About End-of-Life Care

Rising budget deficits have become a principal concern of the American people in recent months, and are already a cause célèbre for politicians in both parties ahead of this year’s midterm elections. Yet the current round of health care negotiations has largely sidestepped one of the most costly elements in health spending: end-of-life patient care.

A September 2005 report by the President’s Council on Bioethics noted that people 85 years of age and older comprise the fastest-growing segment in the American population. Medicare budgets, which the National Health Statistics Group at the Centers for Medicare and Medicaid Services projects to rise to $792 billion by 2015, will be spent largely on treatments given during the last year of life.  Faced with this troubling economic outlook, what, if anything, should the government do to contain costs?

Those in favor of rationing work from the assumption that taxpayer resources are finite, and as the Baby Boom generation gets older, policymakers will be constrained in how they allocate these resources.  The more that is spent on costly end-of-life procedures, the less there is to spend on everyone else.  By rationing end-of-life care, more life years would be saved by spreading these resources to more patients.  People can still choose to spend their own money on expensive drugs and treatments, but government has the obligation to spend these finite resources in the fairest and most effective way possible. 

Some proponents prefer to avoid the “rationing” moniker in favor of an appropriate discussion between patients and the professional medical community on end-of-life issues such as living wills, palliative care, and pain management.  Studies indicate that 90% of people want to die at home, yet only 30% do so.  Thus, a more open discussion will both yield cost savings and better reflect patients’ wishes.

Opponents of the resolution hold that supporters of rationing are committing the fallacy of a false dilemma.  Rejecting the choice between higher spending and reduced services, they argue instead for a third way—adding value and efficiency into the delivery of care.  “High-value” providers such as the Mayo Clinic, Kaiser Permanente, and Intermountain Healthcare offer models for providing better care at less cost and with greater patient satisfaction.  A recent study of nearly five million Medicare enrollees conducted by the Dartmouth Atlas Project found that such high-quality/low-cost measures could have reduced Medicare costs by nearly one-third.  Opponents of the resolution also advocate a more open and humane discussion of end-of-life issues as a component of better care, but not as a vehicle to reduce unnecessary procedures.

Of greater concern to many who oppose rationing are the social implications of such a policy.  End-of-life decisions are among the most personal and difficult decisions an individual or family can make.  Religious or spiritual beliefs often determine, or at least strongly inform, such decisions.  Opponents argue that rationing would take these choices away from people and put them in the hands of government bureaucrats charged with deciding who is worth saving and who is not. 

Most Americans have little problem with distributing scarce resources in the case of transplants, vaccines, or emergency room care.  And rationing has always existed more broadly in the health care system by doctors, hospitals, and insurance companies.  Nonetheless, the idea of rationing has become so poisoned among policymakers that it is no longer part of the political lexicon.  Slowing the growth of health spending and putting the nation’s health programs on a fiscally sustainable path will require a rational, frank, and fully informed discussion of end-of-life patient care.

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