Health care: if you can’t save everyone, who do you save?

By Marshall Scott

It will surprise no one that I pay attention to news about health care. And these days there is certainly enough news to pay attention to. There’s the ongoing work in Washington that we hope will result in universal access to health care for all in America (and I say “we” deliberately in that the General Convention has called for universal access for a generation and more). There have been two reports, one on breast cancer and one on uterine cancer, each suggesting that screenings commonly accepted for some time aren’t as helpful as we thought. Finally, all of these have led to discussions of what we might and might not be able to offer and include in health care for all.

The conversations on all these topics have been heated. That’s because, I think, the topics have been in one way or another about limitation, and sometimes explicitly about how limitation might apply to each of us personally. We’re not comfortable talking about limitations, really; but we get even more disturbed, and even frightened, when we realize we might have to face limitations ourselves.

For me, though, this has focused my attention on a very personal question: what is my life worth? Actually, for me the question has been less abstract and more comparative: why is my life worth more than someone else’s?

In a way, that’s a difficult question to face. That’s because the applications of such a question are very specific. They’re also very critical.

Let me give some examples. According to current statistics there are more than 100,000 persons who might benefit from donation of an organ. However, in all of 2008 less than 28,000 organs were transplanted. That’s not the number of donors; it’s the number of organs. The number of persons who die who become donors are perhaps 6,000. Now, if my heart or my liver begins to fail, I might indeed benefit from a transplant, but I would be only one of thousands. If I accept a donor organ, I can be sure another person will die. So, why is my life worth more than someone else’s?

We don’t have to choose an issue as blunt as organ transplant. Consider the announcement from the U. S. Preventive Services Task Force changing the recommendations regarding screening for breast cancer. One way of understanding the findings of the Task Force is to consider that 1,904 women between the ages of 39 and 49 would need to be invited for screening to have one breast cancer death prevented. Many women, and many physicians, have been very critical. They worry that, based on the recommendation, insurance companies will deny payment for screenings for women younger than 50, whether for those with circumstances that might indicate an exception or for those who simply want the screening. They point to women who have benefited from mammograms, and ask why 1903 unnecessary mammograms aren’t worth the saving of the 1904th – especially when we can’t really know which woman in the 1904 is the one who will actually benefit.

However, that sounds like a choice between spending resources for mammograms or not. That’s not really the situation. How we use resources (including but not limited to money) is important because they’re limited, and as I said above, resources used in one place aren’t available for another. So, where might we use these resources? According to the CDC in 2005 more than 40,000 women died of breast cancer. However, in the same year almost 330,000 women – eight times as many – died of heart disease. So, if we committed the same resources of those 1900 plus mammograms to heart disease screening instead? Would we save eight women instead of one? Why is the one woman’s life more important than the eight women’s?

We have known for some time that achieving universal access to health care is really a matter of political will. We can do it, but we can’t do everything. I remember from my youth that wonderful poster, “What if we had all the money we needed for schools and the military had to have a bake sale to buy a bomber?” So, perhaps one thing that gets us closer to universal access is cancellation of the F-22 fighter program.

The same thing is true within health care. Just how great our resources for care will be is largely a matter of political will (and no, I don’t think the market will be more effective in meeting our needs in the future than it has been in the past), but they will certainly not be infinite. We will be able to do much, but we won’t be able to do anything. We can give that a negative focus and speak of “rationing,” or we can give it a positive focus and speak of “comparative effectiveness;” but we won’t be able to do everything, and we will have to set priorities.

And as we participate in setting those priorities, I think this is a relevant if difficult question: “Why is my life more important than someone else’s?” I think it’s especially apt for Christians. We are the community of him who laid down his life for us. We remember in light of his sacrifice that he said, “There is no greater love than to lay down one’s life for one’s friends.” So, this question is particularly important for us.

Now, I don’t want to claim any particular nobility here. This question may be easy or hard to ask in the abstract, but I have no illusion that it has to be hard to ask in the particular. If the person at the center of the discussion were my wife or one of my children, I don’t know that I could maintain a sense of altruism.

Still, it seems to me the critical question. Whatever our hopes for health care reform, we know we won’t be able to do everything for every person, any more than we are able to now. Within those limitations we are required to set priorities, and in those priorities there will be some who won’t get what they want, or will only get it at great difficulty and expense. We can hold those decisions at arms length, and let politicians and policy makers take the heat and the blame. Or, we can consider what we would forego as individuals, and call on those politicians and policy makers to use wisely the resources we decline. As a people gathered around one who let go of his life that we might have ours, we have a special responsibility for this very question. Why is my life more important than anyone else’s? And, how will I act on the answer I discern?

The Rev. Marshall Scott is a chaplain in the Saint Luke’s Health System, a ministry of the Diocese of West Missouri. A past president of the Assembly of Episcopal Healthcare Chaplains, and an associate of the Order of the Holy Cross, he keeps the blog Episcopal Chaplain at the Bedside.

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