The Runaway Trolley thought experiment was introduced in a previous Topic, on this Blog.The basic lesson was that there are situations where it is quite ethical to take an action that saves (or benefits) a number of people, even if that action has, as an inevitable side effect, the death (or detriment) of a smaller number of people.
This posting has to do with End of Life Issues, and how we might apply the lesson of the Runaway Trolley to the public-funded medical care system. An earlier posting related the Runaway Tolley to Criminal Recidivism
POWERPOINT SHOW AVAILABLE
Click HERE to download a narrated PowerPoint Show that includes animated charts for the Runaway Trolley thought experiment. After the Runaway Trolley is explored, the charts continue and apply the ethical lesson to two real-world issues: 1) Criminal Recidivism and 2) End of Life Issues. The PowerPoint Show is based on a talk I gave to The Philosophy Club at The Villages, FL, on 04 February 2011. NOTE: The Powerpoint Show is Narrated and plays and advances automatically after download to your computer.
PRESIDENT OBAMA'S VIEWS
President Obama, in a moment of unusual candor, expressed his views on end-of-life health care for those with chronic or terminal illness, published in the New York Times Magazine in April 2009. (full text from NY Times website, see section V). I have reproduced the text of that section at the end of this posting. [Some material here is from my earlier posting END-OF-LIFE: Honest Brokers (not Death Panels :^)]
DIRECT OBAMA QUOTES
“… government can … be an honest broker in assessing and evaluating treatment options. … when it comes to Medicare and Medicade, where the taxpayers are footing the bill …
“… using comparative-effectiveness studies as a way of reining in costs, …
“… the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here. …
“…there is going to have to be a conversation that is guided by doctors, scientists, ethicists. … you have to have some independent group that can give you guidance.”
PRESIDENT OBAMA'S GRANDMOTHER
As a case-in-point, the President brought up the hip replacement received by his terminally-ill grandmother mere weeks before she passed away. During his campaign, she was diagnosed with terminal cancer and then, probably due to a mild stroke, she fell and broke her hip. Her condition was analyzed by her doctors who told her she had three to nine months to live due to the cancer. They also told her that a weak heart posed risks for the invasive surgery hip replacement.
In the absence of cost-effectiveness data or guidelines to the contrary, she chose the hip replacement, which was approved by Medicare and done mostly at public expense. She passed away two weeks later, sadly just days before Obama won. It appears the stress of the operation may have shortened her life by several months.
I don't know if Obama's grandmother got approval for the hip replacement because she was related to a prominent person. That would be bad enough, but it would be even worse if we are giving hip replacements and other stressful and expensive treatments to all terminally ill grandmothers and grandfathers.
QUOTING THE PRESIDENT AGAIN
"... in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. ... So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here."
QUALITY ADUSTED LIFE YEARS
A concept called "Quality Adjusted Life Years" (QALY) is in use in the UK and, IMHO, should be adapted for use in the US. The basic idea is to estimate, before approving very expensive, public-funded medical procedures, the probability the procedure will be successful, and, if successful, the number of years the recipient is likely to live and the subjective quality of those years.
Subjective quality is a difficult measure. Fortunately for us, based on experience and practice in the UK and elsewhere, there are fairly well-established guidelines. For example, mobility is an issue in quality of life. If a person is able to walk without assistance that is better than being wheelchair-bound, and a wheel chair is better than being bedridden. Being alert and awake and mentally competent is better than lack of those qualities. Being able to take food by mouth is better than IV, etc.
In the UK, if each QALY is estimated to cost less than about $40,000, and if the recipient wants the medical procedure, it is approved for public funding. On the other hand, if the cost is more than $40,000 per QALY, or if the recipient does not want the procedure, only palliative care, consisting of pain management along with love and attention, is provided, even if this level of care will reduce the likely life span of the patient.
The QALY concept may also be utilized to compare alternative treatment options. For example, if medical treatment procedure A will cost substantially more per QALY than medical treatment procedure B, only B will be approved, even if both are under the $40,000 limit.
Examples:
1) Alice is a candidate for treatment A that is estimated to cost $150K for the treatment and care, has a probability of success of 80%, and, if successful, will provide a subjective quality of life of 60%. Based on her age and medical condition, if the procedure is successful, Alice has a life expectancy of 10 years. The calculation gives her QALY = 5 years, so each QALY will cost about $31,000, which is below the limit of $40,000. The Treatment A is therefore approved for public funding if Alice is willing to accept it.
2) Bob is a candidate for treatment B that is estimated to cost $90K for the treatment and care, has a probability of success of 50%, and, if successful, will provide a subjective quality of life of 40%. Based on his age and medical condition, if the procedure is successful, Bob has a life expectancy of 5 years. The calculation gives him QALY = 1 year, so each QALY will cost about $90,000, which is above the limit of $40,000. The Treatment A is therefore NOT approved for public funding and Bob is entitled to palliative care only.
3) Carl is a candidate for treatment C that is estimated to cost $50K, or treatment D that is estimated to cost $100K.
Treatment C has a probability of success of 90%, and, if successful, will provide a subjective quality of life of 60%. Based on his age and medical condition, if the procedure is successful, Carl has a life expectancy of 5 years. The calculation gives him QALY = 3 years, so each QALY will cost about $19,000, which is below the limit of $40,000.
Treatment D has a probability of success of 80%, and, if successful, will provide a subjective quality of life of 70%. Based on his age and medical condition, if the procedure is successful, Carl has a life expectancy of 5 years. The calculation gives him QALY = 3 years, so each QALY will cost about $36,000, which is below the limit of $40,000.
Both treatment C and D are below the limit of $40,000 per QALY, but C is substantially less expensive and, therefore, only treatment C is approved for public funding if Carl is willing to accept it.
A STORY MY FATHER TOLD ME
Once upon a time, there was a boy in China and he saw his father carrying a large basket on his shoulders. "What do you have in the basket?" he asked.
"Well," said the father, "It is your grandfather."
"What are you doing with grandpa?" asked the boy.
"Well," he replied sadly, "Your grandfather is quite old and he is so sick that we cannot take care of him anymore, so I am going to dump him in the river."
The boy thought about it awhile, and then he said: "OK, Dad, ... But remember to bring back the basket!"
Of course the point of the story is that the boy will learn from his father's actions and will, when the time comes, uses that same basket to dispatch his father.
When my mom's cancer roared up after a year of chemo and radiation, she decided to accept only palliative care. Our family travelled to San Francisco where they lived and said goodby. Hospice provided morphene and a hospital bed for their apartment. We spoke by phone every evening for about a month until she passed away.
My dad made it clear that was what he wanted when the time came.
About five years later he had a stroke and fell and was taken to the hospital where an MRI confirmed a major bleeding in his brain that was terminal. He could not speak or hear or see and was being kept alive with IV hydration and nutrition and oxygen to help his breathing. My brother and I asked the doctors to remove all artificial life support, including the IV and oxygen, and he passed away a few days later.
I have asked my children to do the same for me when the time comes. "Remember to bring back the basket!"
ACT! OR FATE?
If we Accept FATE?
- Do next to nothing to change US health care.
- Health care not fair.
- Given medical advances, End of Life costs escalate out of control.
- Neo-natal care and preventative care are under-funded.
- USA goes bankrupt (like Greece, hedonistic socialism).
If we ACT!
- Enact QALY End of Life guidelines.
- Health care is more fair.
- Given medical advances, End of Life costs are controlled.
- Neo-natal and preventative care are well-funded.
- USA avoids bankruptcy.
- Death with dignity and loving care.
CONCLUSIONS
Although I did not vote for him, and oppose much of his economic policy, I agree with President Obama's remarks on end-of-life treatment.
I wish he and his Democratic allies would be similarly honest and I wish the Republicans who are characterizing the issue as "pulling the plug on granny" would be more thoughtful and helpful and honest as well.
I do not like to hear people call these "honest broker" government medical and ethical tribunals "death panels". However, the 'honest broker" guidelines, when imposed on Medicare and other public-funded medical decisions, will, in effect, cause many of the terminally and chronically ill to be given palliative treatments that will undoubtedly shorten their lives.
Whatever you call them, I believe we need ethical end-of-life guidelines to prevent doctors and hospitals from ordering expensive treatments that are not cost-effective (and that may be done more for reasons of fear of malpractice suits and/or simple greed to increase their incomes).
I am not if favor of further nationalization of US health care. However, with Medicare the primary payer for nearly all of us over 65, we need national guidelines to prevent the program from going bankrupt. (See this and this for more details on my views of what we really need in cost-effective health care reform.)
Let us take the ethical lessons of the Runaway Trolley to heart and ACT! rather than accept the hand of FATE?
Ira Glickstein
PS: For the record, and in case the NY Times takes the page linked above out of their free access, here is the full text of the applicable section of the document from which I quoted Pressident Obama's words.
You have suggested that health care is now the No. 1 legislative priority. It seems to me this is only a small generalization — to say that the way the medical system works now is, people go to the doctor; the doctor tells them what treatments they need; they get those treatments, regardless of cost or, frankly, regardless of whether they’re effective. I wonder if you could talk to people about how going to the doctor will be different in the future; how they will experience medical care differently on the other side of health care reform.
THE PRESIDENT: First of all, I do think consumers have gotten more active in their own treatments in a way that’s very useful. And I think that should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being — that, I think, can be helpful.
I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.
And right now we’re footing the bill for a lot of things that don’t make people healthier.
THE PRESIDENT: That don’t make people healthier. So when Peter Orszag and I talk about the importance of using comparative-effectiveness studies (see note below) as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions.
Won’t that be hard, because of the trust that people put in their doctors, just as you said? Won’t people say, Wait a second, my doctor is telling me to take the red pill, and the government is saving money by saying take the blue —
THE PRESIDENT: Let me put it this way: I actually think that most doctors want to do right by their patients. And if they’ve got good information, I think they will act on that good information.
Now, there are distortions in the system, everything from the drug salesmen and junkets to how reimbursements occur. Some of those things government has control over; some of those things are just more embedded in our medical culture. But the doctors I know — both ones who treat me as well as friends of mine — I think take their job very seriously and are thinking in terms of what’s best for the patient. They operate within particular incentive structures, like anybody else, and particular habits, like anybody else.
And so if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota, and the doctors in Minnesota are getting outcomes that are just as good — then us going down to Florida and pointing out that this is how folks in Minnesota are doing it and they seem to be getting pretty good outcomes, and are there particular reasons why you’re doing what you’re doing? — I think that conversation will ultimately yield some significant savings and some significant benefits.
Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —
Yes, where it’s $20,000 for an extra week of life.
THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.
So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.
And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.
I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.
And it’s going to be hard for people who don’t have the option of paying for it.
THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?
I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.
So how do you — how do we deal with it?
THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.
Note: Comparative-effective studies — which are now done by academic researchers, but not systematically across the medical system — review data to determine which widely used treatments do not improve outcomes and which effective treatments are not used often enough.
