For some years I have been writing about end-of-life care and, of late, focusing on the high costs of that care. I recently had a painful but revealing insight into what the future might look like on both costs and decision-making. It came about from an unexpected angle of vision,  the care provided by a veterinarian in an emergency care center for pets.

            Our much loved dog, Sunny, a 6-year-old Cavalier King Charles, otherwise in good health, began throwing up, ignoring her food, and displaying untoward lassitude. The symptoms got worse within a few days and we took her to a neighboring pet hospital, one that advertises a range of available technologies and treatments equal to that found in a hospital for humans.

             We took her in the morning, left her there, and in the late afternoon were told that she had kidney failure, was unable to pass urine, and had other serious symptoms. The prognosis was not good, but it would take another day or so to see what difference treatment might make. She gradually went downhill the second day, a catheter failing to bring forth much urine and with increased signs of distress.

            At the end of that first day, we were given a detailed set of cost projections. We were required to put up, via credit card, $2,600 as part of an estimated cost of $5,000 or so for two days of intensive care — a treatment plan that could come to $9,000 if it went on for more than three days. I had read about the high cost of upscale veterinarian care, but it had never occurred to us that we would have to face it.

Yet if the projected costs were jolting, something else was no less arresting: the time and care the chief veterinarian in charge of Sunny’s care took to explain exactly what was going on with Sunny, what they were doing, what the prognosis was — and how rapidly the costs would continue to rise if Sunny survived. She was equally frank about the fact that Sunny was not likely to make it and what it would cost us if she did. The veterinarian  told us  in a way that beautifully integrated money, medical candor, and compassion. It was, I thought as she was doing so, just what we might hope for from a doctor for our care, but by no means yet reliably available.

            We agreed at the end of the second day that we would see how Sunny did overnight. If there was no improvement, we decided  it would be best to put her to sleep (I don’t believe her doctor ever used the phrase “put her down”). She did not improve, required oxygen during the night, and passed little urine. Sunny’s doctor called us early the next morning to report the bad news, and I told her to stop. It was both a hard and an easy decision. Emotionally it was hard to say stop, but easy because it seemed the only reasonable decision, and the doctor readily assented.

            What will stay in my mind in addition to the pleasure Sunny brought us in her relatively short life — she was always at our side or in our laps — was the doctor’s combination of  sensitivity and telling the truth. There have been some important medical journal articles in recent months on the importance of restoring the ancient skill of prognosis, long in decline, to end-of-life care for people. Patients and families need to have some sense of what the future will bring, even if it is uncertain. They need to know the likelihood of death and also what may ensue if a very sick patient survives: what then?  Our veterinarian said that if Sunny were lucky enough to make it she would likely remain in poor health, requiring considerable future medical care. Our doctors often fail to tell patients and families about just that disturbing likelihood. Seeing it well done by our vet underscored its value, for our pets and for us.

            But my most telling glimpse into the human future came with the introduction of cost as an upfront consideration, something I believe will soon become common in our health care, perhaps even routine. For us, the $5,000 charge for Sunny’s care was bearable, but the prospect of the cost of successful treatment, had that been possible, would surely have given us pause. I am sure we would have said at some point that, financially, enough is enough, but I am not certain just when that might have been. I am convinced, however, that the future will force us to deal directly with the high, and in many cases insupportable, human costs of end-of-life care and to stop treatment for that reason. Sunny’s quick decline spared us that decision, which was a blessing in a way.

            I was left with some troubling thoughts. Would it have been better if veterinarian medicine had not moved into the high-technology realm once reserved to humans? My wife and I both had dogs (and sometime cats) as we grew up. When they got sick they just died or were put down to save them from misery. I don’t recall anyone thinking that state of affairs was an evil. Are we better off now with that our pets have access to expensive, high-technology medicine — and are they? And how much better off are we as humans because of the way we now often die, sometimes lingering on for years, the beneficiaries, and sometimes victims, of a medicine equal to what our pets can now have? For me, those questions were left hanging in the air.

Daniel Callahan, cofounder and President Emeritus of The Hastings Center, is coeditor of the Health Care Cost Monitor. This essay originally appeared in Bioethics Forum.

Few movements in recent years have come along with the force and acclaim of personalized medicine. Its aim, in the words of one of its founding fathers, Leroy Hood, is to “find the right treatment for the right person at the right time.” The combination of the two fields of genomics and proteomics (the study of proteins) is the engine behind the movement, and its main attribute, called P4 medicine, is that it will be personalized, predictive, preventive, and participatory. Already making its mark in cancer diagnosis and care, personalized medicine aims to understand us in our genetic health and disease particularities, moving beyond the scientific generalities marking current medical practice. As a PriceWaterhouseCoopers study put it, “While still in its early stages, personalized medicine is steadily emerging as the new healthcare paradigm.”

But will it raise or lower the cost of health care? Hard data is scant, in great part, no doubt, because personalized medicine still has little experience or history behind it. But there are claims it can lower costs, and on what seem to be reasonable grounds – that savings in cancer care, for instance, can come from pinpointing treatments that will or will not be beneficial.

Yet while examples of possible savings have been cited, given the scope and ambition of the personalized medicine movement its overall cost impact is far less clear. It is worth keeping mind the well-established estimate that some 50% of annual cost increases come from new technologies or the intensified use of old ones. A 2008 Congressional Budget Office study found that “examples of new treatments for which long-term savings have been clearly demonstrated are few.”

The PriceWaterhouseCoopers study, designed as a guide to investors and business leaders in making the most of the large profits that are emerging, inadvertently paints a less-than-reassuring picture about whether this technology will be one of those few. “The U.S. personalized medicine market,” it says, “is estimated at about $232 billion and is projected to grow at 11% annually, nearly doubling in size by 2015 to over $450 billion.” Now unless I have missed a basic point about American health care, what is a source of market growth and profit for some is a source of costs for others. Someone or other has to pay for those benefits: private insurers, the government, or out-of-pocket for consumers. The study does not mention that point.

A few other points jump out (at least to a cost maven like me), presented as

business tips:

• “capitalizing on preferential use of and premium pricing for drugs of proven benefit”
• “a higher rate” of “repeat prescribing”
• “the emergence of ‘niche busters’” – drugs targeted to small populations but carrying a high price tag – “to replace some of the income lost as blockbusters go off patent”
• “strategies to broaden the definition of what is considered ‘health’”

No doubt this is savvy profit-enhancing advice, of a tried and true kind – “premium pricing,” “repeat prescribing,” and “high price tag.” What’s new is the recommendation to broaden the definition of heath. Many years ago I wrote an article against the 1946 WHO definition of health. “Health,” it said, “is a state of complete physical, mental and social well-being and not merely the absence of infirmity.” The WHO eventually got rid of that preposterous notion, but the medicalization of just about any and all human complaints, physical and mental, has been underway for decades. Personalized medicine opens up some new horizons for that ubiquitous virus.

Neither the Affordable Care Act nor the market-oriented alternatives offered by conservatives who would like to overthrow it bring into their calculations the likely economic impact of personalized medicine. Perhaps it has just been overlooked. But it just the kind of technological development that is most likely to bring distress and maybe havoc to our health care system. The danger is that all the health benefits and the business opportunities it portends will turn out to be true.

No combination of obvious public benefits and industry profits is more potent than that. It could turn out to be good “value for money,” but as I contended in an earlier blog that kind of value is not necessarily affordable. How to say no to those medical technologies that everyone likes for their personal health and industry profits, but that may turn out to be outrageously expensive for the health care system, is the final and most vexing dilemma about cost controls.

My short answer to that dilemma is this: there will always be new and usually expensive ways of bringing us health benefits we desire. We will all get sick of something or other no matter how great our medical progress, and there will no less always be ways for medical research and technological innovation to combat our illnesses. But at some point we will have to acknowledge that it is ultimately a losing game – at least if one is interested in controlling health care costs. The medical bubble is bursting.

Daniel Callahan, co-editor of the Health Care Cost Monitor, is the author most recently of Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.

He came into urgent care with a nasty dental abscess. Cheeks swollen, a look of pain on his face, he struggled to open his mouth wide enough for me to look inside. The smell of his mouth could have knocked over a raccoon.

He needed that tooth pulled right away. So I arranged to get him some antibiotics (which he also needed right away) and called over to the dental clinic to arrange an appointment.

“Is he 100% service connected?” the clerk asked.

“No,” I replied, wondering what that had to do with the care of this grizzly Vietnam War veteran.

“We don’t cover dental care for our patients unless they are 100% service connected,” she explained.

I am proud to have worked in the V.A. health care system for more than 15 years. With a modest budget, relative to Veterans needs, the V.A. does an amazing job of caring for its population. But because of tight budgets, the V.A. must make difficult decisions about what care to offer to whom – what health problems deserve physical therapy, for instance, and how long patients should have to wait for things like hip replacements.

One of the difficult decisions the V.A. has made is to reduce dental benefits for their veterans. The V.A. is not alone in making this tough call. Dental care is often the first thing states trim when they are trying to balance Medicaid budgets.

From a purely medical standpoint, many dental problems do seem far less important than other conditions. Consider my most recent dental problem – I lost one of my front teeth due to trauma. I quickly realized how unnecessary the tooth was, biologically speaking, since I could still bite down on anything I would normally want to eat – crunchy bread-sandwiches, big juicy apples.

I had no pain, and no other medical symptoms. In fact, if you measured the cost and benefits of replacing my tooth, it would come out as a complete waste of money. High cost (several thousand dollars for an implant) and almost no medical benefit.

But sometimes medical costs and benefits don’t capture the entire picture. Losing a front tooth can have pretty noticeable social costs.

I was eventually going to replace my missing tooth with an implant. But for about five months I wore a removable “flipper.” I wore it when at work, doing television interviews, and teaching. But wearing that flipper drove me crazy, so I went “toothless” whenever possible. Walking the dog around our neighborhood with a missing tooth, I’d meet someone and notice the double take when the person recognized that I had a hole in my head. I’d feel the social distance created by my “condition,” a distance that I would try to bridge (not always successfully) with humor. People get freaked out by people who are missing teeth.

Imagine I am a Medicaid enrollee, in no position to joke about my condition, even embittered because I cannot afford a replacement tooth. Everyone I meet notices first and foremost, my damn mouth. How is that going to help my self esteem?

Now, hoping to get myself a job and get off Medicaid, I head out on a job interview. You are my prospective new employer. I have just one question for you: would you hire this guy?

Of course you wouldn’t. Which causes me to wonder: Does it make any sense to lop off an entire category of health services, like dental care, without thinking about the medical and social benefits such services provide?

We pay for reconstructive surgery for people with relatively minor facial injuries. Isn’t a missing tooth worthy of coverage too?

Moreover, some dental care is as necessary for good health as is most medical care, like pulling out rotting teeth that lead to serious infections. It is short sighted to deny patients coverage for such problems, simply because they fall into a broad category of care that we’d like to curb.

Some dental care services clearly deserve low priority relative to other health-related services. Whitening yellowed teeth, for example, is a purely cosmetic procedure that doesn’t deserve social subsidization. But excluding the entire panoply of dental care services strikes me as indefensible. After all, we don’t exclude all ophthalmologic services just because Lasik surgery is a cosmetic procedure.

When seeking out ways to save money on health care, we should look more carefully at which dental services deserve coverage, rather than dismissing the entire category of care. Such a blunt dismissal of dental care feels like cutting off our front teeth to spite our faces.

Peter Ubel, M.D., is the Jack O. Blackburn Professor of Marketing at Duke University’s Fuqua School of Business and a professor of public policy at Duke’s Sanford School of Public Policy. He is author of  Free Market Madness: Why Human Nature is at Odds with Economics—and Why it Matters (Harvard Business Press, 2009). His blog is www​.PeterUbel​.com;  919–660-7700.

One of the most ubiquitous concepts in recent years is “value for money.” It has been proposed as a standard for assessing research investments, the use of various diagnostic and treatment technologies, and as an all-purpose way of judging the efficacy of cost control strategies. The concept has about it a commonsensical appeal, used not only in health care but in the wider world of commerce and advertising. Who wouldn’t want good value for money?

Three different deployments of the concept can be discerned: in contexts where circumscribed comparisons of like with like can be made, where it is a stand-alone principle, and where it is meant to trump short-term cost control in the name of future benefits.

In their influential book Redefining Health Care, Michael E. Porter and Elizabeth Olmsted Teisberg specify a circumscribed comparison, contending that “the way to transform health care is to realize competition with value for patients … value is the health outcomes achieved for value of costs compared to peers.” Analogously, in its simplest version comparative effectiveness research aims to compare various technologies or other procedures with their peers: which among them, or against each other, are for instance good value for money? Arguments favorable to European health care systems in comparison with the U.S. system, because they provide full access and better outcomes at lower cost, would be another example. I count them as valid, meaningful uses of the concept.

That is not the not the case where there is no comparison at all, as some uses putatively have a kind of stand-alone validity. “We want,” Michael E. Chernew and colleagues have written, “to spend more of our growing income on medical advances whose benefits exceed their costs.” European Observatory Study of health technology assessment in Europe concluded that “products that provide the most value for investment must be identified and supported …” In short, some things are simply “worth it” regardless of costs.

Viewed from a cost control perspective, there are three problems with that approach. One of them is that it effectively pushes aside the need for such control, in principle using only efficacy as the standard. Tradeoffs and opportunity costs seem ruled out as beside the point. It no less opens the way for unlimited spending as long as the standard is met, not necessarily a tough one in light of most medical progress producing marginal and incremental but generally desired gains, but often at a high cost.

The line between an individual good and a social good can also get fuzzy with “worth it” arguments. Cancer drugs that provide only a few additional months of life at an exceedingly high cost are the paradigmatic example of that tension. For a dying patient and his family, the high cost may well be judged to be worth it. More life is worth more than no life. Yet for a health care system faced with a steady increase in drugs and treatments whose benefits are expensive but thought to be a good value, they can be an economic disaster.

The European Observatory study ironically makes its task all the more difficult when it says that technology assessments “should adopt a broader definition of product benefit by considering patient preferences, quality, equity, efficiency, and product acceptability among a wide range of shareholders.” Concerning patient preferences, for instance, I was reminded of the house we purchased a few years ago on a Maine island. We paid $250,000 for it, a modest, affordable figure for my wife and me. Yet we were, the island locals told us, city bumpkins for paying such an outrageous price. But it perfectly suited our preferences; it was for us a great value for the money. Similarly, many patients and their doctors prefer an expensive scan to watchful waiting even when the former may be no better than the latter; it just makes them feel more comfortable and secure, a psychological form of symptom relief well worth the money for anxious patients.

Value for money can thus mean many things to many people. Some things, moreover, may pass tests of value for money but simply be unaffordable. There were other houses on our island for sale with prices near a million dollars, but well beyond our income level, even though a good buy for those who could afford them. There is no necessary relationship at all between value for money and affordability.

All of this becomes most serious when value for money is offered as an antidote to cost worries. Two studies, one on prevention, the other on pharmaceuticals, employ that strategy. In “The Economic Argument for Disease Prevention: Distinguishing Between Value and Savings,” Steven H. Woolf and colleagues contend that “the proper question for prevention – and, ultimately, for all of health care – is not whether it saves money but whether it offers good value on the dollar.” They acknowledge at the beginning of their study that there is a cost problem and that “increased spending will only exacerbate current stresses on the economy …”

The other study, by the New England Healthcare Institute on comparative effectiveness research (with pharmaceuticals particularly in mind), makes a similar case, stating that “the debate over cost effectiveness should be re-framed as a debate over long-term value, not short-term cost, in order to sustain innovation.” It then makes a strong and plausible case for innovation as a long-term medical and economic value. As with the prevention study the implicit message is, yes, we know there is a cost problem but we deserve a pass.

No doubt, there are many other areas of health care spending where the upfront costs are high but the long-term gains are worth it. Unfortunately, we have a cost problem here and now, one that will only worsen if we listen to the siren song of eventual payoffs for more spending now. That song has its fraternal twin: if we cut costs, then we will hurt someone and reduce health care quality. In other words, no cuts for anything with a long-term payoff and no cuts for anything that brings short-term harms either.

The sad consequence of our cost escalation is that the upfront costs for later benefits must be cut now, and threats of harm to patients have to be put aside. That is what serious cost control entails if we swear off all evasions and rationalizations. If we fail to do so, our future health care system will have fewer and fewer of any kind of benefits to offer.

Daniel Callahan is President Emeritus of The Hastings Center and the author most recently of Taming the Beloved Beast: How Health Care Technology Costs Are Destroying Our Health Care System (Princeton University Press, 2009). He is co-editor of the Health Care Cost Monitor.

A recent USA Today/Gallup survey found that while a majority of Americans supported the need for health care cost containment, 90 percent did not want any limits on what they or their doctors believed was necessary health care. One (disheartening) obvious implication of that statistic is that our fellow Americans do not want to have their care limited to control costs. This does not bode well for the prospects of health reform.

Is there a way to control health care costs “painlessly”? If we can find ways of purchasing more health good for fewer dollars, then we will be able to cover the uninsured without having to take away health care benefits from people who are currently well insured. Everyone gets what they want and need from the health care system.

But I will argue that this is nothing more than a tempting “moral” mirage, suitably mesmerizing of the public so far as politicians are concerned, suitably congruent with the ideology of the market and its magical powers for solving social problems, but ethically sterile as an approach to controlling health care costs fairly.

Let us consider a few examples. An article in the Washington Post last summer discussed the closure of Pascack Valley Hospital in New Jersey because of bankruptcy. It could no longer compete with the two other hospitals in the area. All three were quite marginal economically, so the closure strengthened the remaining two (fewer empty beds).

Surely this is what efficiency is about; surely this is a virtuous outcome. But a local restaurant owner was interviewed for the story who, at age 58, was very troubled by high blood pressure and high cholesterol. He commented that if he were to have a heart attack he would likely not survive the ambulance ride through heavy traffic to one of the two other hospitals. He may or may not be correct about that prediction, but it is very likely that an outcome such as that will be true for some individuals who would want and need that third hospital closer to where they live.

So a rationing decision has been made through the “magic of the market” rather than the coercive powers of government. But the “magic of the market” is that such bad outcomes will never get public moral attention because they will appear to be merely unfortunate natural deaths. These deaths will never be identified as part of the cost of achieving efficiency and cost control in our health care system.

To be clear, if we have excess hospital beds or hospitals, we ought to close them after we have explicitly and self-consciously assessed the morally relevant consequences of doing so. We have no moral right to hide or ignore or deny such consequences in our quest for a more efficient health care system.

The Medicare system is predicted to face bankruptcy in about eight years. There are numerous reasons for this, but the most prominent of them would be the use of high-cost medical technologies.

We could deny the elderly extraordinarily expensive cancer drugs that yield only extra weeks or months of life at a cost of $50,000 to $100,000, or we could deny the elderly open heart surgery after age 85 because of the relatively long, costly recuperation periods, but both those options represent the painful rationing decisions Americans dread.

A nearly painless alternative would be to raise the eligibility age for Medicare to age 67. The “virtue” of that approach is that no one would be denied any particular health service. That is, there would be no explicit heavy-handed rationing. Individuals with excellent health insurance from an employer would simply continue working for those two extra years.

Of course, individuals in their late 50s or early 60s who are laid off would find it very difficult to get health insurance they could afford. If they remained perfectly healthy until age 67, then being uninsured would have little consequence. But if they had a costly life-threatening medical problem, then they would be in the hands of fate. Whatever the outcome, it would appear to be (morally speaking) unfortunate, not unjust.

Efficiency can have a certain perversity about it. Removing gall bladders and repairing aged and damaged knees used to require a number of days in the hospital. But the development of arthroscopic surgery has had the medical and economic benefit of reducing hospital stays to a day or so. Surely this represents morally virtuous painless cost control.

Arthroscopy surgery costs substantially less and has fewer side effects than conventional surgery. But there has been a dramatic increase in the number of arthroscopic surgeries, and in their total cost.

When gall bladder surgery and knee surgery carried more risks and cause more pain, more patients accepted conservative medical management. But to deny patients access to arthroscopic surgery now and insist on less expensive medical management would be seen as painful, coercive rationing.

We have seen a comparable phenomenon in cardiac care, where there has been a moderate decrease in bypass surgery but a very large increase in less expensive stenting procedures. More conservative medical management will often achieve the same life-saving goal as stenting, but at a much lower cost. But requiring cardiologists to deny patients stenting in favor of less expensive medical management would be seen today as painful rationing by both those cardiologists and their patients.

How should we assess that outcome from the perspectives of both justice and efficiency? Many new, more efficient, and less expensive medical interventions present this question.

The take home message of this essay should be clear: Health care reform will require painful social choices if we are going to control health care costs fairly and reasonably. Rhetoric that invokes increasing efficiency to control costs painlessly represents an anesthetic to our sense of justice when the health reform debates require more vivid ethical self-consciousness and public deliberation.

Leonard M. Fleck, Ph.D.,  is professor of philosophy and medical ethics in the Center for Ethics and Humanities in the Life Sciences, College of Human Medicine, Michigan State University. He is the author of Just Caring: Health Care Rationing and Democratic Deliberation (Oxford University Press). fleck@msu.edu; 517–355-7552.

In 2003, I and other members of the Medicare Coverage Advisory Commission (MCAC) met to consider the benefits and risks of using an implanted but externally powered pump, the left ventricular assist device (LVAD), for “destination therapy.” Destination therapy is for people with congestive heart failure whose age or other diseases make them ineligible for transplants.

The one randomized trial studying its effects showed it reduced the death rate by 48 percent, but half of recipients were dead after a year and three quarters were dead after two years. Many recipients had infections in the first three months after surgery.

The estimated cost of the device and the open-heart surgery to implant it was over $200,000, not including costs of complications. A Blue Cross/Blue Shield estimate of the cost per quality adjusted life year (QALY) was between $500,000 and $1.4 million, making it a true outlier in terms of cost effectiveness. With 5,000 recipients per year – and up to 100,000 potentially eligible – costs add up to $350 million to $7 billion per year.

What is the “opportunity cost” of destination therapy using LVADs? What other benefits could be purchased with the cost of this procedure?

For example, if Medicare invested some of those costs in outreach programs to provide better access to blood pressure and lipid screening, plus treatment, then one could prevent many congestive heart failure cases – lowering mortality rates much more than with LVADs. In short, much more effective and cost-effective alternatives exist than “destination” coverage for LVADs.

Unfortunately, asking this question about opportunity cost – and backing it up with evidence about cost-effectiveness—is not on the agenda for MCAC or the Centers for Medicare and Medicaid Services (CMS). Although the language in the Medicare act says coverage must be provided for “reasonable and necessary” services, it would take an explicit act of Congress to enable MCAC and CMS to consider opportunity costs and to make cost effectiveness analysis a part of deliberation about coverage. That is because no one – the managers of Medicare and the politicians in Congress – wants to face in a public way the need to consider opportunity costs. No one wants to be accused of rationing health care.

Cost effectiveness analysis is an attempt to measure the health benefit per dollar spent. Health benefit can be measured in various ways, including cases of a disease avoided, lives saved, life years saved, and health-adjusted life years saved (HALYs). Since many disease conditions significantly reduce quality of life but may not  be fatal, lives saved and life years saved do not allow us to compare health benefits across as many diseases and interventions for them as we may want to.

A life year discounted for a health decrement provides a way make broader comparisons. In medical contexts, the Quality Adjusted Life Year is the construct most often used, as in the Blue Cross/Blue Shield study of the LVADs cost effectiveness. In public health contexts, Disability Adjusted Life Years (DALYs) are used to estimate the burden of disease and cost effectiveness studies focus on the cost per DALY of reducing that burden.

Public Health Service and Institute of Medicine reports on cost effectiveness recommend that it be an input into a broader deliberation about coverage. It should not be used as a mechanical decision-making procedure. The decision process should be free to consider other ethically relevant factors that cost effectiveness by itself is insensitive to, such as distributive issues. For example, cost effectiveness is intended to help us maximize the health benefit produced per dollar spent, regardless of who gets that benefit or where in a life it goes. Yet most people are not straightforward maximizers of such health effects.

Most people want to give some priority to those who are sickest, for example; cost effectiveness give no such priority. (This point is made famous by the experiment in rationalizing Oregon’s Medicaid benefit. The Oregon Health Services Commission originally thought it could simply rank condition treatment pairs by their cost effectiveness and cover them in descending order of cost effectiveness until funds ran out. But the method ended up ranking some lifesaving treatments lower than some quality of life treatments, and public outrage forced a change in methods.) Most people also want to give people a fair chance at some benefit rather than always favoring those who will benefit the most.

If, however, a decision process about coverage is structured to allow input about cost effectiveness, and to encourage deliberation about distributive or other ethical issues, then the flaws of cost effectiveness can be addressed and the valuable information it gives us can also be acted on.

For example, in thinking about the LVAD case, knowing that LVADs are far less cost effective than preventive programs aimed at reducing the risk of heart failure means that we are holding constant the seriousness of the disease. In listening to information about cost effectiveness, but in the context of treating or preventing the same condition, we are less subject to the criticism that we are ignoring the seriousness of the condition.

Consider another way to entertain ethically relevant considerations while still using information about cost effectiveness. In England and Wales, the National Institute for Health and Clinical Excellence (NICE) has been criticized for using a particular monetary threshold – 30,000 pounds per QALY – as a guide to recommendations about coverage. This threshold has only weak normative support for it, and applying it mechanically overlooks important considerations.

For example, if the only treatment for a condition costs more than that threshold, then many would want to be flexible about paying more. A public method, such as NICE’s Citizen’s Councils, should search for relevant reasons for flexibility.

In short, we need to modify how we understand the language of “reasonable and necessary” in the Medicare law by insisting that opportunity cost be considered. Not imposing great opportunity costs on others would be one way to understand “reasonable.” We could then get relevant information about the opportunity costs from cost effectiveness studies, although we would need to view those studies as but one input into a deliberative process that is ethically informed.

Norman Daniels, Ph.D., is Mary B. Saltonstall Professor and Professor of Ethics and Population Health in the Department of Global Health and Population at Harvard School of Public Health. His most recent books are Just Health: Meeting Health Needs Fairly (Cambridge, 2008), and Setting Limits Fairly: Learning to Share Resources for Health, 2^nd Ed, (Oxford, 2008). He works in the U.S. and abroad on health disparities, health reform, and priority setting for health. ndaniels@hsph.harvard.edu; 617–905-4937.

The long-running, all-time favorite cure for our ailing health care system is to rid it of those malign twins, waste and inefficiency. No one has figured out how to do that, but it sounds so commonsensical that they retain their popularity in the face of a massive failure, well over 50 years now, to even make even a little progress against them.

At the same time, we have heard much of late about their first cousin, marginal benefits, which many see as the low-hanging fruit on the waste/inefficiency tree. By marginal is usually meant treatments, technologies, or other procedures that are either useless or of a wastefully low probability of benefit.

But it is time to recognize that perhaps the most difficult puzzle in the control of costs is to learn what to do with marginal benefits. The essence of the difficulty is that (a) a marginal benefit from a population perspective may be decisively beneficial for some (statistically unknown) individuals, and (b) that individuals (and their physicians) can have radically different notions of what counts as a benefit.

Marginal benefits, moreover, can be of at least two kinds. One of them shows up in a class of treatments that are – often for many – health enhancing (hypertension or arthritis treatments) but where other efficacious treatments are available for the same conditions. The other kind occurs when there is life or death at stake, or some highly desired improvement bearing on a patient’s quality of life (some cancer treatments in the former case and some Alzheimer’s treatments in the latter), and with few or no available alternatives.

These distinctions become important in determining what to do about both kinds of cases. In the instance of health-enhancing but where (perhaps somewhat less) health outcomes can be had with alternative treatments, we might readily let cost considerations enter in. A marginal benefit for one treatment may seem self-evidently worth sacrificing for an (almost) identical health outcome with another one.

The matter will most likely be otherwise with treatments that directly affect survival or make a major contribution to quality of life. A number of cancer treatments, and Aricept and similar drugs for Alzheimer’s, all expensive, fall into that category. Some cancer drugs, for instance, improve overall survival for a short time only for a huge amount of money (Erbitux, $80,000 for 1.2 months additional survival time, and Avastin, $90,816 for 1.5 additional months).

The use of the drug Aricept is a good example of an expensive treatment (over $2,500 a year) that does not extend life expectancy but does seem to slow the progression of the disease for a short period (a few months). For a time Aricept was considered controversial, with the debate focused on whether it did in fact slow the progression. More recently, however, it has generally been accepted as a valid treatment in European countries and in the U.S. Medicare program.

A common description of its benefit is that it can have a small but statistically significant value in marginally slowing the loss of cognitive function and the rise of behavioral problems. In 2006 it was the seventh most prescribed drug in the Medicare program.

Are the cancer drugs and Aricept worth the large amounts of money spent on them? That question seems to me appropriate and necessary, but our culture and our health care system all conspire to reject it for serious consideration.

The most generic way this is done is to declare that life is priceless and even to pose such a question is immoral; and so also with the idea of rationing beneficial treatments. Considerations of cost should simply have no place in our reform calculus.

But there are more subtle ways that cost are sidelined in the reform debate. One of them is the powerful role of the pharmaceutical industry, also taken up in the New Old Age. By treating any consideration of cost as a threat to innovation, both the profit motive is protected (patents run out), and the American romance with endless medical progress is pandered to.

The drug industry spends millions of dollars lobbying Congress and marketing its products, and the latter is particularly important for drugs with marginal benefits. One interesting study found that, almost invariably, industry-sponsored research findings were rhetorically hyped far more than nonindustry results, and that difference was reflected in marketing techniques, especially in the media.

To be sure, the marketing always includes the proviso that one’s physician should be consulted about whether the drug is appropriate for the patient’s condition. But here is where the other subtle barrier to considering the cost of marginal benefits is raised. As the resistance to comparative effectiveness research has made eminently evident, industry and at least some important segments of the medical community want the doctor-patient relationship to remain free of any government interference.

The Senate Finance Committee has made clear that the research findings should not be used to establish practice guidelines or even to make treatment recommendations. In that context, there will be no grounds whatever for a physician or a patient even to resist rejecting a treatment with marginal benefits. They need only to want it. By casting the use of solid scientific evidence as optional if it comes from the government – the only institution with the resources to carry out expensive studies – the classic idea of medicine as a mix of art and science is rejected for policy purposes.

No less rejected is any feasible way to combat the waste and inefficiency brought about by treatments and technologies with marginal benefits, now turned into a private matter between doctor and patient. Almost all new technologies these days are marginal in their benefits. To deprive our society of effective means of coping with them seems to me a disastrous “reform” outcome. A potentially powerful way of controlling costs has been deliberately pushed aside.

Daniel Callahan is editor of the Health Care Cost Monitor.

Imagine someone took you into the woods with three other people: a young child of no particular distinguishing characteristics, a middle-aged drunkard with a family, and a 75-year-old Nobel Prize winner. The person then told you that you had to kill one of the three, and that, if you did not do so, he would go back and kill your child. How would you choose?

The child has more quality-adjusted life years at stake, multiple lives depend (not very well) on the drunkard, and the Nobel Prize winner has made huge contributions to society but may not have much longer to contribute. But there is a better choice:

Shoot the person who gave you the choice. Then your child is safe, and the rest of you can all go home.

Think about this when someone claims that reform of the U.S. health care system must involve rationing care, as Dan Brock did in his post here.

The United States spends 16 percent of gross domestic product on its health care. If our financing and payment system were more like that of other countries, we could be providing the same basket of services, to all our citizens, for around 12 percent to 13 percent of G.D.P.

The most fundamental ethical conflict in the U.S. medical system isn’t which care to provide. It is between the interests of sick people and of all those who make money from the health care system. Some of the latter deserve their current incomes. But some of the incomes in our current system provide no social value at all; and others are surely much higher than they need to be. If we ignore the option of reducing the payments for care, including unnecessary overhead, then we are allowing all the people who make those incomes to tell us, essentially, “shoot the patients but keep us whole.”

Dr. Brock’s analysis ignores this dimension, accepts the current distribution of power and income in the system, assumes it is inviolate, and moves on to identify which patients to hurt. I don’t see how that is wise or ethical.

There are situations in which discussions of relative merits of services are highly appropriate. It is necessary in triage situations. It has to be done to define benefit packages: which benefits we will promise to each other and, even more important, which services we will force some people to subsidize.

But the logic of these applications is less important than the misleading implications of the common claim that ethical honesty requires that reformers admit that national health insurance requires rationing.

The extremely high costs in the U.S. are not due to overutilization. Compared to other countries, they are clearly due much more to high prices and excessive overhead.

Can we in the U. S. reach a point where “rationing,” as Professor Brock has in mind, may be the best way to control costs? Yes, and if we do I will be extremely happy (and I should live so long). As it is, lecturing the public that it must accept rationing is a recipe for political failure, and bad policy as well.

Joseph White, Ph.D., is Chair of Political Science, Luxenberg Family Professor of Public Policy, and Director of the Center for Policy Studies at Case Western Reserve University. His most recent book is False Alarm: Why the Greatest Threat to Social Security and Medicare is the Campaign to “Save” Them. joseph.white@case.edu; 216–514-8337.

Dan Brock Replies

Joseph White is, of course, correct that high prices for drugs and other health care services, together with great and costly administrative inefficiencies, are primary causes of our very high level of health care spending. And, he might have added, spending substantially more of our G.D.P. on health care than any other developed country has not bought Americans better health. I do not believe, and nowhere said, that “the current distribution of power and income” in the system should remain inviolate, and I will gladly join him in supporting proposals to overturn them.

So why argue, as I did, that rationing is ubiquitous, desirable, rational, and ethical, especially when it continues to be the third rail of health policy reform? While I would much prefer a single payer system that could fundamentally change the “current distribution of power and income” in the system that both Prof. White and I lament, no alternative that would do so is on the current reform agenda.

It is widely believed in political and policy circles, rightly or wrongly, that the American people do not want and would not accept such fundamental reforms. “Would you want the government running your health care?” remains a potent charge, however, false and misleading.

Because it is widely believed that most Americans are generally satisfied with the care they get, reform proposals all leave the employer-based insurance system largely in place. Because one lesson commonly drawn from the failed Clinton health reform effort of 1993 is that the drug and insurance companies will defeat any proposal that they see as too contrary to their interests, reforms being considered do not take on these groups head on.

Current reform proposals are limited by judgments of what is politically possible, but in no small part also by trying to avoid the charge that they will lead to rationing. So we pay a price in what reforms are deemed feasible by avoiding the third rail of rationing.

There is reasonable disagreement about whether acknowledging and supporting rationing is counterproductive from a political and policy perspective. Prof. White and others, like Jim Sabin in his blog, may be right that it is. Perhaps we should continue to pretend that we don’t and won’t ration health care to blunt attacks on reform and rationing.

But any reformed health care system will and should continue to ration care, and we should not let opponents of reform get away with attacking reforms on the grounds that they would lead to rationing; a reformed system will only ration in different places and in different ways than we do now. My hope, like that of Peter Singer in his recent piece in The New York Times Magazine, is that if the public better understands that rationing is already commonplace in all health care systems, and that it would be irrational and unethical not to ration care, then the charge of rationing may come over time to lose some of its political force.

Why is the prioritization of health care and rationing such a third rail of health care reform? Individuals are continually forced every day to prioritize their own resources, deciding what to use them for and what to forego. The process couldn’t be more familiar.

Since our wants typically outrun our resources, we learn to make the choices and move on to the next ones. So why is the very idea of prioritizing and rationing health care resources so troubling and controversial?

Americans are deeply ambivalent and inconsistent about health care costs and rationing. On the one hand, many like to pretend that rationing does not take place, but on the other hand they fear being denied beneficial care, in particular payment by their health insurance plans for care they need.

Many say that we are a rich country and have no need to ration health care, but on the other hand they resist rising costs of health care, particularly when they result in greater out-of-pocket costs to them. Many say that life is precious and money should not enter into decisions about medical treatment, but on the other hand they resist the ever increasing proportion of both our national wealth and their own wealth that goes to health care. Many recognize the need to limit the use of some health care, but on the other hand resist those limits when they are applied to them or others about whom they care deeply.

Now these inconsistencies might simply reflect a perfectly common and understandable desire to have more of a valued good like health care, but not to pay more for it. For goods that we must purchase in a marketplace, we soon learn that this is not a desire that can be satisfied – if we want more, we must pay more, and so we must decide how much that is worth to us in comparison with other uses for our resources.

Most Americans, however, do not pay out of pocket the full, or even most, costs of the health care they receive. If insurance pays, it is hardly surprising that we do not support rationing which will have the effect of denying some health care to us.

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefited by that good will not receive it. This allocation or rationing can take place by many means. The use of a market to distribute a good is one common way to ration it.

Most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity. Despite this widespread view, we remain the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it.

Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. The avoidance takes many forms. As already noted, a prominent one is just to deny that significant rationing takes place. When this denial becomes increasingly difficult to maintain in the face of the realities of the health care system, a typical alternative strategy is to condemn rationing as unjust or unethical and so to deny that it should take place.

If people widely believe that health care rationing does not take place, and that if it did it would be wrong, it is hardly surprising that we have not had a responsible public debate about when and how it should be done. But both of these beliefs that health care rationing does not take place, and that if it did it would be wrong, are false.

Perhaps it is inevitable that rationing must occur if others limit resources available to physicians to care for their patients, but many deny that resources should be limited in this way. This is a mistake, however, and it is important to understand why.

As long as there is some limit to the resources available for health care, health care will have to be allocated to those who need or want it – with not everyone getting all they need or want. Allocation in the face of scarcity is inevitable.

The only to avoid scarcity in the health sector would be to provide all services to all patients who are expected to benefit, no matter how small and uncertain the benefits, and no matter how high the costs. This is clearly impossible.

Everyone might benefit from having a private physician accompany us when we travel, or from unlimited resources for research for diseases that we have or have some chance of getting. Everyone may benefit from having an MRI on the very tiny chance that a brain tumor may be causing the headache they are experiencing. Yet none of this would be possible without enormous increases in health care costs.

More important, even if possible, none of it would be rational or desirable. To avoid scarcity by providing everyone with all care of any positive expected benefit would have tremendous opportunity costs.

We would have to devote enormous additional resources to health care that produced minimal benefits when we could have used them to produce vastly greater benefits elsewhere, such as in education or rebuilding the country’s infrastructure. Even within the health sector, trying to provide all beneficial care for some patients regardless of costs would inevitably prevent us from treating other patients who would benefit more.

So the only way of avoiding the need to ration health care would be irrational and undesirable. It would also be arguably unethical. We would have to use resources in a very inefficient manner producing far less by way of overall benefits for the population served than if we did ration care.

And since society has other ethical responsibilities to its citizens in areas such as personal and national security, education, and so forth, failing to ration health care would inevitably result in failing to meet these other ethical and political responsibilities and obligations. How to ration health care is the subject for another blog, but that it is and should be done is undeniable. Health policy analysts understand all this – the momentous task for health reform is to bring the public to understand and accept it.

Dan W. Brock, PhD, is Frances Glessner Lee Professor of Medical Ethics, and Director of the Division of Medical Ethics at the Harvard Medical School, where he also directs the University Program in Ethics and Health. He was a member of the Ethics Working Group of the Clinton Task Force on National Health Reform in 1993 and is an elected member of the Institute of Medicine. His most recent book is From Chance to Choice: Genetics and Justice (with Allen Buchanan, Norman Daniels and Daniel Wikler), and his main current research interests are in health care resource prioritization. This blog draws from his paper, “Health care Resource Prioritization and Rationing: Why is it so Difficult?” Social Research, 74, 1 (2007): 125–148. dan_brock@hms.harvard.edu; 617–432-5131.