Medical Ethics Video – University of Newcastle
Medical ethics: four principles plus attention to scope
Medical Ethics – American Medical Association
Why undervaluing ‘statistical’ people costs lives
Whether happiness be or be not the end to which morality should be referred – that it should be referred to an end of some sort, and not left in the dominion of vague feeling or inexplicable internal conviction, that it be made a matter of reason and calculation, and not merely of sentiment, is essential to the very idea of moral philosophy . . . (J. S. Mill, London and Westminster Review, 1838)
The cash value of life
In January 1997 Tony Bullimore was attempting to sail round the world in the Vendée Globe race. He had reached the dangerous and cold waters of the Southern Ocean, over 1,500 miles south of the Australian coast, when his boat was capsized by hurricane force winds and enormous waves. He spent four days trapped under its hull before he was rescued in the largest and most expensive such operation ever undertaken by the Australian defence forces. How much money should a civilized society be prepared to spend in order to save a life? Is the answer ‘whatever it takes’, or should there be a limit? When is the chance of success too low even to attempt a costly rescue operation?
Let me pose a more general question. What is the cash value of a human life? This question is a disturbing one to ask but, paradoxically, there are situations where avoiding the question may cost lives, and allocating scarce medical resources is one of them.
There is no health care system in the world that has sufficient money to provide the best possible treatment for all patients in all situations, not even those that spend relatively large sums on health care (see box). New and better treatments are being developed all the time. On average, in the UK, about three new medicines are licensed each month. Almost all have some benefit over existing treatments and some will extend people’s lives. Many of these new medicines are expensive. When is the extra benefit worth the extra cost? This question must be asked by all health care systems, whether private systems, such as ‘managed care’ in the US, or publicly funded systems, such as the British National Health Service. If the best treatment cannot always be provided then choices have to be made. The general question of how our limited health care resources should be distributed is one of the most important in medical ethics. The quality and quantity of thousands of people’s lives will be affected by the answers that we give.
National expenditure on health: examples of some of the wealthier nations
Country – % GDP – per capita purchasing power ($)
Australia – 8.6 – 2085
Canada – 9.3 – 2360
France – 9.4 – 2043
Germany – 10.3 – 2361
New Zealand – 8.1 – 1440
Norway – 9.4 – 2452
United Kingdom – 6.8 – 1510
United States – 12.9 – 4165
Quality of life
Some medical treatments have little or no effect on life-span but improve quality of life: hip replacement for osteoarthritis is an example. One rather deep problem that faces us in thinking about the right way to distribute health resources is how we compare and evaluate the relative importance of improving quality of life vis-à-vis extending it. I am not going to tackle this issue, nor the problems associated with the measurements of quality of life in the first place. I will focus exclusively on life-extending treatments since there are more than enough problems in thinking about allocating resources to these treatments alone. There are many examples of life-extending treatments. Surgery for appendicitis extends life because without such surgery most people would die.
Breast cancer screening can extend life because early detection and treatment can increase life-span. High blood pressure increases the risk of death from heart attack and stroke. Treatment that lowers blood pressure reduces, although it does not eliminate, this risk. Renal dialysis keeps those people alive whose kidneys no longer function adequately. Each year of dialysis is a year more life.
In control of a budget
Imagine that you are in charge of a health service for a particular population. You have a limited budget – you cannot afford the best treatment for all of the people all of the time. You have decided how to spend most of your budget and you have a few hundred thousand pounds left uncommitted. You sit down with your advisers to consider the best way of spending this last remaining tranche of money. There are three possibilities and you must choose one of them.
The possibilities are:
(1) A new treatment for bowel cancer that gives the relevant patients a small but significant chance of increased life-expectancy;
(2) A new drug that lowers the chance of death from heart attack in people with genetically induced raised blood cholesterol;
(3) A new piece of surgical kit that ensures a lower mortality from a particularly difficult kind of brain surgery.
On what basis do you choose between these possibilities?
One approach that has a lot going for it is to say: there is no good reason to prefer one person’s year of life over another person’s, or to give any priority to people who would benefit from the bowel cancer treatment over people who have the genetically induced high blood cholesterol or to people with the brain tumour. In each case people stand to die prematurely and in each case the treatment increases the chance that they will live for longer. What we should do, therefore, is to spend the money so that we can ‘buy’ as many life years as possible. By doing this we are treating everyone fairly: we are valuing one year of life equally, regardless of whose life it is.
The distribution problem
Even amongst people (like me) who are attracted by this approach there is an issue that needs to be faced: the ‘distribution problem’. Take a look at the three interventions described in the box.
Choosing between three interventions
Intervention – 1 benefits 10 people total life years gained: 35
Intervention – 2 benefits 15 people total life years gained: 30
Intervention – 3 benefits 2 people total life years gained: 16
Suppose that all these interventions cost the same and that we can only afford one of them. Suppose further that the distributions are as follows. The two people who are benefited by intervention 3 will enjoy 8 more years of life each. Of the ten people who are benefited by intervention 1, the average benefit is 3.5 years and the range is 2–4 years. Of the fifteen people who are benefited by intervention 2, the average benefit is 2 years and the range is 1 to 3 years. Which of the three interventions should we go for?
If we think that what we should do is to ‘buy’ the maximum number of life years that we can (the maximization view) then we should put our money into intervention 1 because we buy 35 life years, which is more than we will get if we spend the money on either of the other two interventions. Some might argue that intervention 2 is preferable because we help more people (15 as opposed to 10) although each person gains fewer extra years of life. Still others might argue that intervention 3 is the best option because the two people who are helped receive a really significant gain (eight years of life) whereas no one gains more than four years of life with either of the other two options.
The question of whether it is only the total number of life years that matters, or whether the way in which those years are distributed between people is important, is known as ‘the distribution problem’. Those who reject the maximization view have to specify how they balance the value in helping more people, but each gaining relatively less, against the value in helping fewer people, but each gaining relatively more. Except at extremes I am generally happy to go with maximizing the total number of life years and not worry too much about their distribution.
In being generally happy with using resources to maximize total number of life years I am in a minority – and no health care system in the world behaves remotely in this way. One problem with my position (the maximization view) takes us right back to Tony Bullimore and his attempt to sail round the world. My position gives no moral weight to what has been called ‘The Rule of Rescue’ – and yet this rule seems, intuitively, to be right.
The rule of rescue
The ‘rule of rescue’ is relevant to a situation where there is an identified person whose life is at high risk. There exists an intervention (‘rescue’) which has a good chance of saving the person’s life. The value that is at the heart of ‘the rule of rescue’ is this: that it is normally justified to spend more per life year gained in this situation than in situations where we cannot identify who has been helped.
Consider two hypothetical, but realistic, situations in health care.
Intervention A (saves anonymous ‘statistical’ lives) A is a drug which will change the chance of death by a small amount in a large number of people. For example, out of every 2,000 people in the relevant group, if A is not given than 100 people will die over the next few years. If A is given then only 98 will die. Although we know that drug A will prevent deaths we do not know which specific lives will be saved. Drug A is cheap – the cost per life year gained is Euros 20,000. One example of a medical treatment like this is treatment that lowers moderately raised blood pressure. Another example is a class of medicines known as statins that lower blood cholesterol. Lowering blood pressures, and lowering cholesterol, reduce risk of heart attack, stroke, and death.
Intervention B (rescues an identified person) B is the only effective treatment for an otherwise life-threatening condition. Those with the condition face a greater than 90 per cent chance of death over the next year if not given B. If given B then there is a good chance of cure – say 90 per cent. B is expensive. The cost per life year gained is Euros 50,000. Renal (kidney) dialysis is an example of this type.
There are three, potentially relevant, differences between intervention A and intervention B. The first is that B saves lives within the next year, whereas the benefits of A are not realized for many years. This difference has some moral relevance. A few of those who might benefit from intervention A will die from some quite independent cause before any benefit from A could be gained.
There are also problems in calculating the cost per life year gained when at least some of the costs of the intervention are borne years before the benefits are seen. This is because of monetary inflation. Both these effects can be allowed for in the calculation of cost per life year gained. Having made such allowances, there seems no good reason to value the saving of life years in the future any less than saving life years now.
The second difference between the interventions is that B will almost certainly save the lives of the relevant patients, but A only has a low probability of doing so. Thus B might be seen as giving greater benefit to individuals than A. I will argue, in a moment, that this is false.
The third difference is that intervention B benefits identifiable people. Intervention A benefits a proportion of patients within a group (e.g. those with raised blood pressure), but we cannot know who within the group will benefit (although we may know the likely proportion that will benefit).
According to the rule of rescue it may be right for a health care system to fund intervention B but not intervention A, even though B is more expensive in terms of life years gained. For example, the rule of rescue would provide justification for spending more per life year gained on treatments such as renal replacement therapy, than on treatments like statins.
In practice this is exactly what health care systems do. The British National Health Service provides renal dialysis at costs over Euros 50,000 per life year gained, whilst paying for statins only for those with very high cholesterol levels. This is despite the fact that treatment with statins for those with moderately raised cholesterol levels would cost only about Euros 10,000 per life year gained. In other words, if the money spent on some people for renal dialysis were, instead, spent on some people with moderately raised cholesterol, five times as many life years could be gained. But we don’t do it – because we would feel that we had condemned the person needing dialysis to death; whereas all we would be doing in the case of statins is slightly lowering an already quite small chance of death.
The most powerful reason in support of the rule of rescue is that in the typical case the identified person, like Tony Bullimore, stands to gain a significant increase in chance of life, whereas in the typical case of saving anonymous ‘statistical’ lives no one stands to gain more than a small decrease in probability of death. I will put this argument in favour of the rule of rescue as strongly as I can. I will then say why I do not agree with it.
