The Value of Life at the End of Life: A Critical Assessment of Hope and other Factors

Shields M. , The Thing About Life Is That One Day You'll Be Dead (New York: Knopf, 2008).

Kolata G. Altman L. K. , “Forty Years' War; Weighing Hope and Reality in a Cancer Battle,” New York Times, August 28, 2009, available at <http://query.nytimes.com/gst/fullpage.html?res=9C07E5DD103CF93BA1575BC0A96F9C8B63&sec=&spon=&pagewanted=3> (last visited February 24, 2011).

Id.

Callahan D. , “The Fine Line between Waste and Marginal Benefits,” in Cost Control and Health Care Reform, Act 1, Health Care Cost Monitor, The Hastings Center, at 7–8, available at <http://www.thehastingscenter.org/uploadedFiles/Publications/Primers/2009-Health-Care-Cost-Monitor-Act-1.pdf> (last visited February 24, 2011); Geyman J. , “Cancer and Comparative Effectiveness Research,” in Cost Control and Health Care Reform, Act 1, Health Care Cost Monitor, The Hastings Center, at 11–12, available at <http://www.thehastingscenter.org/uploadedFiles/Publications/Primers/2009-Health-Care-Cost-Monitor-Act-1.pdf> (last visited February 24, 2011).

Fojo T. Grady C. , “How Much Is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question,” Journal of the National Cancer Institute 101, no. 15 (June 29, 2009): 1044–1048. Fojo and Grady's extrapolation about aggregate costs may not be far-fetched. If U.S. insurance reimbursement falls into a pattern of often covering treatments like Avastin and Erbitux at their current expense and effectiveness, pharmaceutical companies would have an incentive to develop such expensive, marginally effective drugs for all cancers. The fact that other first-line therapies were more effective and would be used first would not discourage people from using these drugs for marginally extra survival.

Marchione M. , “$93,000 Cancer Drug: How Much Is a Life Worth?” USA Today, September 26, 2010, available at <http://www.usatoday.com/yourlife/health/medical/cancer/2010-09-26-prostate-provenge_N.htm> (last visited February 24, 2011).

Nadler E. Eckert B. Neumann P. J. , “Do Oncologists Believe Cancer Drugs Offer Good Value?” Oncologist 11, no. 2 (2006): 90–95. With all of these treatments it is important to distinguish retarding tumor growth from prolongation of life. Avastin, for example, postpones the marked growth of breast cancer 5.5 months beyond an otherwise 5.8, but the studies submitted to the FDA did not show that Avastin for breast cancer ultimately prolonged life. See Pollock A. , “F.D.A. Panel Urges Limits for Avastin,” New York Times, July 21, 2010, at B1, 10.

The implied value calculations run like this. Suppose you insist on $10,000 extra annual pay for a job that runs a 1:500 annual risk of death – a death that were it to occur, would probably deprive one of 50 years of life. If 499 fellow workers insist on similar extra pay for such work, the pool of extra pay for all 500 is $5,000,000/year. Divided by the 50 years of the likely one life lost in such a group each year, the implied value of life is $100,000 per year of life.

Becker G. Murphy K. Philipson T. , “The Value of Life Near Its End and Terminal Care,” NBER Working Paper No. 13333, National Bureau of Economic Research, August 2007.

Id., at 4 (emphasis added).

Rasiel E. B. Winfurt K. P. Schulman K. A. , “Can Prospect Theory Explain Risk-Seeking Behavior by Terminally Ill Patients?” Medical Decision Making 25, no. 6 (2005): 609–615. For detailed review of prospect theory generally, see Hastie R. Dawes R. M. , Rational Choice in an Uncertain World: The Psychology of Judgment and Decision Making (Thousand Oaks, CA: Sage, 2001).

The phrase is mine, though the phenomenon it refers to is commonplace in the health policy and health economics literature.

At least in fee-for-service contexts. In some other compensation structures, the fact of insurance would not generally boost providers' incentives in this direction.

This factor is undoubtedly present in some end-of-life situations. It probably is present at the Ronald Reagan U.C.L.A. Medical Center, for example, which is described as having earned a reputation about end of life care “as a place where doctors will go to virtually any length and expense to try to save a patient's life. ‘If you come into this hospital, we're not going to let you die,’ said Feinberg David T. Dr. , the hospital system's chief executive.'” Abelson R. , “Weighing the Medical Costs of End-of-Life Care,” New York Times, December 23, 2009, at A1, 20.

Habitat for Humanity builds houses with people for less than $100,000. The moral concern might thus be provocatively expressed by asking people whether they really want to “eat a house” before they die!

Truog R. , “Is It Always Wrong to Perform Futile CPR?” New England Journal of Medicine 362, no. 6 (February 2010): 477–479.

The response data that follows is simplified for purposes of discussing the moral issues. While the data is not directly quoted, it closely tracks the study reported by Ubel P. Loewenstein G. , “Distributing Scare Livers: The Moral Reasoning of the General Public,” Social Science and Medicine 42, no. 7 (1996): 1049–1055. For similarly interesting data on a related sort of choice involving length of life saved (rather than probability of lifesaving), see Ratcliffe J. , “Public Preferences for the Allocation of Liver Donor Grafts for Transplantation,” Health Economics 9, no. 2 (2000): 137–148.

The plausible number of persons whose hope is seen to be maintained varies with different assumptions. (1) One could claim that hope is maintained for all 200 by reasoning as follows. Regard the 80 in group A who receive organs as patients for whom hope is maintained. The other 20 in A move into the lower prognosis group as it becomes clear that they will not be one of those with high prognosis who receive a transplant for that initial reason; by the decision to split the organs 80/20% they still stay eligible and have their hope maintained. Because 20% of the organs are reserved for the 100 in group B, of course, they also have their hope maintained. Thus, all 200 have hope of getting an organ. (2) By focusing on the additional number for whom hope is maintained by a policy of allocating 20% of the organs to B instead of all 100% to A, however, the apparent number is 100. If all 100 in A get an organ, they don't “have their hope maintained” (they get saved), and none in B have their hope maintained by any prospect of getting an organ, but if 20% of organs are reserved for B, all 100 in B there will be able to maintain their hope.

“Not saving” a net of ten lives is the literally correct descriptor. Many will call this “sacrificing” or “losing” these lives, thinking those descriptions say the same thing, but on some ethical views not saving is morally not equivalent to sacrificing.

See Ubel Loewenstein , supra note 17, who found that “maintaining hope” was a very prevalent reason respondents gave for their decision not to save the maximum number of lives by allocating all of the organs to group A. Even if it is not a dominant reason explaining these or any other study's respondents' choices, a policy of reserving 20 percent of the organs for lower prognosis patients does, as a matter of fact, allow those patients to maintain hope for a lifesaving transplant when otherwise they would not have been able to maintain such hope.

Smith D. Loewenstein G. Jankovic A. Ubel P. , “Happily Hopeless: Adaptation to a Permanent, but Not to a Temporary, Disability,” Health Psychology 28, no. 6 (2009): 787–791.

Martin A. , “Hope and Exploitation,” Hastings Center Report 38, no. 5 (2008): 49–55. See also Schneiderman L. , “The Perils of Hope,” Cambridge Quarterly of Healthcare Ethics 14, no. 2 (2005): 235–239.

Quoted without further source by Levoy G. , Callings: Finding and Following an Authentic Life (New York: Random House, 1997): At 4. Havel's time as a dissident for decades in Soviet dominated Czechoslovakia, including his imprisonment from 1979–1984, presumably provided the setting in which he maintained his hope though optimism was hardly plausible. I owe the observation that hope is different from optimism to Gregory Johnson (Department of Philosophy, Pacific Lutheran University).

Dworkin Ronald Hall Mark Menzel Paul are three authors who argue that there is moral justification to regard this prior point in time, when one is shaping or purchasing one's insurance, as the proper perspective from which to make cost-value decisions about what insurance should include. If it is not always or actually the perspective in which people make such decisions, it is the perspective to which people making them should transport themselves mentally. See Dworkin R. , “Justice and the High Cost of Health,” in his Sovereign Virtue: The Theory and Practice of Equality (Cambridge: Harvard University Press, 2000): At 307–319; Hall M. , Making Medical Spending Decisions: The Law, Ethics, and Economics of Rationing Mechanisms (New York: Oxford University Press, 1997): 193–227 especially; and Menzel P. , Strong Medicine: The Ethical Rationing of Health Care (New York: Oxford University Press): At 3–36. The three authors use different terminology for essentially the same concept in talking about limitations on covered care: Dworkin, the “prudent insurer”; Hall , “bundled consent” to limitations; Menzel , “prior consent” to limitations. In “Justice and the Basic Structure of Health-Care Systems,” in Rhodes R. Battin M. Silvers A. , eds., Medicine and Social Justice: Essays on the Distribution of Health Care (New York: Oxford University Press, 2002): At 24–37, Menzel expands the argument for cost-controlling measures in insurance contexts with explicit moral principles of presumable prior consent and personal integrity.

Menzel P. Gold M. Nord E. Pinto-Prades J.-L. Richardson J. Ubel P. , “Toward a Broader View of Values in Cost-Effectiveness Analysis of Health,” Hastings Center Report 29, no. 3 (May-June, 1999): 7–15, at 11–12. Ubel P. Loewenstein G. , “The Efficacy and Equity of Retransplantation: An Experimental Survey of Public Attitudes,” Health Policy 34 (1995): 145–151.

Daniels N. Sabin J. E. , Setting Limits Fairly: Can We Learn to Share Medical Resources? (New York: Oxford University Press, 2002): at 43–66.

These reasons and their implications are spelled out in two essays by the author. Menzel P. , “Justice, Liberty, and Efficiency in Health System Structure,” in Rhodes R. Battin M. Silvers Anita , eds., Medicine and Social Justice: Essays on the Distribution of Health Care, 2nd ed. (New York: Oxford University Press, forthcoming 2011), and Menzel P. , “The Cultural Moral Right to a Basic Minimum of Accessible Health Care,” Kennedy Institute of Ethics Journal 21, no. 1 (March 2011).

Wasteful, excessive use of services is probably common in U.S. health care. For one well-known slice of the voluminous evidence for this claim, see Gawande A. , “The Cost Conundrum: What a Texas Town Can Teach Us about Health Care,” The New Yorker, June 1, 2009, available at <www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande> (last visited February 24, 2011).