Thursday, October 18, 2012

The Ugly Truth underpinning New Age Medical Care: What price a Life?

Update: Lateline ran a story on the ethics of End-of-Life care. They stopped short of examining Affordability and Rights to Basic Healthcare.

I was reminded on the radio yesterday of the simple question, "What price a life?"

This is the fundamental underpinning of Aged Care and End-of-Life Medical Care where a huge fraction, heading to 50%, of our total taxes gets spent.

As we Baby Boomers move to retirement and needing increasing levels of Healthcare and Residential Care, this is a question that must be answered, we can't adopt a Policy of "Head in Sand", "just do the Max".

If we don't have a nation-wide debate on this, consider it explicitly, we will have bureaucrats and politicians decide it for us, implicitly. The decisions they make and inherent resulting bias and who is selected as "privileged" won't please anyone, and probably not even the favoured few.

This is real, this is near, this is important, this affects every one of us.

State of the Art is the Oregon Healthcare Plan, formed with the explicit intention of more accessible, equitable care ("effective and efficient use of public money") and rationing benefits.

An example from the Wikipedia page:
During 2008 and 2009, the Oregon Health Plan stirred up controversy when enforcing 1994 guidelines to only cover comfort care, and not to cover cancer treatment such as chemotherapy, surgery and radiotherapy for patients with less than a 5% chance of survival over five years.
The answer to widespread good health is affordable, accessible quality healthcare.

The only route there now that we can potentially spend infinite amounts in prolonging life is to explicitly decide what we'll spend: What Price a Life?

For anyone who answers "all lives are priceless and must be maintained by all means, regardless of cost", I invite you to start paying 150% tax, because that's what you need in the foreseeable future.

This could be one of the hardest questions individuals, communities and nations have to face: Who gets taxpayer money for their healthcare.

The complementary question is: What can we afford to pay for medical facilities equipment, practitioners and drugs/treatment?

Just because we have the technology to prolong life, doesn't mean we are bound to use it. The incremental cost of each extra day of life rises exponentially. When is the economic pain too much? When is the best use of our scarce public (taxpayer) money the roads, wharves, soldiers etc?

Currently it's a situation of "charge whatever the market will bear", resulting in massive wealth for "gatekeepers", massive profits for medical equipment businesses and Big Pharma and crippling costs to the patients and taxpayers.

We already have the sentinel warning, the "canary in the coalmine", the USA.
Nations who do not act  deliberately and decisively are committed to that path. And how do you unring the bell of expectations and expected privilege? With massive social unrest and political upheaval...

The USA have, for me, an unconscionable number of people with no free basic healthcare, an alarming proportion of medical bankruptcies (unknown elsewhere), and 18% of the GDP (and growing!) spent by the three payees of healthcare: Insurance, Government and Individual Out-of-Pocket. Over the last 5 decades, Medicalcare in the USA has consumed increasing amounts of the GDP - from under 5% to nearly 20%. This has not been a conscious or deliberate decision, just the inevitable outcome of a system driven by opportunism and no clear limits.

I'm advocating that, as a society, we explicitly ask the unthinkable question and choose our priorities:

  • What constitutes basic healthcare for each stage of life?
  • What are our priorities?
    • Should everyone in our nation be entitled to affordable, accessible basic healthcare?
      • Who should be left out, who should be subsidised, by how much?
    • Should people who cause harm to themselves get free extreme measures, like liver transplants?
  • What proportion of basic care should be "free" (taxpayer funded) to the individual?
  • What are the Limits to Free Treatment in the most expensive, highest intervention areas, like Critical Care and End-of-Life care?
    • i.e. What constitutes the boundary for "Extraordinary Measures"?
If you haven't seen a loved one die in the modern system, you are probably unaware of how monstrous and uncaring the standard treatments and processes are.

People may die with good pain relief, but this is far from a given.
But their passing is not swift, painless or dignified, even when the medical prognosis is unavoidable death.
This is not good Medicine, this is not caring or respectful treatment, this is not kind to the victim or their family, this is not prudent or careful husbandry of scarce public (taxpayer) monies.

Nobody except Big Pharma and Medical Equipment vendors benefits from this treatment plan, everyone else suffers or pays.

Lets stop the nonsense, ignoring the Elephant in the room, and be courageous enough to have the conversation and ask, "What Price a Life?"

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