For America's aged, surgery at any price?

Jul 7 2009

When doctors decide whether or not to go ahead with an expensive surgery, "age is no longer the deciding factor, even for invasive treatment such as open-heart surgery," The Philadelphia Inquirer reports.

One question is "whether this never-too-old approach is an example of U.S. medical progress, or an example of why Medicare -- federal health insurance for people over 64 -- is headed for insolvency. The answer, experts say, is both. Which is why the current debate over expanding federal coverage to all uninsured Americans is an ethical and economic minefield. 'Forty years ago, it was taken for granted that the elderly were not good candidates for organ transplantation, dialysis, or advanced surgical procedures. That has changed,' Daniel Callahan, cofounder of the Hastings Center, a bioethics research institute in Garrison, N.Y., wrote recently. 'Under the best of circumstances, age should be irrelevant in the Medicare program. But so far, the cost of care has not been considered, and it can hardly remain irrelevant in a program strapped for money.'"

In the Philadelphia region, "Medicare pays an average of $40,000 to $60,000, depending on the open-heart procedure, but many elderly suffer complications that can inflate the total. The risks of open-heart surgery, while still substantial, have steadily declined," including for the elderly. In a 2003 study, "for octogenarians, mortality ranged from 7 percent to 11 percent, depending on the procedure." The study found that those odds "are two to three times greater than for patients ages 50 to 79." But "complicating this calculus is the issue of quality of life. Even with advances, surgery and its aftermath are traumatic, especially for elderly with chronic conditions such as diabetes or kidney failure."

David Callahan, also cofounder of the Hastings Center says, "I believe it's gotten harder for doctors to find a bright line between living and dying. Physicians feel compelled to offer heroic measures. They say, 'Let's not give up hope.'" But "that attitude may be uniquely American" because "in Western countries with government-sponsored health care, both the amount of care and access to it are limited." With Medicare projected to "run out of money in about seven years, 'I suspect there will have to be some form of rationing. … The question is whether age is the only - or even one of many - factors that should be used,' said Olivia Mitchell, "an expert on insurance and risk management at Penn's Wharton School" (McCullough, 7/6).