The Fake 'Mid-Death Crisis'

As Ezekiel Emanuel and colleagues have shown, preferences about care at the end of life are not stable. Faced with a hypothetical situation in which they are going to die anyway, survey respondents, looking ahead, will say they would choose to die at home, surrounded by family, and so on. Faced with actual death, people tend to grasp at the slimmest hope. In many cases, when a person knows his or her days are numbered, the days become more, not less precious. We should be very leery of bioethicists who project their own beliefs upon the dying, or who claim that people who are not near death can tell us what choices they would make as death approach. Some, as in Mr. Duncan’s story of Mr. Shinkle, will be consistent. Many will not.

(6) A lot of very sick people do not die. Spending on very sick people who do die has risen no more quickly than other medical spending. Doctors are not very good at figuring out who will die, when. So the argument that we should save money by reducing care at the "end of life" reduces to a claim that a good way to save money is for doctors to play God, make their best guesses, and "educate" really sick people to refuse care.

This may seem sensible to some people. To others it will seem sick. Do we really have to rely on inaccurate rationing to save money? The people who claim this is an "ethical imperative" are saying, in essence that there are not better savings. At their worst, they are making a political analysis: that other forms of cost control are not possible, so we should go for the kill-the-elderly approach. As a political analysis, this is almost as crazy as the "death panel" exaggerations. As a policy analysis, it’s simply irresponsible. There are many better ways to save money.

(7) In fact, experience in other countries does not show that the cost control solution is to ration care at the end of life. The differences between the United States and other countries are due mainly to higher prices and administrative costs in the U.S., not due to the U.S. providing more services. (For a variety of sources, see this discussion.) Some of the large difference between costs in the United Kingdom and the United States is due to lesser availability of some services in the U.K. But that’s not an encouraging example because life expectancy at age 65 has actually been slightly lower in the U.K. than in the U.S. (For a wide variety of comparative health care statistics see here.) So the U.K. does not show that "excess" U.S. services do no good.

Nor does Britain’s "NICE" (National Institute for Clinical Excellence) process show that "rationing by cost-effectiveness" is the way to constrain costs. NICE was only created in 1999. Since that time, the Labor Government, in response to a strong perception that care was too strictly limited in the U.K., has increased spending at least as quickly as spending has increased in the United States.

NICE itself was not created to limit care. The British were limiting care only too well before then. NICE was created to rationalize the limits, so that, for example, policies would be uniform across the country. Nor does NICE even show that explicit rationing by cost-effectiveness makes sense. Mr. Duncan cites the example of not paying for Avastin because it was deemed not "cost-effective." But this explicit rationing is a lot harder to defend than the hidden rationing that occurred before. And it simply asks the wrong question: the right policy would be to demand a lower price for the drug.

Rationing by cost-effectiveness challenges a patient to justify an attempt to save her life; why is this more ethical than challenging a drug company to justify high profits? The greatest flaw in the whole argument that we have to let old people die to protect the rest of the country against health care costs is that its advocates claim to represent ethics and responsibility while letting all the people who profit greatly from the health care system – including the bioethicists who make good money from talking about ethics so the medical establishment can believe it’s paying attention to ethics – off the hook.

While bioethicists who make claims about economic imperatives are speaking beyond their competence, there are good reasons to think about improving health care at the end of life. Care should be based on some reason to believe it will do good. Care in many cases could be better, pain could often be reduced, and sometimes spending is excessive. But the idea that there is a "mid-death crisis" that has to be resolved in order to control spending is simply false.

Joseph White is Director of the Center for Policy Studies at Case Western Reserve University.