Thursday, November 09, 2006

Tradeoffs and Medical Values

Newsflash: health policy and medical practice are value-laden, and may involve tradeoffs. That should hardly be news. Yet there are doctors in the news who don't appear to realise that it's true at all! See, for example, this article on active euthanasia for severely damaged newborns (HT: inactivist):
John Wyatt, consultant neonatologist at University College Hospital, [said]: "Intentional killing is not part of medical care... once you introduce the possibility of intentional killing you change the fundamental nature of medicine. It becomes a subjective decision of whose life is worthwhile."

But aren't such decisions ubiquitous in modern medicine? Given the fact of limited resources, doctors can't always provide all patients with the care (or organs, etc) they need. They must make "subjective" (but hopefully reasonable!) decisions about which lives to save, and which to let die. Perhaps in cases of scarcity they can avoid assessing the quality of lives by simply aiming to prolong as many of them as possible. (Though such an approach implicitly assumes equal worth, so it's not as though they can avoid value judgments altogether!) But there's still the issue of passive euthanasia, or withdrawal of life-support -- which might still be desired in some cases even if resources were not an issue -- implying that the machine-supported life is not worth living.

You can argue that there's something importantly different about intentional killing, as opposed to simply "letting die", but the difference isn't the introduction of "a subjective decision of whose life is worthwhile." Sure, the policy would lead to some tough ethical decisions for medical practitioners. But that's nothing new -- bioethics has been around for a while now.

The second example comes from the Canberra Times:
"How do you put a cost on saving anybody's life when prevention is at hand?"

Of course, the existence of opportunity costs reduces this to pure rhetoric. Each dollar the government spends here means one less available for other -- perhaps more effective -- policies. By my rough calculations, the vaccine discussed in the article costs over $1 million per life saved. (Better journalism wouldn't leave this calculation to the reader.) Are there better ways the money could be spent? If we truly value human life, wouldn't we do better to demand, say, a huge boost to the foreign aid budget? I bet that if the federal government gave that money to Oxfam instead, it'd do a whole lot more good. So why don't they?

In a flourishing democracy, such trade-offs between conflicting values would be recognized, and the hard questions about our ethical priorities would be central to public debate. As things stand, they're simply ignored. Such complexities are overlooked throughout the article, starting with the headline, "Women miss out on free lunch cancer vaccine" (oops, my slip), and the rest is no better. For example:
The vaccine costs about $460 for the recommended three doses but will be free if subsidised by the Federal Government through the national immunisation program.

This is a little misleading (especially in the context of the whole, one-sided article). It would be "free" in the sense that the patients are not directly charged for it. But that doesn't mean the costs disappear, of course; they're simply shifted on to other taxpayers. Is it worth it? The article precludes discussion of this key question by pretending that the trade-off doesn't even exist. As if we could judge the merits of a policy by looking at the benefits alone! What sorry journalism.

2 comments:

  1. Excellent post. I've argued myself that health care policy making is value laden, and that these values need to be made explicit. In particular I argued that otherwise doctors are likely to game and thus thwart prioritisation systems (if you're interested, the paper is forthcoming in the Journal of Medical Ethics and is called "Am I my brothers gatekeeper? Professional ethics and the prioritisation of health care")

    Having talked to health care managers in NZ about this, they have said that one of the things that prevents them trialing new drugs is that if they turn out to not be cost effective, they cannot withdraw them because as soon as they try there is patient outcry, and then media attention and then the minister steps in and saves the poor patients from those hard hearted health care managers...

    There was btw an excellent paper about active voluntary euthanasia and prioritisation of health care resources a few years ago, arguing I thought quite cogently that denying people active voluntary euthanasia while at the same time allowing others, who want to live to die due to a lack of resources was perverse. Unfortunately I cannot remember the authors name nor the title off hand.

    David Hunter

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  2. Democracies are doomed to have trouble with these sorts of things because the public just can’t get their heads around the “price to a life” thing BUT to allocate resources correctly there must be one. If you don't do that you will tend to spend 10 million saving one guys life and refuse to spend 1 million saving someone else’s.

    Also good point about the euthanasia. Although, I think there is a moral purity argument going on there, which is one way to look at it even if I personally would be concequientialist. Maybe the public want the medical system to be ‘morally pure’.

    As to explicit policy (at a theoretical level) would not there be a problem with some people making decisions on one basis and others making decisions on another basis and thus creating a suboptimal system by either (or even combined) standard?

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