We need an informed societal debate on how much prolonging life should be allowed to cost
(Note to our readers: This is a re-posting that was first published on Monday 27 February in the Basler Zeitung)
Recently, the Secretary of Health for the Swiss canton of Zurich, Thomas Heiniger, called for a “fact-based societal debate” on how much prolonging life should be allowed to cost. He explained his call by stating that in other areas such analyses are quite common. “If, for example, avalanche protection for a road or village is planned, or the elimination of an unsafe railroad crossing, experts calculate how much you have to invest to save one life. It is only in healthcare that such considerations are largely taboo.” That may sound quite factual. Yet, I am not quite sure if Thomas Heiner fully realizes what he compares and what the relative costs of saving lives are.
Indeed it is true that cost-benefit calculations for transport investments are quite common. In many countries the accepted cost for saving a life by eliminating railroad crossings at roads is estimated at about four million Swiss francs. However, given that nothing comes cheap in Switzerland, this figure is now considered too low for transport investments in the Swiss Alps. This holds even truer for a life saved by avalanche protection which costs around five to ten million Swiss francs, according to the former director of the Swiss Avalanche Research Institute.
Of course, few people would object to considering cost-benefit analysis and demanding better efficiency in healthcare. Personally, I believe that the approach from the “Choosing Wisely” campaign initiated by the American Board of Internal Medicines is a good case in point. Driven by Hippocrates’ oath of “First do no harm”, the objective of “Choosing Wisely” is to identify and eliminate healthcare procedures and treatments considered by doctors as doing more harm than good for patients. Pursuing this goal mitigates unnecessary risks, leads to better care and probably lower costs. Nobody would argue against such a medically-driven approach. Alas, in the Swiss debate on “Choosing Wisely” this strictly medical and ethically undisputed approach is also often tainted with cost considerations. This is precisely where the debate becomes problematic, in particular, when somebody such as Thomas Heiniger refers to the so-called QALYs (quality-adjusted life-years) and implicitly argues for thresholds on how much a year of life should be allowed to cost.
Setting thresholds that are too high or too low costs lives and such setting across all diseases is problematic. What’s the issue here? In essence, cost-benefit analysis converts all benefits to a cost equivalent. Thus, the lower the cost-per-QALY, the better and more acceptable from a reimbursement point of view. The shortcomings of such an approach can be seen in the attempt to define a universally valid QALY upper limit based on how much society should pay for treating a given disease. Even in England where QALY thresholds are common and where rationing was always part of the NHS, compromises have had to be made. Even more problematic is the attempt to define a universally valid upper limit for social payments. Strict QALY limits, for example, would discriminate end-of-life treatment and elderly people as well as patients who are unfortunate enough to suffer from a rare disease. Accordingly, such limits are simply socially unacceptable.
Whoever calls for a specific societal debate about thresholds in healthcare and postulates age as a criterion for rationing should be careful in drawing comparisons with protection from avalanches or the dangers of railroad crossings. Surely, such cost benefit analyses for transport investments must be made, but no one wants to see a village buried in an avalanche just because the building of an avalanche barrier is too expensive. We all believe that it is quite normal to pay with taxpayers’ money whatever it costs to reduce such avoidable risks. Likewise, in healthcare we understand that it is difficult for human life to be measured by money. Quite apart from such considerations, taking into account the actual areas of high expenditure in the Swiss healthcare system ─more than half of healthcare expenditure goes to hospitals whose efficiency is hardly ever questioned, it appears unacceptable to deny patients life-saving treatments or improved quality of life.