Science always races ahead of our moral, philosophical, and ethical understanding.
—Richard J. Boxer, MD, FACS
An 80-year-old patient with metastatic prostate cancer asked me to discontinue his treatments, which were costing him more than $1,000 every 3 months. Although he had Medicare, he did not have secondary insurance. I told him that I would seek compassionate-care payment from the pharmaceutical company, but he insisted. I was perfectly willing to accept Medicare as the only payment, but in the perverse rules of the Centers for Medicare and Medicaid Services, it is a crime to accept Medicare as payment in full because then I am “overcharging” Medicare. A colleague tells me that being compassionate by not charging the patient the co-pay is a crime in Nebraska. This is the best definition of “No good deed goes unpunished.”
The gentleman knew he was going to die soon and that the money expended now for a few more months of life would be essential for his wife after he was gone. He died later that year, without receiving any more treatment.
Societal Costs of Cancer Care
Science always races ahead of our moral, philosophical, and ethical understanding. Can we honestly say that the present or future $100,000/year miracle medication that gives an additional 4 months of life is rational given our nation’s fiscal constraints? Does it make sense to prolong a life (or prolong the onset of death) by a few months with such a hefty price tag when the money might be better spent to address the desperate needs of many others in the country?
The cost of cancer care as measured by the value in increased life, especially quality of life, has commonly been a discussion about the impact on the individual, and there is great reason for that. However, there should be room for the cost to society in that discussion. Science creates targeted therapies, but should there be a targeted future with a rationale?
Cost-effectiveness analysis, intensely discussed 7 years ago, provoked our understanding of the issue of value (of care) and values (of humanity).1 Studying the effect of new treatments on quality-adjusted life-years brings some measure of rationale to the discussion. However, as Douglas Owens said in his editorial, “Cost-effectiveness analysis is a tool that cannot substitute for value judgments. We must still decide how much money we are willing to spend to improve our health.”1
So where does this leave our cancer care community? We must continue to push the envelope in basic and clinical research to find the next discovery that will lead to improved treatments, prevention of disease, cures, and quality-adjusted life-years but should never forget that we live in a complex society, where the value placed on life should not prolong inevitable death at the expense of society as a whole. ■
Disclosure: Dr. Boxer reported no potential conflicts of interest.
1. Owens DK: Interpretation of cost-effectiveness analyses. J Gen Intern Med 13:716-717, 1998.
Dr. Boxer is Voluntary Professor of Urology and Scholar in Residence (Business of Science Center) at the David Geffen School of Medicine at UCLA. He is also Professor of Clinical Urology at the University of Wisconsin-Madison.