Over a quarter of Medicare spending goes toward a patient’s last six months of life. This monopolizes limited resources, both in the hospital and in the federal budget. Much of the blame for this overspending is placed on institutional incentives or medical training for promoting aggressive end of life care, but some would also place the blame on patients or their families, arguing that this behavior is a flaw in our culture. The argument goes that if people would learn to be less afraid of death, then they would forego this costly life extending care and die peacefully, while allowing these resources to be available for use elsewhere with greater utility. In this argument, there is potentially a worrying conflation of moral and economic reasoning, which would be problematic if applied in other contexts.
It would be one thing to say that, given a limited pool of resources, a cost-benefit analysis indicates that end of life care is inefficient and quality-adjusted life years across the system would best be maximized if the money was spent elsewhere, and those in need of end of life care and their families will need to adjust their expectations. But integral to the argument in the first paragraph is that this misallocated spending is the result of a moral failing, perhaps not of the individual but of the society that imbued the person with the preference for aggressive treatment, and that this failing is worth changing, not only because it will save money and make individuals more comfortable with the fact that there are no longer the resources to support end of life care, but because it will provide some moral benefit to those whose values are changed.
My curiosity is how the economic argument (that it would be a better use of resources to spend money elsewhere) informs the moral argument (that it would be better if people accepted their death). This is peculiar to me because this type of reasoning does not show up consistently throughout health rationing: if a country decides to spend limited resources on HIV prophylactic drugs rather than HIV treatment drugs, no one would argue that it was in any way unreasonable for the HIV positive individuals to want treatment and that they should be more at peace with a terminal illness.
Here I propose three different ways of thinking about the issue, which I will develop further in my next post. First, it is possible that acting to extend life through end of life care out of a fear of death is, in and of itself, a moral failing regardless of whether it depletes scarce resources, and the fact that it does deplete scarce resources brings it to public attention. Second, it is possible that it is a moral failing because an individual is knowingly depleting scarce resources that could be more efficiently spent elsewhere, but it would not be a moral failing if it were free. Third, it is possible that it is not a moral failing at all, it is simply a resource allocation issue that implicates two competing values, fear of death and no fear of death, and one value is in line with the more efficient allocation principle and thus touted as superior. In the next post I will explore these three possibilities in greater detail.