Policy experts complain that America has been slow to address its long-term economic problems – and unrealistic when such issues are actually discussed. But there has been even greater evasion and denial when it comes to the ethical dilemmas that will accompany those economic problems, especially where healthcare is concerned. Politicians talk as though relatively painless solutions can be found. But in reality there is no magical escape from difficult choices – they can only be dealt with by facing up to them squarely.
The chief cause of these problems is demographic. People age 65 and older accounted for 10% of the U.S. population in 1970, are more than 13% today, and will be around 20% by 2050, according to projections by the Population Reference Bureau. That will result in a massive rise in healthcare spending, because medical costs for someone over 65 are more than triple those for younger people. Moreover, advances in technology are further pushing up costs for the most effective treatments. As a result, overall healthcare spending is projected to rise from 17% of GDP today to 25% within 25 years, according to the Department of Health and Human Services.
Some of this will fall on elderly individuals themselves. Between 2010 and 2040, the median share of household income spent on health care by Americans age 65 and older will likely increase from 10% to 19%, according to the Urban Institute. The median out-of-pocket costs for individuals age 65 and older will more than double in constant 2008 dollars, from about $2,600 a year to about $6,200.
Much of the increasing cost, though, will be borne by society collectively. And as that spending soars, thorny ethical questions will become more urgent. One of these has already been discussed to some extent: When should aggressive treatment be limited for someone who is terminally ill? More than 30% of the Medicare budget is now spent on patients in their last year of life, and the benefits of that treatment vary enormously. Both my own parents died of cancer, and while the surgery my father received made his last year much happier, my mother’s surgery was worthless, and may even have made matters worse. Who decides how much to do? I can tell you from experience that doctors don’t want to make that call, but frankly I wouldn’t have wanted to make it either.
But that’s just the start of the ethical dilemmas. The deeper questions are even more troubling. For example:
Does everyone deserve the same care? Most people would agree that in a civilized society, no one should starve to death, but that not everyone has a right to eat in the same fancy restaurants. Similarly, everyone should have shelter, but not necessarily a penthouse apartment. And there is no inalienable right to wear Armani. Yet many people insist that everyone should have the same healthcare.
Of course, there are several reasons healthcare might deserve to be treated differently from other necessities. For one thing, it’s possible to eat cheaply and still have a satisfying meal, whereas low-cost medical care could cost some people their lives.
In fact, though, people tend to react very differently depending on how the question is framed. If you ask whether a two-tier healthcare system is fair, most people would say no. But if you ask whether it would be a good thing to guarantee everyone access to some kind of basic care, while at the same time allowing those who are happy with their current healthcare plans or who want additional protection to pay extra for them, then most people would say yes – and yet the result would, in effect, be a multiple-tier system.
Is medical progress always a good thing? Sometimes new technology actually reduces healthcare costs. But mostly it drives spending higher. If you ever read British newspapers online, particularly the Daily Mail, you may be familiar with the following type of story: The British National Health Service denies some patient a new high-tech treatment. The treatment is hideously expensive and has only, say, a 5% chance of extending life by three months. A public outcry ensues, and the NHS eventually agrees to pay for the treatment, unless the patient has died in the meantime. Whatever the outcome is, no one is ever really satisfied.
Is there ever a case for discouraging the development of a technology that is socially disruptive? The best historical example, although from a different context, is that Japan famously prohibited the manufacture of firearms for more than 300 years to preserve the Samurai. But when it comes to controlling technology, directing medical research is not as easy as banning the gun. Some discovery that affects only an obscure disease might be the key to unlocking something much more important. And having made such a discovery, is it ethical to refuse to make it available to someone whose life might be saved, even if the odds are low? Similarly, should a hospital not buy and use some exotic scanning machine if that might be the only way to diagnose certain rare diseases? Should progress be limited simply because it might lead to higher costs?
How much happiness do people deserve? The summer before I went to college I worked in an institution for the mentally retarded. Like most college-bound kids, my value system was all about achievement – how smart you are, how articulate, how athletic. But some of the mildly retarded people in the institution rated poorly on all those scales, yet were cheerful almost all the time. Before I left, I realized that there is no way you can really assess what makes someone else happy or causes them pain.
Without getting too philosophical, the question of what people need for happiness – and what they have a right to expect – is at the heart of the healthcare debate. We might agree that someone whose life is at risk has a legitimate claim for assistance. But how far does that claim extend? Do people have a right to be free of every discomfort, or are there some things we should be expected to live with? And what about pain that is psychological rather than physical? Should society pay for cosmetic surgery? How about treatments to make short children taller? And what about sex-change surgery? Some countries pay for time at a spa to relieve stress. Is that a medical expense or a vacation?
In practice, these questions get answered by default. People ask for various kinds of treatment and the system evolves to cover those that seem reasonable – contraception, for example, is considered medical and not an entertainment expense. The trouble is that as money gets tight, people start being denied treatments that are too expensive or seem less essential. That results in endless legal fights, and more important, is no way to craft a rational health-care policy. Not only will money be wasted, but decisions also will be arbitrary, inconsistent and sometimes unjust. The only solution is to get out in front of the problems and to try to formulate some consistent moral framework. Evasion and denial just won’t work well over the long term.