Cutting Human Lives
What should we make of Arizona's new law for rationing organ transplants?
But state politicians got bad medical advice. Liver transplantation is far from "optional"; it's the standard of care for cirrhosis caused by hepatitis C.
What's more, the procedure often prolongs productive life by many years. Although most patients can expect their new liver to be reinfected with the hep C virus, which is still in their bodies, two-thirds enjoy up to a decade or more of life. The vast improvement in health enables many leave the Medicaid disability rolls and become taxpayers. As for saving money by denying liver transplants, even this is not a sure thing, as end-of-life care for many patients with liver failure (that is, those who did not get a new organ in time) is likely to equal or exceed the $200,000 that Francisco Felix was told to come up with.
The Arizona decision is doubly wrong, technically and morally. To regard transplantation as "optional" is a grievous medical error. When suitable patients receive organs, they can live meaningful and longer lives as parents, spouses, neighbors, and workers. Morally, it is troubling enough to deny life-saving treatment by never guaranteeing it in the first place; it is even worse to pull the plug on people's hope—and, with it, their lives. At the very least, the state should have grandfathered in those already assured of coverage. Then, going forward, in refusing to transplant those who could not afford it, Arizona would be making more explicit the economic rationing that already exists.
Uneasy questions of apportioning arise in environments of scarcity. Who will stay in the crowded lifeboat and who will be thrown to the sharks? This age-old tension between utility to society (the maximum good for the maximum number) and fairness to the individual is a crucible for American medicine. David C. Cronin, director of the Liver Transplantation at Children's Hospital of Wisconsin, sees Arizona's effort as a "dress rehearsal" for future cutbacks in a healthcare system where the government is poised to expand its role as insurer. "For a state agency to deny and even revoke approval for an accepted standard of care is new territory," he says.
I see a more immediate lesson, relating to what sociologists and economists call the problem of "identified lives." Flesh-and-blood people—Uncle Bernie with cancer rather than all people with cancer—elicit empathy and feelings of duty. Bioethicist Al Jonsen coined the term "Rule of Rescue" for the powerful human imperative to save a single endangered life, regardless of cost, over nameless throngs who may be in similar peril.
In the end, Arizona attempted to save money by curtailing expensive procedures that were believed to be relatively ineffective. From the standpoint of hard choices and cold calculation, this principle is defensible. But there is little reason to believe that Arizona undertook the time-consuming and painstaking data collection and cost-benefit analyses that should inform such policy change. Instead, it clumsily targeted a discrete group of people with names and faces who will die without a standard procedure that is proven to be successful in so many cases.
Thus public outcry over Arizona's blunder will, I suspect, lead the state legislature to reverse the cuts when it meets in January. As Francisco Felix's wife told the Times, "You can't cut human lives. … You just can't do that."
Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute.
Photograph by Thomas Northcut/Digital Vision.