Average life expectancy is one of two statistics commonly used to compare the health-care systems of different nations. (The other is infant mortality.)

One of the puzzles about the U.S. system is that we spend far and away the most money per capita for health care, but we rank 50th in average life expectancy ― after Macau, Malta, and Turks and Caicos, among others.

We are all familiar with statistics about how much of health-care spending takes place in the last year of life, and with stories about old people who are tortured with costly treatments they don’t want and which prolong dying but don’t extend life in any meaningful sense. (Michael Wolff’s confessionary tale about his mother in New York magazine is a vivid example.)

Certainly, ailing old people should be allowed to die in peace, if that’s what they want, and not be subject to excruciatingly painful surgeries and drugs that will do nothing for them. These are more the fault of lawyers than doctors. In our experience, doctors can be all too cool and rational in their thinking about the end of life. It’s fear of lawsuits (or, in a few cases, trolling for customers) that prevents doctors from behaving rationally when prescribing treatment for the old and terminally ill.

But not providing treatment to people who don’t want it won’t save enough money to rescue the U.S. health-care system. Nor will eliminating new and expensive pills, and other therapies, that do no good at all or are no better than existing therapies.

So what do we do about old people who, on balance, would rather get even older ― whatever that means in terms of “quality of life” ― than give up? This is one of the indelicate, unmentionable questions in the health-care debate.

The slope here is slippery indeed. You start by obeying the wishes of someone with at best two months to live, who wants to trade them in for one month with no pain and no intrusive treatments. Next you’re assuming that this is what someone who had expressed no preference (and is now demented or sedated) would have wanted. Then you are subtly, or not so subtly, pressuring her, or her children, to get with the program. Or you are even enacting regulations that deny Medicare reimbursement for treatments that don’t meet some criterion of benefit.

In short, all the Republican talk during the health-care- reform debate about “death panels” was melodramatic and unfair, but not ridiculous. One way or another, holding down health-care costs will require policies that deny treatment to people who want it. And want it because it will extend their lives.

This goes on already, all the time. Health insurance companies have been known to deny payment for treatments deemed unnecessary. Age limits for organ transplants are another example. All policies that involve denying care because of “quality of life” considerations are, in effect, “death panels.” But no society can afford to give every citizen every possible therapy. Medicare is going broke trying.

How do other countries manage to give their citizens longer life expectancies than the U.S., at a lower cost? One way or another, they spend less on the dying and more on the living.

A $200,000 operation can add a year or two to the life of an octogenarian, or it can save decades of life for younger people. In a country like the U.S., with an average life expectancy of 78.5, it takes 10 septuagenarians who get an extra five years from the health-care system to balance a single 30-year-old who gets 50 extra years. Or save the life of a newborn, who then enjoys a normal life span and dies at 78.5, and you have the same impact on national life expectancy as 16 operations on septuagenarians. The average national life expectancy can increase even as the cost goes down.

How do you persuade fellow citizens to accept limits on their right to consume health-care resources? The trick, we think, is to ask them when they’re healthy, not when they’re sick. If you think a $200,000 operation is going to give you a few more years to live, it’s going to be hard to convince you that it’s not worth the cost. But before then, when your odds of needing that expensive operation are the same as everybody else’s, you might well choose a system that offers a higher life expectancy, even though it costs less. In fact, why wouldn’t you?

(Bloomberg)