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THE PRICE OF LIFE : How High the Cost Before It Becomes Too High?

August 29, 1993|Ronald Dworkin | Ronald Dworkin, professor of jurisprudence at Oxford University and professor of law at New York University Law School, is author of the new book "Life's Dominion" (Knopf), which deals with the issues of abortion and euthanasia.

MARTHA'S VINEYARD, MASS. — Was the fiercely expensive Philadelphia operation to separate Siamese twins who shared a single heart a humanitarian tribute to the sanctity of life? Or was it an unjustified waste of public funds and medical resources needed by others who are poor and sick? The parent's own doctors in suburban Chicago said the babies should be kept free from pain and allowed to die. But surgeons at Children's Hospital of Philadelphia offered to separate the twin girls, even though one would certainly die, the other would have only a 1% chance of surviving more than a few months, the quality of any life she could live if she did survive was doubtful and the total cost of the procedure might exceed a million dollars.

Kenneth and Reitha Lakeberg, the parents of the twins, decided to take the gamble. He said, "It's like people win the lottery every week. Why can't we win on life? Why can't we gain a life here and defy the odds?" (They have no health insurance, but their home state of Indiana will contribute $1,000 a day and hospitals will assume the rest of the cost.) The operation was performed, and one twin, Angela, is still alive and doing well eight days after the operation, though she remains in critical condition.

Lakeberg's question--Why not defy the odds when life is at stake?--is an important one, particularly now, when the United States is trying to make its medicine cheaper, fairer and more rational. The chief surgeon at Children's Hospital gave one answer: "There has been a unanimous consensus," he said, "that if it is possible to save one life, then it is worth doing this." For ages, doctors have celebrated this "rescue" principle--never give up on life when any hope remains.

But we must face the fact that this is an impossible, even absurd, ideal. Scientists continue to develop phenomenally expensive diagnostic techniques and more and more heroic transplant procedures, for example, that offer significant life-saving opportunities in some circumstances, but only a remote chance of saving life or prolonging it beyond a few marginal months in others. Any nation that tried to provide every possible treatment, no matter how expensive, even when the treatment had only a small chance of working, would have little money left for obviously valuable medical policies, like immunization for children, or for education, or for sustaining an economy so that its people could have rewarding jobs. Its people would probably not, on balance, lead longer lives, and they would almost certainly lead worse ones.

So the rescue principle, noble as it seems, must be abandoned. What should replace it? President Bill Clinton's health-care proposal is expected to guarantee all Americans a basic package of care. How should we decide what that basic package should contain--whether, for example, it should provide stupendously expensive neo-natal operations with only a marginal chance of success? Lakeberg's remark about lotteries offers a helpful clue, though we should be thinking about the right kind of lottery--an insurance policy--and about an insurance decision made at the right time--in advance.

Suppose the Lakebergs had been people of average wealth, and that when they were married they had been offered the opportunity to buy, for an annual premium reflecting the true actuarial cost, one of two insurance policies. The first provided that if any of their children were born with a life-threatening defect, neo-natal treatment would be covered only if it offered a reasonable (say a 25%) chance of success. The second--much more expensive--provided that such treatment would be guaranteed even if it offered only the barest hope.

The Lakebergs might well have decided that it would be better for them and their family to buy the first policy, and to use the premiums they would save each year to benefit their healthy children in other ways--to provide better routine medical care, or better housing, or better education, for example--even though they knew that they were giving up the chance for a desperate gamble if they ever did have a defective child. Most people would make that choice, and it seems wrong that public money and scarce communal health-care resources should be distributed according to priorities so different from those people would have chosen for themselves, in advance, if they had an opportunity to do so.

We can generalize this approach. When we ask whether money the community might spend on high-tech medicine for particular conditions would be better spent in other ways, we should answer that question from the perspective of ordinary people's own priorities. We should ask: Would most people buy insurance, in advance, to provide that technology for those medical conditions if they had the opportunity and could afford the probable premiums?

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