Let’s get normative! Octogenarians and heart surgery

Healthy octogenarians are apparently good candidates for heart surgery. Now I can’t say that this surprises me. Those who take care of themselves and have good genes are experiencing longer and longer lifespans. This is basically true even in developing nations — if not to the degree that it is in developed countries. We have record numbers of people living beyond the age of 100. From a human perspective, this is an amazing achievement. But from a pessimistic, Malthusian point of view, death is useful.

Patients 80 years and older who are in overall good health are perfectly able to withstand open-heart surgery, according to the latest study of Dr. Kevin Lachapelle of the McGill University Health Centre (MUHC). His findings were presented this morning in Toronto during the 2008 Canadian Cardiovascular Congress.

“Age should not be a reason for doctors to rule out the possibility of heart surgery for their octogenarian patients,” explained Dr. Lachapelle. “If patients with heart problems are otherwise in good health, this surgery can significantly improve their quality of life.”

Well that’s fantastic. (It really is, I’m not being sarcastic.)

Economics is fundamentally the study of the allocation of scarce resources subject to effectively infinite demand, and while we like to think that healthcare is an infinite good, it most certainly is not. Specifically, normative economics is the process of incorporating value judgments into economic arguments. Most economists avoid making value judgments because there are always exceptional cases, and because it often leads to spectacular foot-in-mouth syndrome. That said, I can’t help but have thoughts that tend toward the normative when I read paragraphs like the one I quoted.

Sure, octogenarians may survive and even have a net positive outcome. But what are the opportunity costs associated with operating on individuals who have already exceeded the mean lifespan for someone of their sex? Are we operating on these folks while leaving those that are younger — and therefore potentially more productive — in the lurch? Are we forgoing an operation on someone much younger? How does the fact that the average 80 year old is not as productive as the average 40 year old factor into this equation? Generally taxpayers want something in return for their investment. Do we want the government subsidizing a procedure on someone whose primary income is their monthly Social Security check, and if the answer is yes, how do we prioritize who goes first? How do we manage that inevitable wait list? Generally we subsidize healthcare because we expect some kind of benefit in return, usually in the form of economic output.

I’ve worded my questions provocatively, but I don’t really have an opinion one way or the other, except to say that I’m glad that I won’t be the one who has to make these decisions in the coming years. These questions aren’t purely rhetorical either: these are very real, difficult questions that are going to have to be addressed as we move inexorably toward some kind of basic universal health coverage in the United States.

As I pointed out yesterday, Americans don’t like to be told “No,” and we don’t like to wait for things, and I mostly include myself in that generalization. If we postpone, or worse, opt to forgo very costly surgeries on the elderly because a cost-benefit analysis doesn’t add up, will our culture be able to accept it?

My guess is no, and as soon as it happens, there will be some very ugly public political lynchings.

What are your thoughts?

3 thoughts on “Let’s get normative! Octogenarians and heart surgery

  1. I would have to say that ‘yes’, I don’t like that question. Defining ‘productivity’ in our elderly ‘living treasures’ may not result in increased (economic) GNP, but if the quality of life can be maintained, then the benefits of expending required effort, and way of valuing our elders may have to measured in other ways than in tangible and measurable work output. Gerontologists and healthcare economists may be developing different cost-benefit analysis algorithms in the future. I don’t really know.

    Maybe this is commentary on the dearth of workers in the aging population, due to decreased childbearing and what those one-issue voters would decry as the scourge of an abortion-happy society?

    I know that there are pockets of societies throughout the world in which average lifespan is quite high compared to others. I can imagine that in order to live that long and so well, that the octagenarians live a rigorous and vigorous lifestyle. Now, in opposite circumstances with elderly in poverty-stricken nursing home ‘farms’ (deliberately provocative scenario) whether someone can say that there’s a quality of life in ‘artificially’ maintaining lifespan of living tissue may be a different matter.

    I went to a regional symposium on arrhythmias and HF earlier this month. In an open forum, a panel of cardiothoracic surgeons were asked what the age of the eldest patients they performed open heart surgeries. I recall answers generally were in 90’s. It seemed that if the patients were well enough to reach that age and still be able to tell the doc to go ahead and do it, and chance for full and complete recovery was technically good, the docs felt compelled to go for it.

  2. Heart disease is preventable (and so is afib, and thus coumadin therapy as well). If silent inflammation is controlled, then many chronic disease states can be controlled without medications (or at least much less — don’t worry — us rph will still have jobs).

    I think Americans will always expect ‘heroic’ measures for non-heroic diseases. How do we add quality to our years? And not just numerical meaningless years…??? I certainly don’t want to retire from pharmacy and have degraded movement/hearing/vision/sight/etc whilst injecting insulin, popping coumadin and ‘limiting’ my greens, despite all the fancy pharmacogenetic testing…which will probably be administered by new graduating classes of pharmacists — betw MTM, counseling, filling and 15-min lunch breaks (I’m being sarcastic *ha*).


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