Miracles, Choices, and Justice: Title and subTitle BreakTragedy of the Future Commons

The landmark Patient Protection and Affordable Care Act of 2010 will soon extend insurance coverage to millions more individuals in the United States. Simultaneously, the first of the baby boom generation will reach age 65 years and enter the age group that has the highest rates of health care use. Meanwhile, technological advances in medicine continue to proliferate. As these trends intersect, difficult questions will arise about the who, what, and for how long of health care. The stories of 2 patients provide insights into the present and future states of health care in the United States.

The first patient was an 89-year-old woman with atrial fibrillation and functional impairment requiring a caregiver 24 hours per day. She presented with acute right-sided hemiplegia and global aphasia. During the emergency department evaluation, she developed respiratory distress and was intubated. A middle cerebral artery clot was found on angiogram but a mechanical embolectomy to remove it was unsuccessful and the patient remained obtunded, unresponsive to verbal stimuli, with no spontaneous movement of the right upper and lower extremity. The patient's son, who was her durable power of attorney for health care, remained hopeful for some recovery and wanted to proceed 10 days later with tracheostomy and gastrostomy tube placement. Two months after admission, her clinical status had not improved and she was transferred to a long-term care facility for ventilator-dependent patients.

For this patient, it was the best and worst of times. She had access to a remarkable array of medical services that might have been helpful, but were not. For her, it was the age of hopelessness. Because of her son's decisions, she was maintained in a state that most would not want.^{1 - 2}

The second patient was an 81-year-old homeless woman with Parkinson disease who presented with a urinary tract infection. She had recently been discharged to a shelter after a prior urinary tract infection. On several previous occasions and now, her medical needs had met criteria for postacute rehabilitation but she had exhausted her 100 days of coverage under Medicare and would again need to be discharged to a shelter.

In medicine there are 3 do’s: the can do, the actually do, and the should do. The can do reflects what is possible and is driven by science and technology. The can do has no bounds; more is always better. Innovations that treat disease are desirable and the government (eg, through the National Institutes of Health), foundations, and the private sector promote advancement of the can do. During the past 30 years, the can do has increased substantially and will continue to do so. Procedures and devices such as thrombectomies, intracardiac defibrillators, and stents for a variety of vessels were science fiction in the 1970s. Now they are commonplace and more are on the way.

In contrast, what is actually done for patients is driven by clinicians and patients and is determined by availability of services, access to these services, insurance, practice patterns, and patient and clinician choices. Like the can do, the actually do has also increased over the last 3 decades. Discrepancies between what is possible and what is actually done result from underuse (failing to provide recommended care)^{3 - 4} or appropriate use (the should do). However, these discrepancies are not as large as they should be. The care that is actually provided also includes the provision of inappropriate health care that does not benefit patients (eg, unnecessary tests and procedures). Overuse is waste, which by some estimates is responsible for up to 30% of the health care spending.⁵ On the whole, the scorecard for the care actually provided is not impressive. Health care in the United States is characterized by high expenditures, poor performance on quality measures, and poor health status compared with other countries.⁶

The should do is determined by medical evidence with modification by personal, societal, and ethical values. For the first patient, the physicians believed that the should do was to provide comfort care during terminal illness and attempted to convey this to the patient's son without success. Situations such as this are common in practice and often lead to countless hours of discussion and sometimes animosity between patients' families and physicians. To date, there has been little investment in promoting the should do. At both individual patient care and policy levels, conversations and action are exceptionally difficult and the potential for public backlash (eg, fear of death panels) is high.

In the future, the discrepancy between the actually do and the should do will likely increase, wasting scarce resources and violating the principle of distributive justice (resources should be spent to provide the most good for the most people). The cost of a bed in the intensive care unit for 1 week for the first patient would more than pay for health insurance for a family of 4 for an entire year.

In his classic 1968 essay “The Tragedy of the Commons,” Hardin presented the dilemma of situations for which there is no technical solution.⁷ Hardin used the example of cattle overpopulating a pasture, which benefits the individual herdsman who reaps the benefit of the sale of an additional cow but punishes all herdsmen by a small amount because of overgrazing. He argues that to resolve such issues, the only approach is to change human values or ideas of morality. In 21st-century medicine, it is naive to appeal to the conscience of a physician or patient to make such difficult decisions. Physicians are much more comfortable deploying resources to promote the health of individual patients than to steward resources so they can be distributed for the greatest good. The only solution, argues Hardin, is mutual (agreed upon by the majority of those affected) coercion,⁷ which in health care includes rationing.

In the case of the second patient, the Centers for Medicare & Medicare Services has placed a finite limit on the skilled nursing facility benefit of 100 days per episode. This restriction is known to every hospital discharge planner and is accepted as a rule of the Medicare Part A benefit. Yet it is a clear example of rationing that has slipped into the Medicare regulations without public outcry. When this benefit is exhausted, patients and families must assume responsibility for the next step, which is usually either going home or transitioning to custodial care.

The influence of insurance coverage on behavior stems from the principle of moral hazard. According to this principle, individuals with insurance may take greater risks than they would without insurance because they know they are protected.⁸ Conversely, moral hazard can result in underinsured or uninsured individuals avoiding preventive measures and not seeking needed medical attention because these are out-of-pocket costs.⁹ However, at the other end of the spectrum, when patients are consuming high–health care resources with minimal hope of benefit, attenuating moral hazard by setting limits on coverage can help promote the larger perspective and promote the should do. Little value was gained from the large amount of money spent on the care of the first patient, whereas the second patient might have benefited greatly from a much smaller amount devoted to a better long-term care benefit.

With the aging of the population and the proliferation of the can do, the increase in future health care capabilities and costs is an impending tragedy of the commons. The most important challenge for 21st-century medicine is not to expand the can do. Rather, it is to bring the care that is actually provided into line with the should do. Failure to do so will result in a health care system that certainly will be fiscally, if not morally, bankrupt.