Resuscitating Health Care

I am a second year student at UCSF Medical School. Health care policy and reform fits into the fringe of our basic science curriculum, which focuses on clinical diagnosis and patient care. My classmates and I are about to graduate from the basic science part of our curriculum and move into the clinical years of our education.

As we progressed through various organ systems over the past year and a half, I imagined myself in various roles as a physician; could I see myself practicing as a gastroenterologist? Neurologist? Cancer surgeon? Infectious disease specialist?

Our current course is called, “Lifecycle,” and has covered principles of reproduction, embryology, pediatrics, childhood development, and geriatrics. I have again been moved to think about myself in various practice settings. In recent exercises, about a dozen classmates and I have discussed neonatal emergencies and even simulated the resuscitation of a high-risk infant. We discussed the trajectory of a fetus born with a hole in the septae of the heart and instances in which the fetus is deprived of oxygen and sustains brain damage early in life or even in utero.

We discussed the ethical implications of the cases. Less than 25% of neonates born at 24 weeks survive without brain damage. Hospitals vary in their willingness to resuscitate neonates born between weeks 23-26 of gestation. Who makes the decision about resuscitation? Who represents the fetus? What happens if the parents disagree among themselves or with the doctor?

I threw in the question, how much does it cost? No one really talks about that. According to our discussion leader, one of the chief residents in pediatrics at UCSF, a day in the neonatal ICU can easily run between $20,000 and $30,000. As I understood it, sick babies can walk out of the hospital with million dollar bills, with no improved prognosis, and with the likelihood of returning for more costly care in the early years of life.

We talk about the ethics of neonatal resuscitation and who gets to make tough decisions, but what about the ethics of cost? The burden of cost on the hospital and society is not trivial. Most families wouldn’t have the resources to cover such a hospital bill, so either a government program or private insurance would end up paying.

The government, as we know, is broke. And health care spending is helping break it. National health spending totaled 17.3% of the national economy last year. Health spending share of the GDP increased 1.1% last year, which was the greatest increase since 1960. It is estimated that by 2019, health care spending will make up a full fifth of the national economy.

Could resuscitating preterm babies be responsible for underfunded education? Deteriorating infrastructure? Cuts in other social programs? If the parents of the child could pay the bill in full, then by all means, they can decide how to spend their money. But it the government is paying, shouldn’t there be some ethical consideration of the other beneficiaries (stake-holders?) of its service?