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Culture of Life? Or Culture of Cost-Benefit?

A fascinating article from The Oregonian (courtesy of a friend in Portland) puts the "culture of life" in perspective:

WASHINGTON -- As President Bush awaited legislation to save the life of Terri Schiavo last month, he urged the nation to build a "culture of life where all Americans are valued, welcomed and protected."

But at the same time, Bush's budget office continued its pursuit of a more sweeping regulatory policy that conflicts with core values of the pro-life movement.

Under Bush, the White House Office of Management and Budget has encouraged federal agencies to weigh relative, "quality-of-life" factors such as the health and age of people who would benefit from health and safety regulations....

Lacking a better yardstick, many agencies count benefits in dollars per life. The Environmental Protection Agency, for example, has in recent years chalked up a standard, $6.1 million benefit for every premature death prevented by reductions in air pollution.

Under Bush, the White House budget office has scrutinized whether that approach does the most good for society. And it has raised a difficult moral question: Can a single dollar amount reflect the value of a healthy 40-year-old as well as a 65-year-old with chronic illness?

In 2002, the budget office helped prepare an "alternative analysis" of Bush's Clear Skies Initiative that assigned benefits per "life year" realized by reduced emissions. The result of the new approach was a lower value for the lives of older people. Critics dubbed it "the senior discount."

The whole article is worth reading.

As the article goes on to suggest, without much background for non-Oregonians, there's more to this than just hypocrisy, although that's not a minor thing. The reason they're particularly interested in this in Oregon is because the business of weighing relative quality-of-life factors so closely resembles the Oregon Health Plan of the early 1990s, probably the most daring of all the efforts to deal with the health coverage crisis of the time, until it was shut down by the Bush I administration. The Oregon Health Plan tried to provide basic health benefits through Medicaid to all adults, paying for them by rationing benefits based on efficacy and quality of life. The core of the plan was a ranking of 800 medical treatments based on those standards, similar to the "benefits per life year" suggested by OMB.

This is the kind of issue that everyone's on all sides of. The Oregon plan was designed by liberal Democrats, notably physician John Kitzhaber, a legislator at the time and later governor, but the opposition came from Democratic Rep. Henry Waxman and from Al Gore, then a Senator, and finally it was Bush I's HHS Secretary, Louis Sullivan, who denied the state the waiver it needed from federal Medicaid rules to enact the experiment.

It's easy to jump on the hypocrisy of the Shiavo demagogues here. But it's also important to acknowledge that, like it or not, if we're ever going to treat health care as a public good, we are going to have to wrestle with these ultimately unresolvable moral questions endlessly -- such as the 28% of Medicare costs that are spent in the last year of life -- and neither Bush I's punting, nor Bush II's vacuous "culture of life" sloganeering helps resolve these questions.

Posted by Mark Schmitt on April 9, 2005 | Permalink


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I used to be appalled at this kind of cost/benefit analysis. It seemed so go against everything I've been taught about the equal preciousness of every human life. Then I started looking seriously into how much of our healthcare is poured into end of life treatments that in many cases simply prolong suffering at great cost.

It's hubris to proclaim our need and duty to do all we can for every Terri Schiavo when so many of our children are uninsured.

Posted by: battlepanda | Apr 9, 2005 11:37:49 AM

There is a great deal of waste in the delivery of health care that can be eliminated with out compromising health in any way. Unfortunately, because of the third party payment system, the economic delivery of medical care is distorted and we don't have the usual market check on system excesses.

My favorite example, for instance, is the beloved yearly "complete physical" and its accompanying "bloodwork". Medically, this is utterly useless for maintaining health in otherwise healthy young adults. However, studies(!!!) have shown that if you just provide age and history appropriate testing, patients go away dissatisfied. Since the doc isn't paying for it and the patient isn't paying for it, it makes everybody happier to just waste the money. Many of the sob stories that you hear about HMOs are denial of things that are really not very useful. Some years ago there was a lot of flap and fuss over HMO denial of bone marrow transplants -- then an experimental procedure -- for advanced breast cancer. Well, it turns out that that $500K procedure provides absolutely no benefit for this type of cancer.

Add our tendency to repeat diagnostic testing because results of earlier tests are inaccesible due to an exagerated fear of privacy compromise and you wind of with monetary waste that some people estimate to be as high as 25%

Posted by: J Beqn | Apr 9, 2005 12:27:37 PM

You know, pro-Federalism right-wingers never seem to think it applies to Oregon. They'll invoke "experiments in democracy" all day, as long as it doesn't involve actual progressive, ya' know, *experimentation".

Posted by: Tad Brennan | Apr 9, 2005 4:11:19 PM

Thank you for this useful and provocative post. I've had two elderly relatives die recently--both after long periods (years) of end-stage type care. In both situations, the major cost was salaries for US citizen caregivers (not for doctors, nurses, drugs, etc.); this appeared to be true in the Schiavo case as well. If this observation is representative, then an economic analysis of eliminating some fraction of what might be considered "futile" care would need to consider the effect of lost service jobs and lost taxes. It's not as though the money is being literally destroyed or even sent offshore.

Posted by: SusanJ | Apr 9, 2005 9:54:17 PM

Uh...no. You could hardly find an industry in the U.S. that is more burdened with monopolies, special privileges, and what amount to royal charters. The level playing field is warped into a Mount Everest environment, where those born on the top stay there, and those born at the bottom stay there.

You have your AMA, which effectively controls med schools, which are funded as the primary public education thrust in healthcare. Public health education and influence is left far behind.

You have your private hospitals and clinics, originally a form of tax dodge and profit maximization for MDs, now morphed into dysfunctional entities of their own right.

You have your 'non-profit' hospitals, to some extent holding companies for the wealth of the church.

Then you get into your drug companies, the makers of medical equipment (CAT scanners etc), suppliers of medical goods, and even, alas, the publishing companies, which flood professionals with pricey 'journals' and the public with books about how to be healthy without professionals. Next time you're in a bookstore, look at how big the 'Health' section is. Fat lot of good it does us.

But wait! There's More! Making the War on Drugs a criminal justice subject has created untold misery in an arena that should be public policy and civil jurisdiction. Lax regulation of pollutants has created a huge subset of chronic illness. The lack of universal care allows minor problems to fester into big medical bills.

And I could go on. Our approach is not just uncoordinated, it is encrusted with some of the most gilded monopolies the world has known, which monopolies have perfected the wholesale purchase of legislators.

What appears increasingly likely is that an empire which would ask citizens to die, rather than assert control of the monopolies, cannot last forever. If we accept the idea that aging empires are trapped by their own 'success' and can no longer consider the changes that might save them, it doesn't look good for the ol' U.S. of A..

Good health, approached sensibly, is one of the cheapest things we can buy. It's not the practice of good public health that's costing us the money.

Posted by: serial catowner | Apr 10, 2005 12:32:34 PM

I don't really see how this kind of cost-benefit analysis conflicts with the "culture of life" theme, except maybe on an unrecognizable caricature of that view. A "culture of life" is one in which each life is valued individually and for its own sake, apart from the "quality" of that life (since a fetus and an unconscious old person lack "quality") and apart from the moral guilt of the person whose life it is (since someone on death row is presumptively guilty). What does that have to do with the principle that spending $1000 to extend one life by five years is better than spending the same $1000 to extend another life by one year? Or even, more controversially, spending more money on young people who will reap more benefits because they have more years of life remaining?

That principle is debatable on all sorts of grounds, but a "culture of life" is obviously not supposed to be one in which we spend every available dollar on extending every person's life at all costs.

Admittedly Bush and the Republicans are using the "culture of life" slogan in all sorts of politicized and rather despicable ways.

Posted by: Chris | Apr 13, 2005 12:06:36 AM

I think Chris is wrong in a non-trivial but understandable way. The culture of life is absolutist and so makes it impossible to compare the benefits in any meaningful way. I think he is actually wrong to say that ... "but a "culture of life" is obviously not supposed to be one in which we spend every available dollar on extending every person's life at all costs". Who says? It may be that purported "culture of life" people do not think we should spend every available dollar on extending every person's life. But if so on what basis do they draw the line. As .. "each life is valued individually and for its own sake, apart from the "quality" of that life" they rule out any possibility of cross personal comparison. So what do they do when resources are limited? Toss a coin? Let the poor die first? Wartime triage is surely impossible if you take such a philosophy seriously. This is a debate that needs to be held seriously. Medical ethics in a technological society are fundamentally incompatible with laisez faire economics and it is an enormous problem. To pretend otherwise is simply putting one's head in the sand.

Posted by: Jim Brady | Apr 13, 2005 9:42:26 AM

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