Miller Center Debate: Does the U.S. Need to Ration Costly End-of-Life Care?

March 26, 2010 — A man has an 86-year-old grandmother, who is dying from cancer and has less than a year to live. When she falls and breaks her hip, the man decides that the hip should be replaced at the cost of $45,000. However, the grandmother dies a couple of weeks after the operation.

Did the man make the right decision? It turns out that this scenario actually happened to President Obama when he was forced to confront difficult end-of-life decisions concerning his grandmother.

A March 24 debate, on the rationing of end-of-life care, was the second event of this season's National Debate Series, sponsored by the University of Virginia's Miller Center of Public Affairs.

Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center, and Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics, argued for the resolution, "The United States must ration costly end-of-life care."

They faced off against Ken Connor, Gov. Jeb Bush's attorney in the Terri Schiavo case, and Marie Hilliard, director of bioethics and public policy at the National Catholic Bioethics Center, arguing against the resolution.

The debate, moderated by Susan Dentzer, editor-in-chief of "Health Affairs" and a "PBS NewsHour" analyst, took place in front of a live audience at the National Press Club in Washington.

Caplan stated in his opening remarks that by covering high end-of-life costs, we are forgetting the 40 million uninsured Americans who have many years left to live.

"People over 65 consume three to five times as many medical resources as those under" that age, he said, adding that the elderly population is only getting larger with time.

According to Caplan, the issue is not if we ration, but how we ration. "How will we be fair? How will we be just? How will we not pick on particular groups and [not] discriminate against them? And can we allow people to have the kind of dying that they want? I don't believe they want that technological blitzkrieg in their final days … and one form of rationing is to ask people to forgo," Caplan said.

Arguing against the resolution, Connor, who is also chairman of the Center for a Just Society, said that Americans do not want "bureaucratic bean counters in government" telling them how to make end-of-life decisions, especially since these decisions are often associated with money.

He said, "Medical decisions are best made by people at the bedside: families, physicians, the patients themselves."

Connor added that rationing devalues human life, not only for the elderly but for "anyone who costs more to maintain than they produce." Instead, we should focus on curbing Medicare/Medicaid fraud.

Connor concluded, "Something is profoundly wrong in America … when we can spend trillions of dollars bailing out banks and brokerage houses and the big dogs on Wall Street … but we're going to deny medical care to those who are sick and dying."

Byock, the author of the book "Dying Well," countered that we must distinguish between quantity of life and quality of life.

"Some allege that in allowing people who are approaching the end of life to die gently, without subjecting them to CPR and breathing machines and dialysis and feeding tubes, doctors and nurses are guilty of promoting a culture of death," he said. "…. We must understand that some treatments, when they are intended to save or prolong life, make no sense at some point."

Hilliard stated that rationing end-of-life care goes against certain ethical codes in the medical profession, such as consent, autonomy, justice, and non-discrimination. We should instead focus on better health care education for senior citizens, ages 65 to 85, before they need to make these tough decisions.

Caplan argued that eliminating fraud is not enough and that we should ration procedures, not people. "What's marginally effective? What doesn't do very much good at all? And then, if we start to explain this to people, I believe we will see some forgo the marginal, the hyper-expensive, the painful and burdensome," he said.

Connor explained that the government is not equipped to make end-of-life decisions because money always clouds judgment.

He argued, "When savings are made, there are 535 members of Congress who are eager to pounce on that savings so that they can put it in pursuit of some special project in Peoria or perhaps award a favored campaign contributor with an earmark."

The debaters also discussed the rationing of health care for children and the uninsured; the establishment of a transparent community from all walks of life that would establish standards; the underfunding of other needs because of exorbitant end-of-life costs; the potential inequality caused by rationing; and the use of less expensive options, advanced directives and comparative effectiveness research (given the name "death panels" by some Americans).

During closing remarks, Hilliard argued that rationing end-of-life care would introduce some troubling scenarios, citing England, "where a person in a wheelchair automatically is determined to have 25 percent of a quality of life. And therefore, the allocation of resources is diminished as such."

She recommended that we should turn our attention instead to increasing our overall resources and to educating the public about their options.

Byock concluded that we have to allocate resources because there are simply not enough to go around and that there are worse things than dying.

"It's having someone you love die badly, suffering as they die, feeling undignified, feeling a burden to their families. Perhaps the only thing worse is realizing later that the suffering was largely unnecessary," he said.

The Miller Center National Debates are produced for broadcast by MacNeil/Lehrer Productions. "PBS NewsHour" airs highlights from each debate, and PBS stations around the country will air them throughout the spring. Check local listings for details.

A Miller Center debate on Feb. 26 asked if Americans need to go to college in order to compete globally. Future debates will examine the cost of higher education and the impact of the Internet on democracy.

More information, including debate video and a transcript, is online here.

— By Kim Curtis