Who gets treatment?

There was good news for thousands of patients last week when the Ontario government announced it had earmarked $50 million to cover the costs of cancer treatment drugs Avastin, Sprycel and Alimta.

The announcement, however, raised important medical ethics issues: who gets treatment, and how do we decide?

“Governments are terrified of this stuff,” says Margaret Somerville, a medical ethicist at McGill University.

Dr. Brian Day, president of the Canadian Medical Association, warns that as the Canadian medical system moves away from hospital-based care to more drug-based treatments – plus gene therapy procedures and stem cell remedies just over the horizon – pressure on governments to fund ever-more expensive procedures will only build.

But providing every available procedure to every patient who might need it would bankrupt medicare, he warns. Better, he says, to figure out a way to ration treatment to ensure universal health care remains available to all.

To understand his point, try picturing a lifeboat. It holds 60 people, but there’s only 50 on board. Dozens of people are swimming just metres away, struggling to keep their heads above water. The question is, who do you bring on board, and why?

That, in overly simple terms, is the growing dilemma facing the medical profession, the governments that finance it and, ultimately, all of society. The people in the water represent cancer patients. The extra 10 seats on the lifeboat represent the ability to save only some of them.

Day would like to see a national body of experts set up that would make non-binding recommendations about who should be eligible to receive expensive new treatments and who shouldn't.

Somerville agrees that some sort of procedure might be needed, but points out that the essential ethical issues still need to be dealt with. She divides the issues into generally micro and macro categories.

On the micro level, she says, there are individual patients who need the treatments. It would be unethical, she says, to deny them. On the macro level, however, there's the question of whether the money spent to help such patients might be better used to help the overall medical system.

"You can get conflict over what's ethical at one level and what's ethical at another," she says. "That's when we end up in a knot about all this."

Day says that in the absence of a meaningful discussion about rationing, we end up with a "self-rationing" medical system of long waiting lists, crowded emergency rooms and patients with no family doctor.

Canadian Health Coalition director Michael McBane fears that decisions on who gets care depend more on the pressure applied to politicians than anything else.

"If they don't get embarrassed in the media, they don't move," he says.

Day says the issue will only get bigger in coming years as new treatments come available and baby boomers age, putting added strain on the medical system. At the same time, he says, the number of taxpayers left behind after the boomers retire may not be enough to maintain the system.

"In 20 years time, I am going to be in my early 80s and demanding more healthcare, but there won't be enough taxpayers to pay for it," he says.

"Society just isn't ready for this."

Comments

[Robert V Stull]

we can either provide the treatments to everyone or no one. that is the only fair thing to do. i do not want a doctor or government stooge deciding id i am to live or die.

people will go on forever about how the rich and affluent can afford it so we should give it to the poor or less affluent.

as good and fair an idea that might be , we simply cannot afford it. we just cannot afford to pay for every possible treatment that can be given.

yes it sucks ass that the rich can just jet off to the US and get what they need. they in some cases will have their lives extended by these treatments. and we the rest wont.

the one thing here that could fix things, the government wont do. the drug companies charge criminal amounts of money for these treatments and the government lets them get away with it. the drug companies come up with many ways to justify this.

let the government do or fund ALL drug research. that way they own the rights to the drugs and could charge reasonable prices for them. they could conceivably even turn a profit on them when they sell them to the rest of the world.

that could conceivably save the health care system a ridiculous amount of money.

start up costs would of course be very high. i think canadians would be willing to pay knowing they wouldnt be fiscally gang raped by drug companies.

thx for your time

[Ian Gibbard]

Doctors already decide who gets treatment and who doesn't.
They do not seem concerned at the Shouldice Clinic about ethics.
They consistently turn away most overweight people because it may decrease their success rate.
Must be a medical status symbol or something.
They do not mind taking government money for the exams though, even though they know beforehand the people they will reject.
To do nothing to help those in need, take their money and waste theirtime, is not good doctoring.
Isn't it ironic that overweight people who need help and pay the same tax rates as others are denied reasonable service by the medical profession that is supported by those tax dollars?
So much for the promise of the Hippocratic Oath.

[Medical Center]

Robert: Isn’t it ironic that the first treatment for obese people is “weight loss”

[Constantine Kritsonis]

The drug lobby industry ( and others) have thier nose too far up the governments rear end. Perhaps someone will start an anti lobby movement!

Further, there are experimental treatments that show good possibilities. However those are barred to most of the terminally ill. The reason given is that they are too dangerous.
Take for expample injecting terminally ill cancer patients with huge amounts of thier own grown white blood cells. Medicine as usual will not fast track a mass program to do this for the hundreds of thousands that only have a few weeks left. Too dangerous. This atrtitude had the demoralizing effect of letting people go down bound and slaughtered -as opposed to putting up any sort of a fight.

[Avramopoulos]

HI

It is a great and nice post and I like this post.

[Student Nurse]

In reply to Robert:
You suggest it isn't fair that overweight people pay the same taxes as the healthy weighted population, so they should get the same treatment. The fact of the matter is they do get the same treatment, infact, statistically they get a lot more. I think you should look at it from another point of view. Do you think it's fair that a healthy weighted person should pay the same amount of health taxes as a person who has made the wrong lifestyle choice? As a nursing student in her last year I have learned that overweight people and smokers are hospitalized and ill substancially more then people who take care of themselves. Do you think its fair that people who take care of themselves pay the same taxes as people who don't?
Obese people have no idea how they impact our healthcare system. I am 22 years old and already have a bad back because I had an obese patient which I had to turn, lift, etc. There has to come a time where people stop relying on our "great healthycare system" and start relying on themselves. I used to be 190 pounds and am now currently 140. If I can do it, anyone can.

[Marie of Barrie]

Student Nurse, as I'm sure you know, losing weight is hard and I congratulate you for loosing quite a bit! However, I'm not always sure everyone CAN loose weight as you have. I agree, many people just need to get their rear in gear and they'll drop a few pounds (like myself). However, I think some people have different challenges when it comes to weight loss, challenges beyond what everyday people face. Is it justice to deny them the care that they need to function closer to the level of you and I? In one of my courses it was said, 'equality is not just ensuring everyone gets to start at the same place, it is ensuring everyone has an equal chance to finish the race'. Perhaps this case study will help prove my point.

In an album in my basement there are pictures of a little girl in the arms of a trim, smiling man in a blue wind breaker. They are working together to plant a garden of healthy food. 17 years later the wind breaker remains, but much else has changed. The wind breaker now belongs to the girl, it is almost a foot too long, but it is still handy to pack up when she is rushing around. The jacket will no longer fit the man. It hasn't for years. He is overweight. He has high blood pressure and needs a special machine to help him breathe at night. He has asthma and high cholesterol. His vertebra are deteriorating and he has to deal with chronic pain. Every morning he swallows a small pile of pills. At his last check-up his doctor told him he was pre-diabetic. He is less than 55, he has almost no grey hair, and a hairline that 30 year olds are jealous of yet his body is beginning to fall apart. His wife offers to walk around the neighborhood with him every evening, tries to cook him healthy food, and worries constantly. If he lost weight almost all of his conditions would fade. He would be able to take his 12 year old son camping. He would look much younger. If he doesn't he will eventually die, and it will be one hell of an unpleasant death. The stakes couldn't be higher. Tonight he sat in front of his TV while his wife and the girl went on a walk.

I don't think anyone fully understands why he does this. But I think it has to do with one more condition the man has. This condition is one of the worst known to humankind. Until you have watched it destroy loved ones, perhaps felt it yourself you will never understand the ravages of depression.

For some reason the man cannot understand that his life can change and that he is empowered to do it. To him, it is hopeless. There is no point in even trying. Depression, not obesity is killing the man.

The fight against being overweight must be fought with social programs, with healthy eating, and with exercise. But from what anecdotal evidence I have seen I believe that mental health issues also play a significant role in weight loss for some people, especially the more severely overweight. Some of us are lucky enough to be able to change our lives, but I think for others, the focus needs to be not on the pounds, but on what is causing them to slowly choose a horrible decline into illness and eventually death.

[Alain of St Thomas]

Weight gain often causes hernias. By losing weight, the hernia goes away. Why have unnecessary surgery Robert?

[Medical tourism]

This is an interesting post that focuses on the ageing population and rising US healthcare cost at the same time. Medical tourism does seem a comparatively feasible solution.