DEATH IN WINNIPEG:
How Medicare Makes Villains out of the Sawatzkys,
their Doctors, and Us

It seems hard not to sympathize with Helene Sawatzky and her husband Andrew. Mrs. Sawatzky had to go to court to force Winnipeg’s Riverview Health Centre to remove a “Do Not Resuscitate” order from the chart of her 79-year-old husband. Mr. Sawatzky suffers from dementia, Parkinson’s disease, has had a series of strokes, has contracted pneumonia, has difficulty swallowing, cannot talk, and breathes through a tracheal tube. As it stands now, the Manitoba Queen’s Bench ruling obligates Riverview to perform cardiopulmonary resuscitation (CPR) on Mr. Sawatzky if he lapses into cardiac arrest, at least until independent medical opinions are sought by Mrs. Sawatzky, Riverview, and the Manitoba Public Trustee in an attempt to reach mutual agreement on Mr. Sawatzky’s status.

Yet many do not sympathize. “I am amazed at the irrationality of the Sawatsky [sic] family,” wrote Dr. Gordon G. Aitken in the Nov. 11 Globe and Mail. “Were the profession to follow such a futile course ... within a month every ICU in Canada would be converted to a charnel-house.” According to Charles Wright of Vancouver Hospital (in the same day’s letters): “It is not ethical for a physician to prescribe a course of action for a patient that is both useless and harmful,” which he expects CPR to be for Mr. Sawatzky. Notes Adam Plackett in the Globe’s Nov. 24 letters: “No wonder it is difficult to control [health care] spending when consumers such as Mrs. Andrew Sawatzky ... insist on keeping their husbands alive at all costs and against all odds.”

Who should decide Mr. Sawatzky’s fate? The ethicists have weighed in, naturally. Dalhousie University’s Charles Weijer declares that Riverview is “riding roughshod over the religious beliefs, and the religious rights, of families and patients”; the Sawatzkys are Jehovah’s Witnesses. On the other hand, the University of Manitoba’s Arthur Schafer cautions that the Sawatzky case is about “perhaps unrealistic expectations that some families may have that there is a modern technological miracle that can restore someone who is at the end stage of a chronic mortal disease.” In the face of such public vehemence, private anguish, and ethical impasse, where does one turn? The suggestion here is economic analysis, a powerful and humane ethical solvent.

The economics of death

While the certainty of death is axiomatic, its timing is not completely so. How long we live is, to some extent, the product of our individual choices. Does one eat fat, drink gin, drive fast? Such choices do not precisely determine age of death, but they affect whether it’s sooner or later. As eminent University of Chicago economist Gary Becker expressed it, “According to the economic approach ... most (if not all!) deaths are to some extent ‘suicides’ in the sense that they could have been postponed if more resources had been invested in prolonging life.” Medical advances and jurisprudential expansions have forced us to confront this choice in a more focused and profound sense.

Should the law influence whether one chooses to live or die? The simplest economic analysis would say no: all costs and benefits from living reside in the individual, so any interference by the state distorts her decision-making. The realities of the Sawatzky case and the Canadian medical system modify this conclusion, however. Two major complications are the issues of competence and existing government intervention.

In order for an individual to choose in his own best interest, he must be able to weigh his expected benefits and costs accurately. Typically, economists and judges presume that individuals are competent to do so. Is Andrew Sawatzky? According to Justice Beard, author of the Manitoba opinion requiring CPR, he is “a patient who may not be able to understand fully his condition,” and Riverview’s affidavit attested that “Mr. Sawatzky is able to convey his wishes only on a very inconsistent basis, and most through nonverbal signals, and only for very basic needs.” Mrs. Sawatzky naturally disagrees.

Apparently Mr. Sawatzky did not provide an advance directive (‘living will’) as to his wishes regarding resuscitation. Because of his dementia, he is not legally allowed to stipulate his wishes, even if he could speak. In a prior Manitoba case it was ruled that consent by family members is not required if “the patient is in an irreversible vegetative state,” although Manitoba College of Physicians and Surgeons registrar Ken Brown notes that, “Regardless of the competency of the patient, discussion with the family, and hopefully their consent, should clearly be sought.” Furthermore, according to Brown, “If the patient is competent, the patient’s wishes prevail.” If we surmise that Mr. Sawatzky is no longer competent, then the legal right to withhold or provide resuscitation appears to reside with the hospital.

Is this assignment of consent socially desirable? In a world without health insurance, the answer is yes. In such a world, medical care is purchased just like any other good, in that consumers pay the full cost of that care and, thus, only purchase care when its value to them exceeds its cost. In such a world, if the hospital held the right to whether Mr. Sawatzky would be resuscitated, and Mrs. Sawatzky wanted him kept alive regardless, she would willingly pay for resuscitation and his continued long-term care. The hospital would get what it wants—reimbursement—and Mrs. Sawatzky would get what she wants. (Whether this would mean that Mr. Sawatzky gets what he wants is another question for another day.)

In the real world where there is health insurance, what Mrs. Sawatzky wants unfortunately may conflict with the desires of the other members of the insurance plan. Insurance creates this conflict because it allows the insured to pay less than the full cost of whatever treatment they receive. Therefore, treatment which is worth $1000 to the patient will be chosen if the cost to the patient after insurance coverage is less than $1000. In some cases, although the after-insurance cost to the patient is less than the cost to the plan, and treatment is chosen, the benefit to the patient is less than the cost to the plan. In the example of the treatment with the $1000 benefit, suppose that insurance only requires the patient to pay 20 percent of the cost to the plan of, say, $2000. Twenty percent of $2000 is $400, so the patient gladly chooses the treatment, even though its cost to the plan ($2000) is greater than its benefit to the insured ($1000). This negative consequence of insurance, what economists refer to as moral hazard, is counterbalanced by the benefit of insurance—risk-reduction. Indeed, in a private insurance market, premiums and co-insurance rates are set by insurance firms so as to balance these social costs and benefits efficiently.

When the government is the insurer, however, it may not get this cost-benefit calculation right. In particular, the “accessibility” provision of the Canada Health Act means that for covered care, the share paid by the patient is not 20 percent, but 0 percent. With such generous insurance, it is undoubtedly true that the cost of moral hazard outweighs the benefit of risk-reduction under Medicare. For Mrs. Sawatzky, it means that she need not consider any of the direct cost to Medicare in determining whether to order resuscitation for Mr. Sawatzky. Under the circumstances, the only way for the cost of Mr. Sawatzky’s care to be accounted for is to entrust the resuscitation decision to the hospital, which bears 100 percent of the costs. Will the hospital also take full account of the benefits to Mr. Sawatzky? If so, it should be making the decision. If not, perhaps Mrs. Sawatzky should be, although the question again arises of whether she is acting in his best interests.

Some might cringe at the seemingly heartless realization that only the hospital takes full account of Mr. Sawatzky’s costs, and might thus be the proper decision-maker. This realization is not, however, cruel, but humane. Given the limited budget allotted to hospitals like Riverview, each additional $1000 they spend on Mr. Sawatzky is $1000 they cannot spend on another far younger critical patient who might dream of living to be 79 like Mr. Sawatzky, but only with treatment. The point is that Medicare is encouraging Mrs. Sawatzky to do what at least some of us would do in her shoes, and is thus making her a villain. But it also makes the hospital’s doctors the villain, because they have to decide when and for whom to cease resuscitation, a role played by an HMO south of the border. But, finally, it makes villains out of all Canadian residents, metaphorical Siamese twins sharing the same collective medical system, who feel guilty criticizing Mrs. Sawatzky, but feel anguished if our own loved ones get less care if we do not. “Do not resuscitate” is perhaps an order best written for Medicare.

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Last Modified: Wednesday, October 20, 1999.