The Sad Case of Nataline Sarkisyan Continues

Almost a year ago, in the context of the New Hampshire primary, I criticised John Edwards for politicizing the death of seventeen year old Nataline Sarkisyan, who experienced liver failure after a bone marrow transplant for leukemia, and whose insurer refused to cover liver transplantation. Here are the concluding paragraphs from that post:

Every health system has to set limits. This would be true even if Mother Theresa were the health czar. It is entirely reasonable to question the evidence basis for UCLA’s proposal or Cigna’s denial. Similarly, it is entirely reasonable to argue that the bar for evidence should be lower in last chance situations than in other domains of care. But Edwards, who I admire and largely agree with politically, does the public a disservice by presenting the denial as a moral crime.

Edwards favors extending Medicare to a wider range of citizens. If he ends up as president, it will be interesting to see how he addresses the issue of limits. As Oregon Governor John Kitzhaber recognized 20 years ago, universal coverage is impossible without limits. No limits, no universality. It is that simple.

True leaders must be educators. Understanding the ethical necessity for limits is counter-intuitive for those who are not familiar with the health sector. Edwards may have done an effective piece of campaigning yesterday, but he was not providing the kind of ethical leadership that improvement of our health system requires.

This is especially unfortunate. Edwards is a superb communicator -- just the kind of voice we need to help us come to grips with the sad fact that health care limits, well set, are an ethical necessity, not a moral abomination.

This morning the Associated Press reported that the Sarkisyan's attorney, Mark Garagos, is suing Cigna:

Insurer Is Sued Over Liver Transplant

The family of a 17-year-old leukemia patient has sued the health insurance giant Cigna over her death in 2007 after the company initially refused to pay for a liver transplant.

The lawsuit, filed last week in Los Angeles County Superior Court by the family’s lawyer, Mark Geragos, accuses the company of breach of contract, unfair business practices and intentional infliction of emotional distress. It accuses Cigna of delaying and rejecting valid claims, which resulted in the wrongful death of the girl, Nataline Sarkisyan.

The insurer, based in Philadelphia, eventually approved the transplant after Nataline’s family held a rally outside its office in suburban Los Angeles. Nataline, however, died hours after the approval was secured.

Chris Curran, a spokesman for Cigna, said the company felt that the lawsuit was without merit. Mr. Curran said the company had volunteered to pay for the procedure out of its own pocket.

Mortality is sad, but the death of a seventeen year old is tragic. For any health system, deciding about coverage in a situation like that of Nataline Sarkisyan, is the most difficult challenge imaginable. While I have no expertise on liver transplantation for patients with leukemia, my impression is that a strong case can be made that not covering the transplant was a fair and justifiable decision. If the case comes to trial that's what the jury will be asked to decide. And if the verdict is appealed the Appellate Court(s) will have to address the issue the U.S. has tried so hard to avoid - rationing.