Special CME Issue - West Virginia State Medical Association

President’s Message
Ethics and Rationing
of Healthcare
While driving to work recently, the
announcement came over the radio
that former Vice President Cheney
had undergone a heart transplant.
The reporter went on to say that the
he was 71 years old and usually the
cutoff for heart transplantation is
approximately age 65. A bioethicist
on National Public Radio did mention
that this brings up the question,
“Should people of Mr. Cheney’s
age, who have had multiple heart
surgeries, which complicate later
surgeries, be on the transplant list?”
This raises the age old question
of “ Is age just a number?” We as
physicians have all seen people in
their 40’s and 50’s who are much
sicker due to poor lifestyle choices,
diabetes, coronary artery disease,
hypertension, etc., than patients
in their 70’s and 80’s. Should the
healthy 70 year old or 80 year old
be denied a heart transplant? The
other side of the coin is the 90 year
old brought from a nursing home
with vomiting. The next thing you
know, an EKG is ordered which is
found to be abnormal that leads to a
heart catheterization and the patient
put on the schedule for coronary
artery bypass surgery. Believe me,
my fellow medical colleagues, this is
being done. Does this represent fear
of reprisal from the patient’s family
or greed on the part of the doctor?
Hospitals and medical institutions
are faced with these scenarios
every day. Ethics committees, if
available, have to examine all of
these challenges, and may end up
making the ultimate decision. In
other parts of the world, medical
care is markedly affected by ones
ability to pay. You literally ‘buy’ a
new heart, lungs, or kidney. Here
in the United States, often a very
ill patient wants quality of life,
but the family insists on quantity
of life. In this scenario, often the
wishes of the family supersede those
of the patient because he or she
did not want to upset their loved
ones. The patient who told his or
her family their wishes but had
no signed directive ends up on a
ventilator, then a tracheostomy, and
weeks of suffering before dying.
I would imagine that if we as a
nation began placing a dollar amount
on medical care and procedures that
was easy for people to understand,
there would be an immediate
reduction in cost, and an immediate
rise in screams to the government.
Is this the world we want? We need
to bring diverse groups together
including physicians, bioethicists,
clergy and ordinary citizens for an
open dialogue. I would hate to see
the day when medical decisions are
made based on economics alone, but
I am afraid that it may be coming.
It may be disguised, but surely it is
coming. Do we want the government
and private health insurance
companies making these decisions?
Have we really had the kind of fair
and open discussions that are needed
in this country on these issues? I
fear that many ordinary citizens are
grappling with these issues and even
discussing them among family and
friends. The ethics community needs
to do more to foster these discussions
so that everyone participates in
the decision-making process and
formulating health policy. This
would truly be democracy in action.
So what is ethics? Is it the science
of morality? Is it the study of good
or bad behavior or values? One
needs to go back through history
to define these values. Ethics is
not a new subject. The discussion
of ethics is found in the literature
of Mesopotamia, the cradle of
civilization. The Sumerians and the
Egyptians and the Greeks, including
Socrates and Aristotle, all wrote
of ethics. If we still have not “got
it right”, do not despair, we are
all still making history together.
MaryAnn Nicholas Cater, DO
WVSMA President
6 West Virginia Medical Journal