The Cost of Healthcare

As the economy worsens and the costs of health-care continue to rise, the confident assertions from academics and politicians that (with party X’s plan) everyone will get everything they need have dried up and discussions have shifted from whether health care should be rationed to how it should be rationed.  As such, we need to be increasingly vigilant against calls to devalue human life as a means to that end.  This piece on CNN, for example, is a classic example of allowing a perfectly reasonable observation about the absurdity of our practices to become an incredibly dangerous reduction of life to mere mechanics.  To sum it up as briefly as possible, enormous and unbearable costs are being paid for extraordinary lengths taken to stave off imminent and inevitable deaths.  Many proponents of  “futile care theory” suggest we sacrifice the elderly on the altar of utilitarianism to alleviate these costs.  To his credit, the author resists this temptation; to his detriment, he merely seeks to swap victims.

On one hand, I completely understand not wanting to go to bizarre lengths to cheat death for another week.  It is undignified and unseemly to desperately cling to life as though it is the most important thing in the world.  Since such behavior is not good in the first place, it would hardly be appropriate to pursue as part of public policy.  This is the reasonable observation.  On the other hand, I can by no means advocate the underlying conclusion that life isn’t worth fighting for or sacrificing for when that life is sick, suffering, or soon to be extinguished–to demand the public proclamation that some people are simply unworthy of the life they possess.  If we cannot disentangle these two conclusions, perhaps we need to re-evaluate the assumptions that tie them together–for example, the idea that health care is the burden of society at large rather than of family and friends.

When a person or a family is responsible for one who needs help, they can help them as much as God has enabled them to do so.  Those with means can pursue those extraordinary treatments they find valuable.  Those without means can, in the last days of life, provide the comfort and palliative care recommended by the article without any guilt.  Either way, they can carry out the vocations that are given to them to the best of their means & ability.  There will be tragedies, but nothing to demand that people cause tragedies.  Furthermore, when tragedies do occur, their reach is only to the family involved.

Government responsibility, however, is different from family responsibility–it is, by necessity, generic in nature.  Practicality demands that it work on the level of categories rather than individuals and with resources that are limited not only by simple magnitude, but in that every dollar spent on one category is taken away from another.  Accordingly, government must deny those resources to some of those categories.  When the burden of caring for the sick is placed on society at large, the vocation of governing absolutely demands asking whether life of a particular sort is really worthy of the resources expended to keep it alive–the cost, after all, is ultimately always in other lives.  It’s a horrible question to ask, and inasmuch as it depends on  us, we should not be putting ourselves in a position where we have to.  It forces those involved in government to do that which does earn them guilt–condemning people to death because their lives simply aren’t valuable enough to bother with.  This is one of the primary reasons medicine shouldn’t be socialized.  Not because government is evil or incompetent but because it is government.

Furthermore, when worthiness must be measured, criteria must be established.  As the article points out, age is a poor criterion to use for when life becomes unworthy of life.  But is the author’s answer any better?  “The capacity to recover and return to a meaningful life is the proper criterion.”  This sounds good initially, but goes off the rails as soon as you get into the nitty-gritty of nailing down what “meaningful” means.  The author’s examples basically come down to personal happiness and societal contribution–whether the patient and those around him will enjoy the life that is saved.  But this is exceptionally narrow.  Historically speaking, few of the wise have held that enjoyment is the sum-total of a life.  As the Apostle Paul put it, “More than that, we rejoice in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope, and hope does not put us to shame, because God’s love has been poured into our hearts through the Holy Spirit who has been given to us.”  My example is Christian, but the Christian worldview is hardly the only one which has recognized meaning in suffering.  While it is surely an error to seek out suffering as the ascetics do (as though life does not offer us enough on its own), it is just as much an error to assume that our suffering is less meaningful than our enjoyment.  If suffering is not meaningless or even if it is not necessarily meaningless, then categorically refusing life-extending treatment to a person who has nothing but suffering to look forward to is cruel.  We reduce them to an animal who cannot gain character, knowledge, wisdom, or anything else through suffering.

I am not suggesting a more refined criteria for “futile care” that leverages the value of suffering into the equation.  I am suggesting that the value of life is not mathematical at all–it cannot be reduced to the contents of a flowchart, no matter how complicated that flowchart might be.  Expanding the flowchart only expands the scope of life on which one must past cruel judgment–the author, for example, certainly wastes no time to expanding the refusal of care from the old to the young and from the sick to the injured.  This is why judging whether particular kinds of life are worthy has never lead humanity to anything other than grand atrocity.  No matter how wise or informed one is, such a judgment can never be made with wisdom.  If a particular course of action would demand that we make such judgments, then the wise would seek out a different course of action altogether.

There is no denying that our health care system is in a dire state that one way or another cannot continue.  That doesn’t mean we can’t make it worse or allow even a justified fear to drive us to a greater evil.

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