Paying for Gramp's "lifestyle"

BOSTON — 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 two-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's 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 or cosmetic surgery. But what exactly is a lifestyle drug?

King said Medicare and Medicaid are only for lifesaving 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 lifesaving 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 ArtCaplan 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.

There are many, like Jonathan Weiner, a health-policy professor at Johns Hopkins, who believe that "we should not be paying for sex for elders as long as we aren't paying for basic coverage for everyone." But the issue of coverage for everyone isn't even on the table.

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 "lifesaving" 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 why 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.

Ellen Goodman's column appears Friday on editorial pages of The Times. Her e-mail address is ellengoodman@globe.com