Economics, ethics, and end-of-life care.

PRESSURE TO REDUCE TOTAL HEALTH CARE EXPENDITURES IN THE UNITED States has intensified. Despite a contracting health care budget that has sensitized society to the issues of resource allocation, the demand for the health care dollar has continued to expand. The disciplines of economics and bioethics have each outlined strategies to mitigate this conflict. Yet because of divergent core preferences, the proposed strategies are discordant. Whereas economics is chiefly concerned with the quantitative analysis of the production, distribution, and consumption of goods and services—an approach that often creates value-loaded trade-offs— bioethics often addresses the variance among competing values without accounting for resource scarcity. When the overall priority is to decrease monetary costs, selecting the most desirable way to allocate resources depends on which values are assumed to be paramount. If we are to develop morally acceptable principles for allocating scarce resources, the two approaches must reach a concordance. Decisions regarding the delivery of health care at the end of life underscore the inherent conflict between economics and bioethics. Many argue that because 10% to 12% of all health care expenditures and 27% of Medicare expenditures are spent at the end of life, and because these expenditures frequently fail to provide significant health benefits, the elimination of such care would make resources available for other unmet needs. Opponents counter that cost savings projected from reduced care at the end of life are illusory, and that such reductions in care breach the maxim that the least advantaged should be accorded the maximum benefit from an unequal distribution of any primary good. Rationing itself is not denounced as ethically unacceptable, so long as the deprivation of goods is egalitarian. This attitude contrasts with British National Health Service guidelines that explicitly refuse specific health care services to persons because of advanced age. This month, MSJAMA considers how economics and bioethics can reconcile in order to generate strategies for delivering care at the end of life. Because the United States accords no general legal right to health care, health care at the end of life, extensive or minimal, is a moral claim. However, structuring resources according to a population-based health approach, and forgoing care of marginal benefit, would potentially achieve greater utility. But to apply a policy of rationing to persons at the end of life—the necessary consequence of a population-based approach—is inconsistent with many principles of social justice. As cost pressures continue to conflict with accepted ethical standards, medical students and physicians, as patient advocates, will be required to examine death more broadly, and pursue constructs outside the biological sciences.