Why Deny Health Care?

by Robert K. Oldham, M.D.

Most Americans would agree that "Health care should be available equally to everyone." But now the thesis of equal availability of health care is beginning to translate into a sub-thesis of "If everyone can't have a health-care service, then no one should have it."

Recent medical advances have made available a variety of in-depth approaches to the treatment of serious disorders such as cancer, AIDS, and major organ failure that allow for correction or a research-based attempt at correction of the disorder. Transplantation brings forth a large number of potential recipients, a small number of donors, and huge costs for each kidney, heart, or liver transplant. These transplant stories are often in the news and may involve distressing reports of the need for a transplant in a child, a young mother, or a productive, breadwinner father.

The relative infrequency of the transplant dilemma has been a major saving grace. Our sympathies go to each patient, and many of us have contributed to help a specific patient. No effective system-wide solution to this expensive technology and its limited availability has come forth.

Individuals who can afford to pay for these transplants represent a major revenue stream for hospitals with transplant services. There is little discussion when the individual has the capability to pay for a transplant. Is it not a wonder that the issue of restricting availability to those who can afford the transplant hasn't been raised by ethicists? There has been broad negative reaction to the idea of "selling" organs, but transplant programs go forward when organs are available for individuals who can pay for the procedure.

More difficult is the issue of a new cancer treatment or a new approach to the devastating problem of AIDS. In both of these situations, there has been much discussion about access and opportunity, the cost of research and medical services, and the issue of availability. Government and university officials have often voiced the view that a certain number of research-based approaches should be available through their hospitals. Individuals should line up and wait for the opportunity to avail themselves of these research services.

Such a system resembles the National Health Service of Britain, except that in the United States, contacts, political pressure, and money often can abridge a system of equal opportunity for all. One is reminded of kidney dialysis in its early days -- an expensive technology for which committees were created to judge the worthiness of individuals in need. In spite of such committees, patients with resources were generally able to avail themselves of dialysis.

Once rejected from such a system or once on a too-long waiting list with too little time, why restrain an individual with resources from pursuing private options? It would seem obvious that an individual with resources should be able to use those resources as he or she sees fit, while alive and able to make rational decisions. Yet, there is an increasing call to restrain such individuals from pursuing private-sector opportunities to gain access to new medical technologies for the treatment of cancer or AIDS.

The arguments go something like this: "If a medical service isn't available for everyone, should it be available for a few? Isn't it unethical or morally repugnant for someone with assets to be able to pursue a new, research-based treatment approach when others, without these resources, cannot? Shouldn't there be restraints on the private sector in the delivery of medical services to those who wish to pay for them?"

This thought process would indeed be bizarre if it were applied to a vital product such as food. At the moment, no one is crying foul if someone with resources chooses to eat more than the minimum daily requirement. In a similar manner, there has been no call to restrict the availability of air conditioners for those who wish to purchase them in spite of the obvious health advantages of air conditioning to the sick and elderly who can't afford them. There has been no call to remove private rooms or executive suites from hospitals where they are available to patients with resources. There has been no call to restrain travel by those who wish to fly to Switzerland or Italy or to a clinical facility in the United States for specialized medical care.

As a physician, I often receive calls from individuals who ask if I have access to a specialized technology, a research-based approach, for the treatment of a relative. I am struck by the fact that the individual, often a practicing physician, has not called me about his patients. I am struck that such individuals often work in government or universities. Some have been openly critical of privatesector systems of cancer research that might provide opportunities for those with the resources to afford them -- until someone close needs access and opportunity. What are the ethics of one standard for a relative and a different approach for a patient? This curious schizophrenia that everyone should have equal access and the corollary that if everyone can't have it, no one should, represents a dangerous thought process.

To then translate that to a system where no one can have access to more health care beyond a set standard would be a grievous error. Such thinking outside of the health field is clearly anomalous. Let's not apply a unique standard to health-care services but let's apply the same rules of logic to all basic services that individuals might utilize, given their resources.