suicide.

This lady is setting it up as a moral judgement that the government is making a value judgement on 1,2,3, or 4 years of life.

To me “less than 5% chance of surviving five or more years” doesnt sound like curative treatment doesn’t have a very good chance of buying you even one year of additional life. I think that she has an unrealistic view of what it means to have a less than 5% chance of surviving five or more years” means.

Heres the story:


It’s all yours, folks.


  1. Thanks, PalMD!

  2. D. C. Sessions

    It’s a zero-sum game, people. How many immunizations, how much prenatal care, how much physical therapy, can the same money pay for?

  3. andy_w_harris

    If you make public health care the top most budget priority at a federal level and a state level, then it will not be a zero-sum game. You could have money for immunizations, prenatal care, physical therapy, and long shot “curative” therapies for terminally ill patients.

    However, in the current real world, lawmakers have to make choices between the lesser of two evils. Taking a chance at saving a few terminally ill patients when most will perish seems noble until you have to sacrifice the money that could actually prevent illness and death for many others.
    So yes, it is a zero-sum game right now. It sounds more like a “sucker’s choice” to me. That is, it’s an artificial construct we create when we fail to seek out more mutually beneficial alternatives. The idea was coined by Kerry Patterson in Crucial Conversations. We set ourselves up for this sucker’s choice when our priorities at the federal level are so focused on war making that we leave the individual states to find compromised solutions for systemic public problems.

  4. This lady is setting it up as a moral judgment that the government is making a value judgment on 1,2,3, or 4 years of life.

    Well, no kidding. The government has put a dollar value on people’s lives and body parts since…well, for a long time.

    Last I heard the value of a healthy person, killed on the job by safety violation or in a car accident, is about $5 million dollars.

    If an otherwise healthy person is worth $5m, what is a person who is 95%+ likely to die in less than 5 yrs worth? Cynical, disgusting, yes. But when we stop calling people employees and people and human beings and begin calling them human resources, what do you expect? A resource has a dollar value. That’s just how capitalism works and capital is only invested in those most likely to return a profit. It’s easier for those making the decisions not have work with language that makes them realize that it’s other people, like them, for whom they are making life and death decisions. It’s just resource allocation and cost/benefit analysis. The government is not independent of these things. They have a budget and they have to pay for services just like anyone else.

    Not saying it’s right; that’s just how it is. If we don’t like that, we have to change it.

  5. yogi-one

    So your mother is diagnosed with terminal cancer, given by the hospital doctor a leass than 5% chance of surviving one year.

    Your mission, should you decide to accept it:

    Sit down with a calculator and do the math. Figure out how much your mom is worth, and figure out how many people people could benefit if the same money was spent on preventative care for others (we’ll drop the discsussion of whether that’s where that money would actually go, that’s another whole debate).

    Now the fun part:

    Go to your Mom’s bedside and say:

    “Mom, I have some news for you. We’ve crunched the numbers, and it looks like the most efficient thing to do is give up on the healing and just increase the painkillers as the time approaches.”

    “Not saying it’s right, Mom, that’s just how it is.”

    If your Mom has half a brain, she’ll go behind your back get a lawyer, cut you out of the will and the insurance policies, and sue your friggin’ ass, because that’s what a person who would treat their terminally ill mother that way deserves.

    There IS a place for morals even in a capitalist economy.

  6. Brief interjection:

    Captialism and utilitarianism are not mutually necessary nor mutually exclusive.

  7. manigen

    There are only limited resources available for each patient. Even if health were the first priority in public spending this would still be the case. Eventually, no matter how much you spend, some people will die.

    Don’t get me wrong, I’m not saying there isn’t a good argument for re-evaluating the priorities of public spending (I’m english and so I’m poorly placed to evaluate the situation on that side of the atlantic). What I am saying though is that eventually you have to make a call, something like “We have X dollars to spend this year, do we spend it on breast cancer screening or breast cancer treatment?” That’s when you find out how much a human life is worth, and how much you can justify spending to save any one person.

  8. I guess my big question is: is this even a question? Would spending the money demanded by these “pro-lifers”
    actually extend the person’s life.

    Since roughly a forth of the people I know who have been treated for cancers were killed by the treatments (and one has opted for only palliative treatment, since the treatment almost killed her twice…), Im wondering how often a curative treatment for someone with a LESS THAN 5% survival rate would actually do more good than harm.

  9. melospiza

    This is the way the Oregon Health Plan was set up; medical care is rationed by diagnosis. There was another flap a few years ago because the plan wouldn’t pay for a multi-organ transplant on a young woman. Since there isn’t enough money to pay for everything for everybody (and not even enough money to pay for the Oregon Health Plan), I approve of this method–it sure beats the rationing method we have now, which gives care to those with employer-paid insurance or wealth. At least there’s a modicum of fairness.

    It was horrendously tactless and offensive, however, for the letter denying the therapy to say that, oh, yeah, we’ll pay for assisted suicide. You can’t have chemo, but you can kill yourself on our dime.

    I’m all in favor of physician-assisted suicide here in Oregon, too, but this was not well done.

  10. The letter mentioned it as one of the options, including hospice/palliative treatment.

    I don’t think it’s tasteless to include all possible options in a list of possible options.

  11. ANonAthlete

    Re: andy_w_harris

    >We set ourselves up for this sucker’s choice when our priorities at the federal level are so focused on war making that we leave the individual states to find compromised solutions for systemic public problems.

    Or, alternatively: if the federal government isn’t providing effective health care, stop relying on the federal government for health care. Raise state taxes, adequately fund state health care policy, and stop waiting for national level health care, which is broken.

    Or, vote with your feet/wheelchairs: move to another state where phys-assisted suicide is illegal.
    That’s real change.

  12. Mark P

    It’s important to focus on the real issue, as some comments have done. The real issue is that Oregon doesn’t have enough money to pay for all medical treatments for all patients. Given that, some choices must be made, and it seems reasonable to pay for treatments that have a good chance of working over a reasonably long term. Now if you don’t like it, the thing to do is start working on reducing funding for other programs or increasing taxes to pay for all treatments for all people.

  13. There are several different issues involved here.

    First of all, a human life by necessity has to have a value on it. It’s got nothing to do with capitalism, it’s just simple fact that we live in a finite environment. There will always be difficult policy decisions to make, and long shots will always be less favoured. And rightly – if a little unpalatably so.

    The second issue is money. Now, as nice and easy as it is to say that the money from the War on Iraq could have been spent on health care, that’s a big disingenuous. You already spend an obscenely ridiculous amount of money on healthcare. You spend more than twice the amount per capita than we do in the U.K., and we have universal health care FFS. You really need, as a nation, to start asking your government where the fuck the hundred of billions of dollars you’re pouring into the health system each year is going.

    Just my tuppenceworth.

  14. And tuppence is worth what, like 10 USD these days?

  15. Dianne

    I’m unsure how to judge this because I’m not sure what they mean by “palliative care”. Take, for example, a person with metastatic non-small cell lung cancer. They have basically no chance of a five year survival, except in very special circumstances (i.e. operable lung nodule, isolated met to head). For an otherwise healthy person, the first line treatment in this case would probably be carboplatin + taxol. And it would be palliative care: chemotherapy can extend life and improve quality of life in metastatic cancer but, except for a few types of cancer, rarely if ever cures. So the standard of care would be covered under Oregon’s plan, it seems to me–not likely to be detremental to anyone’s health.

    On the other hand, they may have defined “palliative care” such that it does not include chemotherapy or other aggressive interventions. In which case, it is likely to do a certain amount of harm. How much is hard to say, lacking a clear definition of what is and is not covered.

  16. carbo-taxol is a pretty standard regimen, i wouldn’t be surprised if it’s covered as palliative.

  17. Drowned

    Apologies in advance for a long-ish comment.

    I think this discussion neatly throws into focus how a lot of different people think about healthcare. The answer could be approached from a number of different ways (and frequently is) but as health economist the way I would think about it is as follows. Deciding to give someone (A) a particular treatment for an illness in a public healthcare system involves an implict imposition on someone else (B). By using our resources to treat A, we have decided that B will not get that money for their treatment. So the opportunity cost of treating A is to not treat B. This problem arises in every sector of the economy, and families face these decisions every single day. We can’t have it all, because our resources are limited.

    The way I see it, the job of a public healthcare system is to buy as much as health as it can (as opposed to healthcare, an important and occassionaly forgotten distinction). To do that, someone, somewhere in the system, has to sit down and decide which treatments for which illnesses get funded, and which don’t. Do we treat A or do we treat B? One way to do this is by a cost-benefit analysis – do we buy more health treating A than we do by treating B. This is roughly what the system in the UK tries to do, and to a large extent it works, but not always.

    This sort of system occasionally fails for two very related reasons. One is that while we can identify person A (the woman with the 5% chance of five-year survival), we don’t know who person B is. If we spend on A we may be denying treatment to someone with a 20% chance of survival with a different cancer, but we’ve used our money on the long shot. The second is that because we know who A is, we can be swayed by the story of A because they exist. For some treatments, this can be very persuasive. People getting denied cancer treatment makes a great headline. Unspecified person B being denied treatment for an unspecified condition (or for lung cancer, no one seems to care much about lung cancer in the policy world) because A was treated does not.

    People aren’t trying to be cruel by saying no to certain forms of treatment. Just the opposite, they are trying very hard to be fair. But no system is perfect and there are lots of problems. There is a pretty good discussion here about some of the problems in cost-effectiveness analysis. It focuses on ageism but the same problems crop up all over the place. The argument about double jeopardy by John Harris (cited in the linked document) can be particularly persuasive.

  18. OK, first the disclaimer: I’m a card-carrying bleeding-heart liberal.

    Having said that, I still recognize that there will NEVER be enough resources to provide unlimited services to everybody.

    We’ve got to make choices, both as individuals and as a society.

  19. Dianne

    To people considering medicine as a price/benefit to patient tradeoff, be careful. Sometimes the best care available is also the least expensive. Take the lung cancer example again. I remember a trial in Canada where they compared chemotherapy versus best supportive care (including radiation) in metastatic lung cancer. Patient who received chemo not only lived longer and felt better than those getting BSC, their care actually cost less. It’s by no means clear that even very high tech, high price procedures such as bone marrow (or more usually peripheral blood stem cell) transplant can save money compared to less expensive but less effective procedures more likely to leave a patient to die, expensively, over a period of weeks or months, in the ICU. Thus, I am wary of any plan that says, “we will absolutely not pay for X.” This could be very penny wise-pound foolish.

  20. melospiza

    Dianne brings up the whole issue of end-of-life care, or how much should we be spending on people in their last month of life? Even when we can be pretty certain it’s their last month? How many interventions, diagnostic tests, ICU days, surgeries? Who decides? And when? I sure don’t know.

  21. D. C. Sessions

    In no particular order:

    1) This was the week of the funeral for my mother’s younger brother, and neither she nor her surviving brother are in all that great shape. This isn’t an academic question for me.

    2) Wouldn’t it be wonderful if, as a condition for senior healthcare (e.g. Medicare), people were required to keep end-of-life instructions on file? Sure beats denial and CYA.

    3) I find it much easier to think in terms of what I would do if all of my medical expenses were out-of-pocket. Would I want to spend my grandchildrens’ educations on extending my own life a few literally miserable months? Days, even? Even if it’s not my grandchildren particularly, it’s someone’s. My late father taught me to pay anything I owed to him forward.

  22. DC, I think you exactly hit the nail on the head.

    It is primarily the “pro-lifers” who want to preserve (some) human lives at any expense. Education is the last thing they want money spent on. Much better to pour that money down a rat hole keeping a comatose body warm than spend that money on education.

    If people were educated they just might be able to think beyond reciting what ever talking points are put in front of them.

  23. @yogi-one

  24. @yogi-one

    Well, I hope my Mother would be a bit more rational than the way you wish she would be. I know that my Aunt was when she got her diagnosis. They aren’t part of the do anything/everything possible camp of medecine. They understand how the world works fairly well.

    You are right that there is a place for morals in a capitalist society, but sometimes the moral thing to do IS to make a distateful decision and live, or not as the case may be, with it.

  25. D. C. Sessions

    It is primarily the “pro-lifers” who want to preserve (some) human lives at any expense. Education is the last thing they want money spent on. Much better to pour that money down a rat hole keeping a comatose body warm than spend that money on education.

    I don’t think it’s nearly that simple.

    Remember, geezers vote and babies don’t. Nobody likes to plan their own deaths, but “failure to plan is planning to fail.” The families are both sentimental and conflicted, in that they stand to benefit from reduced spending on Grandmother — and are likely to bend over backwards as a result. Nobody wants to be a grasping heir, and of course if the Government is footing the bill …

    Finally you have the poor MDs, who are themselves in a bind. Not only are they conditioned to see Death as the Great Enemy, not only are they as vulnerable to sentimentality as anyone, but our legal system offers them the prize of malpractice claims if they skip possible interventions. Well, OK, they also get paid for those interventions.

    It’s really a mess. Which gets back to my proposal that anyone receiving senior care be required to have an EOL plan on file as a precondition.

  26. melospiza

    It’s not just seniors. It’s homeless heroin addicts with massive strokes, young women with widespread metastatic breast cancer, and comatose patients with anoxic brain injuries. Yes, it’s a mess, and there is no one cause or easy answer. When do we give up, and when do we decide it costs too much? There are families, doctors, and even politicians who insist on useless tests and interventions.

    There are many worse things than death, and I expect everyone here knows it, but the USA is very bad at dealing with death.

  27. usually not anon

    As one who has recently (and very unfortunately) qualified for the Oregon Health Plan, I have to say that this is the only way for it to work. While Oregon’s economy is better than economies in many other states, we too are in pretty rough shape. The money just isn’t there to provide for everything and this is just one example of where the lines are drawn (the organ transplant kerfluffle being another).

    I would also note that the “suggestion” of utilizing the death with dignity act, is nothing of the sort. It is just on the list of things that the OHP will cover for people with terminal illnesses, who are reaching the end. Not only would it be rather unethical for a doctor or someone from the DHS to suggest it, it would also be illegal according to the DwDA.

    I should also note though it’s OT, that one of the attractions that moving to OR had for me was the death with dignity act.

  28. A little tidbit of information that some of you may not know: the usual cutoff value used by the insurance industry to determine if a treatment is worth covering is $50,000 per life year gained, with quality adjusted life years often used.

  29. DC, I was thinking of the Teri Schiavo fiasco and how Bush signed both the Texas Advanced directives Act which lets a health care facility stop treatment they consider futile or just too expensive

    and his attempts to go around the state courts in the Schiavo case.

  30. Be prepared for this sort of “dilemma” nationally if some form of universal health care is mandated. Liberalism cannot make economic laws disappear, and budgets will require rationing quite soon.

    On the one hand, you can understand, from a fiscal perspective. The medical industry, on average, makes *a lot* of money during the last months of a person’s life. It is shameful sometimes.

    On the other hand, it seems better for families, and not bureaucrats, to make this type of decision.

    Which is why I opposed universal health coverage.

    When the king of Jordon needs a checkup, he doesn’t fly to France….he comes to the U.S.

  31. Oh Great Bearded One, can you explain why the US spends more per capita and as percentage of GDP on health care and yet has some of the worst outcomes in the developed world?

  32. dhogaza

    When the king of Jordon needs a checkup, he doesn’t fly to France….he comes to the U.S.

    Someone doesn’t understand how the French health care system works.

    Nor does he understand how the health insurance system works. It’s not families who determine whether or not the insurance system will cover a particular course of treatment, it’s the insurance company. The fact that The Oregon Health Plan doesn’t cover a course of treatment doesn’t stop a patient’s family from deciding to pay for treatment themselves. Gee, just like insurance.

    This is the way the Oregon Health Plan was set up; medical care is rationed by diagnosis. There was another flap a few years ago because the plan wouldn’t pay for a multi-organ transplant on a young woman.

    Yes, there was a huge flap by extreme right-wing conservatives in Oregon, who used this as an argument that the Plan should be ended. In other words, if we don’t cover the most extreme cases, then it doesn’t work, so end coverage altogether so the poor get nothing.

    The founder of the Shilo Inn chain, Mark Hemstreet, led the anti-Oregon Health Plan charge on the issue, and paid something like $500,000 for the poor young woman’s triple (heart/lung/liver) transplant and leveraged it into a hugely public (but entirely unsuccessful) attack on the plan.

    The young woman got her triple transplant, and died quietly not long after.

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