In the year since Healthy Debate published Fewer hospital staff on weekends put some patients at risk, evidence of a “weekend effect” at hospitals has continued to mount. Today, the Canadian Institute of Health Information released a new report which further reinforces that for some patients admitted to hospital on the weekend, there is a small but real increase in their risk of death. The question is, as evidence for the weekend effect accumulates, will we actually do anything about it?
While there can be very little doubt at this point that the weekend effect is real, there is still a lot we don’t know about it. For example, we don’t know with certainty what causes it: it may be due in part to a larger proportion of sicker patients being admitted on weekends (personally, I think this is unlikely since a UK study found the same effect among patients undergoing elective surgery). Or it may be due to lower staffing levels or less experienced personnel working on weekends as compared to weekdays. But most importantly, we don’t know how to stop it. More staff on the weekends might be the answer, but for all we know, increasing staffing levels on the weekend could increase staff fatigue during the rest of the week, which carries its own risks.
Given the renewed interest in the weekend effect, I suspect new research will eventually fill in many of these gaps in our knowledge. However, there’s one question about the weekend effect that can’t be answered through observational studies or randomized control trials – a question that’s traditionally been the domain of philosophers: what is the value of a life?
Why should we think about that question? Because the risk posed by the weekend effect is very small. There are roughly 75,000 in-hospital deaths in Canada’s nearly 700 hospitals each year. According to CIHI’s data, the weekend effect is responsible for only 400 these. If the best way to address the weekend effect turns out to be by increasing hospital staffing levels on the weekends, the cost to the system would be considerable. How much are we willing to spend and what sacrifices are we willing to make to save those 400 lives?
Questions like these are difficult to answer, but this one is especially hard because we are not very good at thinking through abstract ethical problems – we react powerfully to harm caused to people in front of us but we often can’t find the same connection to people outside of our field of view. I think any of us would go to enormous lengths – even risk our own lives – to save a drowning child in front of us, but most of us can’t muster the same passion about 400 people we will probably never meet. But, objectively, a life is no more valuable just because it happens to be known to us. Taking the ethical problem posed by the weekend effect seriously means overcoming this bias we all have to undervalue abstract lives.
So how much do you value a life? And by extension, how much would it be reasonable for our health care system to spend to eliminate the weekend effect? At what point would the money spent on the weekend effect be better spent on some other intervention elsewhere in the health care system (or outside of the health care system)?
While philosophers have generally avoided assigning dollar values to individual lives, economists have not been so squeamish. Indeed, the quality adjusted life year has become a staple health technology assessment, and the value of a statistical life has become common in environmental protection. Economists don’t agree on how the dollar value of life should be determined, but estimates range anywhere from a relative low of $50,000 per year of life in perfect health, to a relative high of $9.1 million for a life.
Let’s imagine for a moment that eliminating the weekend effect completely would provide those 400 people with an average of 10 more years of life. Let’s further imagine that these individuals make a complete recovery, so that these additional ten years are spent in nearly perfect health. And for the sake of argument, let’s set the value of a quality adjusted life year at an arbitrary $100,000. This all adds up to $400 million. Do we value those lives that much? If not, how much do we value them? Would we willing to pay more tax to save these lives, or would we increase staffing on weekends at the cost of depriving educational or other social programs of much needed resources? Until we confront these uncomfortable ethical questions, I don’t think we can make an well informed decision about what to do (or not do) about the weekend effect.
We know the weekend effect is real. The question is whether we should do anything about it. It’s not an easy question, but it’s not one we should avoid forever.