Should a 97-year-old man undergo an expensive, dangerous open-heart operation to repair a lethal tear in a main artery of his heart?
No, concluded the patient, Michael DeBakey, the world-famous cardiovascular surgeon who pioneered the operation. Yes, said his family and surgeons, who prevailed after DeBakey lapsed into coma.
DeBakey later said they did the right thing. After a long, touch-and-go recovery, he resumed a busy schedule before his death last July at age 99.
DeBakey was a visionary, a genius, but his dilemma has become increasingly ordinary. Age is no longer the deciding factor, even for invasive treatment such as open-heart surgery.
"You have to get out of the idea that there's a threshold age where we think about this surgery differently," Charles Bridges, Pennsylvania Hospital's chief of cardiothoracic surgery, said. "With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don't?"
A more basic question is whether this never-too-old approach is an example of U.S. medical progress, or an example of why Medicare - federal health insurance for people over 64 - is headed for insolvency.
The answer, experts say, is both. Which is why the current debate over expanding federal coverage to all uninsured Americans is an ethical and economic minefield.
"Forty years ago, it was taken for granted that the elderly were not good candidates for organ transplantation, dialysis, or advanced surgical procedures. That has changed," Daniel Callahan, cofounder of the Hastings Center, a bioethics research institute in Garrison, N.Y., wrote recently. "Under the best of circumstances, age should be irrelevant in the Medicare program. But so far, the cost of care has not been considered, and it can hardly remain irrelevant in a program strapped for money."
Americans 85 and older are a small but exponentially growing bunch, according to census data. Fifteen years ago, there were 3.4 million. Now, there are six million. By 2050, baby boomers will swell the number to 20 million - 5 percent of the U.S. population - including one million centenarians.
Life expectancy at such old ages is relatively short, emphasis on "relatively."
"It's not as short as you might think," Bridges said. "If you're 81 and a woman, your life expectancy is about eight or nine years. At 90, it could be five or six years."
Last fall, when 87-year-old Ruth Fritz of Harleysville consulted Bridges, her outlook was more like a year. Her aortic valve had become rigid and immobile, hampering blood flow through the artery that supplies most of the body's major organs. Despite overall good health, her heart was failing.
"I knew it was either a case of going through the surgery and surviving, or just going on trying to live, never knowing when my heart would give out," the petite widow said last month, immaculately turned out in a kelly green blouse and navy skirt.
For Bridges, Fritz's age posed less of a challenge than did her religious convictions. As a Jehovah's Witness, she said she would rather die than be given a blood transfusion - even though half of open-heart patients require one.
Bridges minimized blood loss with a variety of techniques, including a miniature heart-lung bypass machine and meticulous cauterization of even tiny blood vessels.
Now, five months later, Fritz goes to a senior center three days a week and says her quality of life is excellent. No matter that she relies on a walker, can't yet climb stairs, and is living with her daughter instead of in her own home.
"I'm still in physical therapy and will be for a while," Fritz said. "But I'd tell anyone that they should go ahead and have the surgery."
Tough to gauge costs
Over the last decade in the greater Philadelphia area, nearly 1,800 people 85 and older have had their chests cut open to repair or replace cardiac valves or vessels, or both, according to hospital discharge data.
The precise costs are hard to say. In this region, Medicare pays an average of $40,000 to $60,000, depending on the open-heart procedure, but many elderly suffer complications that can inflate the total. DeBakey's care, for example, reportedly cost more than $1 million.
The risks of open-heart surgery, while still substantial, have steadily declined.
Consider that in 1988, University of Pennsylvania researchers published what was then the largest series of open-heart surgeries on the oldest patients in medical history. Not one of those 100 patients was over 89. Yet 29 of them - almost a third - died within three months.
Fast-forward to 2003, when Bridges led an analysis of a national database of open-heart procedures, including almost 60,000 octogenarians, 1,092 nonagenarians, and five centenarians. Surgery-related mortality had fallen to 12 percent - and that was for the oldest old, those in their 90s and 100s.
For octogenarians, mortality ranged from 7 percent to 11 percent, depending on the procedure.
"Surgery has gotten better," noted Sharon Kaufman, a medical anthropologist at the University of California, San Francisco. "Even old people who are frail and have chronic conditions can withstand surgery better than ever."
The odds of death for those 80 and over are two to three times greater than for patients ages 50 to 79, Bridges' study found. But again, it's relative.
"If you have a 20 percent chance of dying, that means you have an 80 percent chance of surviving," Bridges said. "And without surgery, there might be an 80 percent chance of death."
Complicating this calculus is the issue of quality of life. Even with advances, surgery and its aftermath are traumatic, especially for elderly with chronic conditions such as diabetes or kidney failure.
"A lot of patients spend months in the hospital, in pain and suffering, and then they die anyway," said Muriel Glick, a physician specializing in geriatrics at Harvard University. She advocates better nursing-home and hospice care rather than "using ever more technology to try to eke out a little more life."
Callahan, the bioethicist, added: "I believe it's gotten harder for doctors to find a bright line between living and dying. Physicians feel compelled to offer heroic measures. They say, 'Let's not give up hope.' "
Limits on care, access
That attitude may be uniquely American. In Western countries with government-sponsored health care, both the amount of care and access to it are limited.
Alan Maynard, a health-economics professor at England's University of York, wryly contrasted American and British perspectives in a 2005 article in the journal Health Affairs.
"Dying is an un-American activity!" he wrote. "This accounts in part for Americans' spending twice as much per capita on health care as the British do. The British reluctantly accept two facts of life. First, they are all suffering from a terminal, sexually transmitted disease called life. Second, with death inevitable and resources finite, health-care rationing is inevitable."
Last month, the latest report on Medicare projected it would run out of money in about seven years.
"The trend is negative and not very encouraging," said Olivia Mitchell, an expert on insurance and risk management at Penn's Wharton School.
She noted that the cost of the program had long been rising faster than the cost of living. What's more, she said, about $88 billion - 27 percent of Medicare's annual budget - is spent on care in the last year of life.
"I suspect there will have to be some form of rationing," she said. "The question is whether age is the only - or even one of many - factors that should be used."
Callahan has been answering that question affirmatively since 1987, when he published a book titled Setting Limits: Medical Goals in an Aging Society. He's been calling for age-related rationing for so long, in fact, that he has reached the age at which he would qualify for a dose of his own medicine.
"In 1987, people said: 'We'll see what you say when you're old.' Well, I'll be 79 . . . and I'm saying the same thing," Callahan laughed.
A philosopher by training, Callahan holds the view that, by age 80, a person has had the chance for an education, a family, a career, travel - a "full life."
"Death after that is sad, but it's not an inherent tragedy. If I die now, no one will say: 'Oh, my God, the lost possibilities! He only wrote 14 books.' "
Even so, Callahan hesitated when asked what he would do if he developed, say, cancer and needed major surgery.
"I find it hard to answer that question," said the former smoker, who has mild emphysema. "I hope I wouldn't push it too far. I'd prefer a situation where surgery is not available anyway."