As a question of social policy and health planning, the basic problem with modern medical care is clear and not new. The ability to employ high-tech medicine to preserve life has outrun society’s current capacity to decide who should use it and for how long. A wider public debate is needed about death, dying and the withdrawal and withholding of care. And we need to discuss in advance the problems that potential solutions can raise.
One approach is to form in-hospital groups to vet each case. This has been attempted at some institutions, including children’s hospitals, under the purview of the Medical Appropriateness Review Committee. But who should sit on the committee, who should have the casting vote, and how would such a group respond when time is of essence and the decision must be made?
Another option is formal protocols. The Oregon Health Plan introduced in the early 1990s a more objective approach to evidence based rationing of health care, including a website that details the circumstances in which care can and cannot be provided.
For example, it was decided that no chemotherapy, surgery or radiotherapy would be funded for cancer cases unless there was a better than 5% chance of five-year survival.
This led to the inevitable headlines about care being denied to cancer patients, and the controversy intensified when the letter declining funding of expensive anti-cancer drugs was sometimes accompanied by another letter offering information about state-sponsored assisted suicide under Oregon’s unique Death with Dignity law.
The debate about the limits of care will probably be forced upon us in the near future for economic reasons, although one can wonder whether the federal government’s plan for Commonwealth intervention into public hospitals will hasten or delay the process.
The US health care reforms could well set off the discussion we have to have. A nation that already spends around 15% of GDP on health care will face some difficult questions when the bulk of citizens have medical coverage under the ‘government plan.’
This is an abridged version of Dr Paul Cunningham’s feature article ‘Debating the Limits of Care,’ which appeared in the Winter 2010 issue of Policy magazine.