For America's aged, surgery at any price?

PHILADELPHIA — 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, co-founder 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 6 million. By 2050, baby boomers will swell the number to 20 million — 5 percent of the U.S. population — including 1 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."