Ethical Wounds Haven’t Healed

Baby Ryan went home last week, but neither his future nor the ethical dilemmas he posed are settled.

Uncertainties remain about whether he will live, what kind of life he will enjoy, and at what costs. Neither medicine nor public policy know how to address those uncertainties.

We can’t just muddle on, assuming that whatever medical technology might do, it must do, regardless of cost. Nor can we treat medicine as a simple science in which the right course of action is clear and the wrong course of action is grounds for a lawsuit. Doctors differ.

You’ve heard the story: When Ryan Nguyen was born Oct. 27 at Sacred Heart Medical Center, a hospital long respected for quality of care and charity toward those who can’t afford it, doctors doubted he would live. Specialists at other hospitals agreed. Ryan’s parents rejected the prognosis and sued to demand continued care. The resulting publicity provoked an offer from a Portland hospital to treat Ryan. Even now, Ryan’s life depends on tube feeding; his shortened intestines don’t work and doctors aren’t sure if they will. There are questions about brain damage.

But there is no question this has been costly. Ryan spent the first six weeks of his life at Sacred Heart, where the bills exceeded $180,000. The hospital bill for the next two months, and the medical bills yet to come, remain to be calculated.

Taxpayers will pay the bills, whatever they are. Ryan’s parents are unemployed. Medicaid, however, pays hospitals at roughly 70 cents on the dollar. Hospitals shift some of the balance onto other consumers in the form of inflated fees, which eventually translate into higher insurance premiums.

Suppose the Nguyens had been employed and insured. Instead of taxpayers, fellow customers of their health insurance company would have paid the bills. But insurance companies, whose cut-off points vary, won’t always cover care that seems futile or lies at technology’s outer limits. This means an insured family can wind up begging, holding bake sales, consulting lawyers.

This is not an equitable, rational, affordable or ethically defensible system. If resources are limited, and they are, at what point should the funds and talent invested in saving one life be spent instead on saving 200 more viable lives, or on preventing disease completely among 2,000?

At hospitals, insurance companies and government agencies, ethicists are drafting guidelines to answer these terrible questions. Guidelines are needed. Next, we’ll need the courage to apply them.

The following fields overflowed: CREDIT = John Webster/For the editorial board