Professor Singer is Wrong: It's Not a Waste to Treat the Very Sick
Peter Singer, the Princeton bioethicist, recently advocated in the New York Times, health care rationing as an approach to financing universal health care coverage. There are not many who are actually opposed to universal health care coverage - the only question is really how to pay for it. Adopting Singer’s proposal that part of the cost could be covered from avoiding high cost treatments that apparently only marginally extend life would be a terrible mistake.
It is not that he is wrong that it is hard to justify spending $250,000 or more to extend life by 6 months. He is wrong because there must be innovation in health care and innovation requires incentives for investing in and pursuing innovation. Singer uses the example of Gleevec, a $40,000 per year treatment for leukemia. Gleevec was not a good choice for Singer. It is a life-saving drug for the treatment of a particularly nasty form of leukemia. It attacks a basic cellular mechanism in leukemia and has none of the side-effects associated with chemotherapy. Its introduction has led to a whole field of research into similar agents that can attack specific cellular pathways in malignancy without disrupting the function of normal cells. It does not cost $40,000 per year because it is made of platinum or some other precious metal. It costs $40,000 per year so that the costs of developing the agent can be recouped and the risks taken by the companies that develop such agents can be rewarded. Some day it will cost not much more than an antibiotic for a mild case of pneumonia- when it becomes a generic agent.
There was a time when penicillin was so precious that Great Britain, fighting the Nazis alone, was unable to afford the development of the drug even though it was discovered and developed by the English scientists Fleming, Chain, and Florey. Britain turned to the U.S. to help create the life-saving agent. It is always like that - innovation is very expensive at the beginning.
Eric Neilson writing in the Journal of the American Society of Nephrology has pointed out the following in arguing for the benefits of basic biomedical research and refers to the economic cost-benefit analyses by Murphy and Topel:
Modern, expensive, halfway technology has redeeming social value when examined from the perspective of producing longer life, particularly if longer life provides more useful days of work in the marketplace. The gains from medical progress on more life-years and days worked per capita between 1970-1998 was 70 trillion dollars at a cost of 27 trillion dollars for health care and approximately 0.3 trillion dollars of taxpayer-supported research.
Laurence Eagleburger writing in the Wall Street Journal noted that arms control negotiators always act like there is no tomorrow, referring to the tendency to take the shortest view of the impact of the negotiation. The same can be said of those who argue against medical innovation. And make no mistake, if the only treatments that are allowed are those that are “cost-effective” in the short run, in the long run… Well you know what happens in the long run.
There are ways to control health care costs that certainly will lead to some restrictions on the provision of some care but there are tremendous savings to be achieved by removing organizational inefficiencies and payment inefficiencies that plague the system, particularly the Medicare system. Just one example - Medicare does not pay physicians for successfully avoiding hospitalizations for patients with chronic conditions. Having a nurse visit patients who have not been hospitalized but who need specialty care to manage their clinical conditions will not routinely be covered yet the savings that might be achieved by such close supervision would be substantial. The trouble is that only Medicare benefits economically from this approach, not the providers of care.