Moral Challenges Ahead as Managed Care Marches On

PHILADELPHIA--Forging ahead with change was the theme of the secondannual meeting of the Association of Cancer Executives (ACE).And for most of the speakers, change meant adapting to the newreality of managed care and hospital mergers.

Leonard Fleck, PhD, professor of philosophy and medical ethics,Michigan State University, took meeting attendees on a tour ofthe moral challenges ahead.

He said that when speaking of cutting costs in health care, "oneperson's waste and inefficiency is another's life-saving care."Dr. Fleck gave an example from a Chicago Tribune article, whichdescribed a patient, Mrs. P, who was being treated for a brokenleg. Because the leg was not mending well and would require expensiveadditional care, her orthopod called her managed care case managerfor authorization.

The manager asked what would be the cheapest way to treat her.The physician sarcastically stated that amputation was the leastexpensive way, but found he had to furiously back pedal when thecase worker took him seriously, offering an $8,000 payment tosever the leg. The physician eventually prevailed, spending about$90,000 in total to save her leg.

Dr. Fleck then turned the question over to the audience of cancerexecutives and other health care professionals. He asked participantsto imagine themselves as managed care providers and to vote, viaelectronic devices he provided, whether it was a morally defensibledecision to save Mrs. P's leg at such a high cost.

More than half (52%) strongly agreed; 33% agreed; 15% were undecided;and no one disagreed. In other words, no one in the audience believedit was right to let managed care providers make such a criticaldecision based solely on money, and 85% were certain that savingthe leg was the right decision.

However, when Dr. Fleck recast the scenario, the voting distributionshifted. If Mrs. P had come into the emergency room with a brokenleg and no insurance, would the hospital trustees be morally justifiedin denying her the costly extra treatment needed to save her leg?

Off With Her Leg!

This time 69% disagreed or strongly disagreed, meaning they werecertain that the leg should be saved regardless of who paid. Onthe other hand, 18% strongly agreed or agreed, meaning that whenthe hospital charity fund was to be the source of the extra money,they could justify cutting off the leg; another 18% were uncertain.

Medical advances are also colliding with the downsizing of thehealth care budget, forcing moral dilemmas upon the medical community,he said. In the 1970s, nobody needed a coronary artery bypassoperation because the procedure had barely been invented. Andyet by 1994, 400,000 patients underwent the procedure at a costof up to $40,000 each.

A still more costly technology looms on the horizon, the totallyimplantable artificial heart, which could be available sometimeafter the year 2000, Dr. Fleck said. In 1994, 350,000 people couldhave used such a device to save their lives, but only about 2,500of these artificial heart candidates were saved with a heart transplant.The shortage of donor hearts has provided a natural rationingmechanism for heart transplant operations, at least for now.

The artificial heart, at about $150,000 per surgery, would addabout $35 billion to the Medicare budget. "This one advancewould wipe out entirely the projected $240 billion Medicare savingsin Congress's proposed budget, to be achieved over the next 7years by reducing Medicare growth," he said.

Is a Ban Morally Defensible?

Dr. Fleck asked, given the potential horrendous economic impactthe artificial heart poses, would it be morally defensible toban access to this device? More than three quarters said no--12%agreed or agreed strongly; 15% were uncertain; 33% disagreed;and 45% strongly disagreed.

When Dr. Fleck added an element of choice, though, by proposingthat artificial heart production be limited to 100,000 per yearand available only to those covered by insurance and under age70, only 39% of the audience objected--7% agreed strongly; 45%agreed; 15% were uncertain; 24% disagreed; and 15% strongly disagreed.

Dr. Fleck said his take home message was that health care rationingis a morally defensible reality. "Making public decisionsabout who to save and who to let die because these new technologiesare so expensive is politically divisive," he said. "Thesedecisions ought to be made through processes of rational democraticdeliberation in accord with norms of fairness that the majoritywould endorse."

In other words, he said, rationing decisions should be made inthe open, publicly agreed to, and, most of all, self-imposed bythe public rather than imposed from an outside force.