The QALY of Mercy
A wonkier version of the reform-equals-rationing argument is based less on panic mongering about Obama's secret euthanasia schemes and more on the implications of something called "comparative effectiveness research." The practice got a jump start in last year's stimulus bill, which included $1.1 billion for the Federal Coordinating Council for Comparative Effectiveness Research. This is money to study what treatments work best for which patients. The most obvious use of such data would be to apply the findings to Medicare, and the effort has already been attacked as the first step toward the government deciding when it's time to kick granny to the curb. Senate minority leader Mitch McConnell (R-Ky.) has said that Obama's support for comparative effectiveness research means he is seeking "a national rationing board."
Evidence-based medicine, in itself, has absolutely nothing to do with age. In theory, it also has nothing to do with money—though it might, as a byproduct, reduce costs (for example, by giving doctors the information they need to resist pressure from drug companies). Yet the desire for cost savings often seems to drive comparative effectiveness research, rather than the other way around. In his Times Magazine interview last year, Obama said, "It is an attempt to say to patients, you know what, we've looked at some objective studies concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one."
One prominent advocate of rationing has suggested that society doesn't have a duty to help those in their 70s and 80s "become still older indefinitely."
Personally, I don't mind the idea of the government promoting the blue pill over the red pill, as long as it really is "just as effective." I certainly trust the government to make these distinctions more than I trust the insurance companies or pharma reps. But I want to know that the only target is genuine waste, and the only possible casualty is profits.
There's nothing to give me pause in the health care law's comparative effectiveness provision, which includes $500 million a year for comparative effectiveness research. The work is to be overseen by the nonprofit Patient-Centered Outcomes Research Institute, whose 21-member board of governors will include doctors, patient advocates, and only three representatives of drug and medical-device companies.
Still, there's a difference between comparative effectiveness and comparative cost effectiveness—and from the latter, it's a short skip to outright cost-benefit analysis. In other words, the argument sometimes slides almost imperceptibly from comparing how well the blue pill and the red pill work to examining whether some people should be denied the red pill, even if it demonstrably works better.
The calculations driving such cost-benefit analyses are often based on something called QALYs—quality-adjusted life years. If a certain cancer drug would extend life by two years, say, but with such onerous side effects that those years were judged to be only half as worth living as those of a healthy person, the QALY is 1.
In Britain, the National Health Service has come close to setting a maximum price beyond which extra QALYs are not deemed worthwhile. In assessing drugs and treatments, the NHS's National Institute for Health and Clinical Excellence usually approves those that cost less than 20,000 pounds per QALY (about $28,500), and most frequently rejects those costing more than 30,000 pounds (about $43,000).
It's not hard to find examples of comparative effectiveness research—complete with QALYs—that hit quite close to home for almost anyone. Last year I was diagnosed with atrial fibrillation, a disturbance in the heart rhythm that sometimes leads to blood clots, which can travel to the brain and cause a stroke. My doctor put me on warfarin (brand name Coumadin), a blood-thinning drug that reduces the chances of forming blood clots but can also cause internal bleeding. It's risky enough that when I go to the dentist or cut myself shaving, I have to watch to make sure it doesn't turn into a torrent of blood. The levels of warfarin in my bloodstream have to be frequently checked, so I have to be ever mindful of the whereabouts of a hospital with a blood lab. It is a pain in the neck, and it makes me feel vulnerable. I sometimes wonder if it's worth it.
It turns out that several comparative effectiveness studies have looked at the efficacy of warfarin for patients with my heart condition. One of them simply weighed the drug's potential benefits against its dangerous side effects, without consideration of cost. It concluded that for a patient with my risk factors, warfarin reduced the chance of stroke a lot more than it increased the chance that I'd be seriously harmed by bleeding. Another study concluded that for a patient like me, the cost per QALY of taking warfarin is $8,000—cheap, by most standards.
Prescription drug prices have more than doubled since the study was done in 1995. But warfarin is a relatively cheap generic drug, and even if my cost per QALY was $15,000 or $20,000, I'd still pass muster with the NHS. But if I were younger and had fewer risk factors, I'd be less prone to stroke to begin with, so the reduction in risk would not be as large, and the cost per QALY would be correspondingly higher—about $370,000. Would I still want to take the drug if I were, say, under 60 and free of risk factors? Considering the side effects, probably not. But would I want someone else to make that decision for me?
Critics of the British system say, among other things, that the NHS's cost-per-QALY limit is far too low. But raising it wouldn't resolve the deeper ethical question: Should anyone but the patient get to decide when life is not worth living? The Los Angeles Times' Michael Hiltzik, one of the few reporters to critically examine this issue, has noted that "healthy people tend to overestimate the effect of some medical conditions on their sufferers' quality of life. The hale and hearty, for example, will generally rate life in a wheelchair lower than will the wheelchair-bound, who often find fulfillment in ways 'healthier' persons couldn't imagine."
Simone de Beauvoir wrote that fear of aging and death drives young people to view their elders as a separate species, rather than as their future selves: "Until the moment it is upon us old age is something that only affects other people." And the more I think about the subject, the more I am sure of one thing: It's not a good idea to have a 30-year-old place a value on my life.