WHEN IS A DRUG A LIFE SAVER?

You have to say that the drug companies asked for it. I mean really
asked for it.

Remember when Viagra first came on the market? The spokesman was Bob
Dole, veteran, Senate leader and prostate cancer survivor who urged
other men to talk to their doctors about erectile dysfunction. The
slogan was: Courage.

Fast forward through the millennium. The spokesman now is a hunky
40-something guy with a 2-day-old beard and a slogan that says: "Keep
that spark alive."

The message today is less about disease and more about delight. We've
seen ads for E.D. drugs that feature one man throwing a football
through a swinging tire - say, what? - and another getting his mojo
back while window-shopping for lingerie. We have a leading lady oozing
her satisfied testimonial to Levitra's "strong and lasting" effects.
We have romantic scenes with the Cialis tag line: "When the time is
right, will you be ready?"

The only warning missing from the stream of side effects listed in these
ads was to the drug companies themselves. Beware: If you pitch Viagra,
Cialis and Levitra as lifestyle drugs, you can't complain when they get
targeted as lifestyle drugs.

It shouldn't have been a surprise when the House of Representatives
voted to ban Medicare and Medicaid payments for erectile dysfunction
drugs. It happened soon after the brain-numbing news that 800 sex
offenders in 14 states had been given Viagra under Medicaid.

As Rep. Steve King of Iowa put it, "We provide drugs through Medicare
and Medicaid that are lifesaving drugs; we don't pay for lifestyle
drugs." We can't tell taxpayers, he added, "We're going to take the
money you earned on overtime to pay for Grandpa's Viagra."

Now sex is ready to rear its head in the Senate version of the
spending bill. Is it possible to have a rational conversation about
rationing?

At the heart of it, this is a conversation about rationing disguised
as a conversation about lifestyle drugs. I don't know anyone who
thinks the government should pay for hair replacement drugs, nail
fungus treatments or cosmetic surgery. But what exactly is a lifestyle
drug?

King said Medicare and Medicaid are only for life-saving drugs. But
where do we draw that line? A drug that reduces the nausea from chemo
doesn't save lives. Reconstructive breast surgery after a mastectomy
doesn't save a life. A nose job to meet beauty standards may be a
lifestyle choice, but what about a nose job after a car accident? When
is a cataract operation life-saving and when is it merely
life-enhancing?

While we are on the subject, if you lose your sense of taste, should
the public pay for a cure? How is that pleasure different from sexual
pleasure? Bioethicist Art Caplan calls the debate about Grandpa and
Viagra "Puritanism masquerading as medicine." It seems that a Congress
that can't even negotiate prices with the drug companies has no
trouble whatsoever with values-based rationing.

While we talk about cost containment for sex, we haven't even begun to
think about what we'll do with the truly expensive drugs coming down
the pike. Some of the new cancer treatments can cost $100,000 in order
to prolong life for a few weeks or months. How does a country divided
over Terri Schiavo's fate wrestle over the cost of that life-saving
health care?

I have no interest in using my tax dollars so a perfectly normal
70-year-old can be ready whenever the time is right. On the other
hand, sex is not just a Cialis ad. One of the reasons many men close
their eyes to prostate cancer is the fear of impotence. It's possible
and sensible to distinguish between the dysfunction caused by disease
and the superfunction that urges 70-year-olds to behave like
40-year-olds. We can fund one and not the other.

For the moment, drug companies have produced their own advertising
blowback. It's too easy to attack the notion of government-funded sex.
But anyone who embraces the matter of health-care costs and choices
had better remember the very first tagline on this subject: Courage.