Life, at What Price?

Five years ago, an American internist and health-care researcher named Peter Ubel wrote a book called Pricing Life: Why It’s Time for Health Care Rationing. His thesis was this: someone has to put the brakes on the rising cost of medical treatment, and that someone is the ordinary physician. Doctors, Ubel argued, should think about cost even as they consider their patients’ welfare, and should somehow balance these two responsibilities. The book never hit a best-seller list, and it was largely ignored by reviewers.

These days, though, its author occasionally gets invitations to speak outside the University of Michigan at Ann Arbor, where he teaches. Here is Dr. Ubel now, speaking on the wrong side of the Great Lakes, as a guest lecturer in a respectably filled auditorium of the University of Toronto. He begins his presentation with a straw poll. “How many here,” he asks, “think health care needs rationing?”

Sixty or seventy hands go up. Just one man — in his sixties, perhaps the oldest person in the room, and the only one wearing a suit — votes no. Ubel smiles, then asks, “How many think physicians should ration care at the bedside? ” The yesses are fewer now but they still, hugely, outnumber the handful of noes. “Freaky crowd,” Ubel says.

Certainly, it’s a self-selecting one, composed of students and teachers in the university’s Department of Health Policy, Management and Evaluation. For people like this, and a slowly growing number of others mostly of the genus policy wonk, rationing is no bogeyman. Rather, it’s an unsavoury reality, a necessary response to a notion that is inching its way into popular consciousness: the “unsustainability” of health care as we know it. This idea is closely linked to another reality: our ageing population (the proportion of Canadians aged fifty-five or over is expected to rise from 22 percent in 2001 to 32 percent by the year 2020). An older citizenry means higher costs: already, people over sixty-five, who comprise just 12.6 percent of the population, incur nearly half of all hospital costs. Ongoing advances in treatments and medical technology ensure that another death-defying cure will always be around the corner. And it will always cost money.

Meanwhile, the cost of existing treatments keeps going up. Peter Ubel flashes a series of PowerPoint slides to make his case. Cost of cholesterol drugs: up 63 percent in one year. Cost of analgesics: up 16 percent. Antidepressants: up 32 percent. Proliferation of mri machines: 61 percent in two years. Of pet scanners: 88 percent. The figures are American, but as he reminds the audience, Canada, too, is one of the top spenders in the world when it comes to health care.

For every dollar in the Canadian economy, a dime is spent on health care. Last year, under the heading of health, a total of $121.4 billion was spent by federal and provincial governments — an increase of 4.6 percent over the previous year, according to the Canadian Institute for Health Information (cihi). And, while governments spent $3,839 annually on health care for the average Canadian, the figure rose to over $17,000 for people aged eighty-five and over. The Conference Board of Canada worries that the overall health bill is currently growing 25 per-cent faster than the economy, though if you look at the trend line since the Eighties—rather than just during the past five years, which saw an injection of government funds after several years of cutbacks—the average growth is just 2.5 percent a year.

Whatever the final tally, it’s a lot of money. Money that won’t be going to schools, roads, sewers, peacekeeping, or aids aid to Africa. Money that we’ll all be paying in taxes, rather than on clothes, computers, or camp fees for the kids.

Unless we start thinking differently about health care.

Peter Ubel says we have to start doing just that. Doctors, he says, should check the price tag before ordering drugs and tests. Take fetal ultrasounds. “My wife had two thankfully normal pregnancies,” he tells the crowd at U of T. “Of course we had ultrasounds done, even though no study has ever shown it does any good . . . . With insurance, it’s a subsidized baby picture. [But] if we’d had to pay for it, I’d have said, ‘Give me a dvd player.’” Similarly, a routine pap smear every three years is enough to catch almost all potential cervical cancers; an annual smear costs $600,000 for each year of life saved through all those additional tests. That, Ubel suggests, is pricing a single human life too high.

But is it? The very idea of pricing life strikes most of us as a moral road that leads straight to hell—as perhaps it should. What doctor, knowing that she might cure a dying patient, wouldn’t do everything she can? What patient, offered that cure, wouldn’t jump at the chance?