An impoverished 69-year-old man is diagnosed with cancer of the pancreas. There is no hope for cure, but radiation and chemotherapy, which could cost more than $150,000, may extend his life for a few months. If this patient unambiguously requests treatment, his doctors may struggle with the decision but will probably provide the treatment, ignoring the cost as a matter of principle.
On the other hand, a health department — or a hospital — proposes an action that would prevent many cases of some forms of pancreatic cancer. It could be offering free education on the effects of alcohol on the pancreas.
In both instances, health experts must make tough decisions that entail weighing the costs of an action against its benefits in extending human life. Why is the value of extending human life the determining factor in the first example and the cost of the intervention the determining factor in the second? These two scenarios expose tangled issues of ethics, cost, and cost-effectiveness and highlight a troubling structural bias against prevention.
Many people reject any attempt to put a dollar value on human life. From such a perspective, any withholding of potentially life-extending interventions on the basis of their costs is unethical. But within every organization and throughout society, limits on funding make it impossible to pay for every conceivable intervention. That reality forces health leaders to make painful decisions about what to pay for.
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