Jane McCredie: The cost of life

RATIONING of health care is always going to be a vexed issue, and never more so than when it comes to neonatal intensive care.

A paper published online last week by the Journal of Medical Ethics puts the question bluntly, asking: “Which newborn infants are too expensive to treat?”

“We are already rationing healthcare, and will always be rationing”, writes Associate Professor Dominic Wilkinson, a medical ethicist and neonatal intensive care specialist at Adelaide’s Women’s and Children’s Hospital. “The only question is how we ration…”

If it is the only question, it’s certainly a big one.

Health resources will always be limited, meaning a decision to provide expensive treatment for one person will have an impact on the care available to others. But some patients will always tug at our heartstrings more than others, making it hard to deny treatment, particularly to a tiny premature baby.

“Should funds be provided to NICUs [neonatal intensive care units] or to other important healthcare priorities such as antenatal care, childhood vaccinations and support for those with disabilities?” Professor Wilkinson asks.

A fair distribution of public health funds would be based on the needs of patients, potential benefits of treatment and an assessment of the costs, he writes.

Such cost–benefit analyses are a routine part of government and administrative decision making, although the exclusion of an expensive new drug from the Pharmaceutical Benefits Scheme can still lead to a storm of controversy.

But for those at the front line of the health care system, assessing whether the potential benefits of a treatment justify the cost is even more fraught.

Doctors face considerable ethical pressure to focus on what is best for an individual patient, Professor Wilkinson writes. And it can be hard for them to acknowledge that a recommendation to limit treatment might have more to do with cost than the interests of the patient.

“It is much easier to convince families to allow their loved child or elderly relative to die if the families are told that treatment can no longer help the patient (even if that is not strictly true)”, he writes.

“Nevertheless, it is, I would argue, a mistake to conflate benefit to individual patients with benefits to others. It is important to keep the two distinct for the sake of clear thinking and honest communication.”

From an ethical point of view, it’s hard to argue with that, though I feel for the doctor trying to explain to relatives that a possibly beneficial treatment is not going to be offered for cost reasons.

In his own field of neonatal intensive care, Professor Wilkinson suggests two possible ways that rationing could be applied.

One would be to offer newborns with a poor prognosis a trial of treatment for a defined period — say 48 or 72 hours. If there is no definite response then treatment would be withdrawn.

A second possibility might be to establish an explicit prognostic threshold below which infants would not receive intensive care treatment.

The location of that threshold would obviously be a matter for debate but babies assessed as having, say, a 10% or lower chance of survival without profound impairment — based on the prognosis for those born at 22 weeks’ gestation — might be identified as a group that would not receive treatment.

Professor Wilkinson’s paper is a commentary on a book by Catholic bioethicist Charles Camosy, who has a different take on the issue.

In his response, Professor Camosy argues that costs of treatment should be a primary consideration as the interests of the individual cannot be separated from those of the community. He also rejects factoring in the child’s likely quality of life as he does not accept that “a child’s life can be more or less worth living”.

Whatever solutions we find — and Professor Wilkinson makes it clear his are only suggestions — we need to find a way to manage the rationing of health care fairly and transparently.

This is not just a question for neonatal care, but one that will become increasingly fraught at the other end of life as our ageing population makes ever more insistent demands on the health system.

Jane McCredie is a Sydney-based science and medicine writer.

Posted 4 February 2013

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