What Are “Appropriate Limits” In Healthcare?

When the title is a question, most authors answer it. I will not and prefer to solicit your input. There are no generally accepted limits on or in healthcare. Should there be? If so, what are they and who decides?

Any Limits?
This morning we discussed a two week old with complex heart disease. Optimal medical care dictates a series of operations at a high volume surgical Center, which means transfer out of State. Mother is 15 years old, speaks no English and is undocumented. She cannot fly commercially because she is too young to travel alone and is in danger of deportation when crossing the State line.

Health care providers are (appropriately) focused on the needs of each individual patient.  Are there ANY limits to health care services?

At the other end of the age spectrum, there was my mother-in-law. (I am one of the rare fortunate people who liked my mother-in-law, a lot.) At eighty-six, she chose not to have a gangrenous leg amputated understanding clearly the [fatal] consequences. She decided not to live that way saying, “It is disgusting, undignified and un-ladylike to have only one leg.” Her attending physician ordered a Psychiatry consultation.

When my mother-in-law established what she thought was an “appropriate limit,” the doctors thought she was depressed and prescribed Zoloft (which she never took).

Did you know that, unless you die outside the hospital like in a car accident, you expend more on medical services in the last six months of life than all the years before that combined? Do you want that? A recent Dartmouth study reported that a majority of seniors do not. Like my mother-in-law, they think that “everything possible” is not always the best care and that there should be limits – limits that can be set by them.

Appropriate, Accepted Limits? Who Chooses?
What might be an “appropriate limit” for health care? The State of Oregon has a list of diagnoses and procedures and what they will pay for each. Every year, they review their projected budget and make a cut-off line below which they will not pay. The “limit” is determined by the State budget.

In Great Britain and Sweden, there are age- as well as monetary limits on various procedures. Over a certain age, you cannot have renal dialysis, a bypass operation or a hip replacement, or at least one paid for by the government.

Where does personal responsibility come into play, if at all? If you weigh 300 pounds, should the government pay for your joint replacements? What about 400 or 500 pounds? Several years ago, a friend and colleague gave up doing gastric bypass operations after performing over 500 procedures. Two patients died: one weighed 480 pounds and the other 540 pounds. This surgeon had the lowest mortality in the entire country for that operation and still the families sued him. (Just remember, there is no such thing as risk-free medicine.)

The smoker and the non-smoker, the 170-pound man and the 400-pound individual, pay the same for health insurance. The person who chooses to smoke cigarettes or decides to eat to obesity by their choice spends more of everyone’s healthcare dollars than the non-smoker or thin man. Is this okay?

What are “appropriate limits” and who decides? My personal opinion matters no more (or less) than yours. What we need is a general agreement, a consensus, on acceptable limits in healthcare. This should be preceded by a nation-wide discussion and transparent decision-making.

We need to answer the title question, together, openly, as a nation.

System MD

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