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Jan. 8, 2014

Leonard Fleck: Ethical dimensions of health care

Jan. 8, 2014

Leonard Fleck, a professor of philosophy and a faculty member in MSU’s Center for Ethics and Humanities in the Life Sciences, is among the foremost experts on the ethical dimensions of American health care.

Which political value ought to be accorded greater weight: protecting individual liberty or enhancing social equality? This is the sort of abstract question with which philosophers are typically associated. It is ultimately a frustrating, unanswerable question because it is so abstract.

In graduate school John Dewey was the American philosopher whom I most wished to emulate. He was a pragmatist. His most important insight (at least for my career) was that these abstract questions are really placeholders for hundreds of real social and political problems that people struggle with in daily life and which philosophers must address. This insight is what directed my career toward medical ethics, health care policy and social justice issues.

The cost of health care has been an intense political concern for more than 20 years. In 2012 total health spending in the U.S. was $2.8 trillion. About $600 billion of that was for the Medicare program.  Projections for 2020 put health spending at $4.5 trillion with $1 trillion going to Medicare alone. The primary driver of these escalating costs is the emergence of very costly life-prolonging technologies.

Here’s an example: Individuals with end-stage heart failure can have their lives prolonged today for an additional two years with a left ventricular assist device at a cost of $200,000. Computer projections show that we could surgically install 250,000 of these devices each year. That would add $50 billion to the cost of health care in America, mostly to Medicare.

What about the 600,000 Americans who die of cancer each year? We now have more than 50 novel cancer drugs called targeted or personalized cancer therapies, which cost $50,000 to $130,000 for a course of treatment. None of them cures any metastatic cancers. On average they yield a gain in life expectancy measurable in weeks or months. Are all of those cancer patients entitled to at least one of these targeted therapies for extra months of life? That would add $60 billion to the cost of health care, again mostly to Medicare.

If we really believe human life is priceless – a belief often expressed in public discourse – do we have any excuse for not paying the additional taxes needed to support Medicare? Are those taxes a threat to individual liberty? Should we save money by only providing these life-prolonging devices to MSU professors like me, and not to groundskeepers? Are there limits to what we owe one another in terms of needed health care in a society that claims to be just and caring? Who should define those limits?

Now we have some genuinely important philosophic questions that cannot be debated for 2,000 years, as has been the case with other questions in philosophy.

These issues have been the focus of much of my academic career as a philosopher. I can provide one confident answer to my last question: Philosophers are not the experts who can define those limits. More generally, no one has the expertise to define those limits. These are fundamental moral and political questions that must be addressed through respectful and rational democratic deliberation – another lesson from John Dewey. The proper role of philosophers is to facilitate that conversation and to criticize those who would subvert civil conversation with irrational rant and rhetoric. There is nothing abstract or disengaged about that Socratic endeavor.