What I found interesting about this article is that the majority of it is actually a reasoned discussion of the factors that need to be and usually are considered in any kind of consideration of rationing. Since these concepts are going to be brought up again and again in the future as we head into the brave new world of "health care reform", I think it is important that everyone be up to speed on the terminology.
The editorial is written by a bioethicist, Peter Singer. Like most discussions that I have read by other ethicists, I can take issue with a few of his points. But I will also acknowledge that some of his points are unquestionably valid, and I have already broached some of these, such as when I said, "for the reality really is we cannot afford to continue doing things the way we have been"; this was just another way of stating that, at some point, rationing of some kind would eventually come into play -- the only issue is whether it is going to be controlled rationing under established rules or rationing controlled by the twisting winds of random fate.
Mr. Singer starts out by outlining that 'health care' resources are "scarce"; I'll dispute that word, but they are finite, and that eventually leads to the same thing. Such scarce resources end up being rationed in one way or another, and the debate is about trying to use these resources in the most beneficial way.
The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?
This is the first point where I take issue with Mr. Singer. I don't think that there are too many thinking persons in this country who believe that we can provide unlimited medical care to all comers. Most people accept (if only subconsciously and reluctantly) that rationing is "inescapable". I will argue that most people do not feel it is desirable. And that is because most people start with the premise that okay, there's going to be rationing, but who's going to be making the decisions and how can I make sure I'm not going to get shafted?
Mr. Singer then spends a few paragraphs beating the dead horse of de facto rationing because of high costs, using drugs such as Sutent and Temodar and Gleevac as examples. Of course the tacit implication is that under rationing some people wouldn't get these drugs. The concept of trying to eliminate some of the factors (such as class-action lawsuits, insurance company formularies, and the glacially slow FDA drug approval process) that might make these drugs cheaper doesn't occur to him, as it doesn't support his argument.
He then tries to claim that lack of insurance coverage itself is killing people:
But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.
I would love to see this study to see how they reached this conclusion. Most people brought in from major trauma events don't even stop at the registration desk. Medical care begins immediately, and the medical team working on the patient has no idea what kind of coverage or lack of coverage any patient has. Since the advent of EMTALA, most of the hospitals I've worked at don't even let the info on a patient's coverage or lack thereof onto the ER chart until after emergency stabilization has been completed. So how is lack of insurance causing this higher death rate? Could there be some other reason?
Those who died were on average around 30 years old ......
Aha! One of the young invincibles! Young, not sick, refuses insurance even when offered by his employer -- a risk taker. And that risk taking likely extends to how he drives. Could it be that the higher death rate has something to do with more severe trauma? Was this even considered in the study? We aren't told. And were the insured trauma victims age and gender matched to the non-insured? Again we aren't told. Since this study was an economics study and not a medical one, I have my doubts.
While discussing years of life saved and Quality-Adjusted Life Years, (see the editorial!) Mr. Singer also covers the fact that human beings are not very good at intuitively comprehending the dimensions of risk reductions from taking certain actions. For example, consider the patient who is excessively worried about his borderline elevated triglyceride level (a minor risk factor for coronary artery disease) while refusing to even consider stopping smoking (probably the biggest risk factor for cardiovascular disease there is). He also discusses, in the concept of QALY, the perceived cost of disabilities by those not disabled and by those that are. And here things get interesting and we get to the heart of the rationing debate -- who's making the decision and how am I going to make sure I don't get shafted?
If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem... [lies]...with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability..... If [we ask quadriplegics themselves to evaluate life with quadriplegia,] and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over... the lives of people with disabilities....... This method of preserving our belief that everyone has an equal right to life is... a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication ... would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.
The real problem here is that Mr. Singer thinks it is a paradox that persons with disabilities want both their disabled lives prolonged and their disabilities cured. The man off the street wouldn't see this as contradictory. This would only occur to ivory tower eggheads. And maybe to eugenicists. Everyone else recognizes that people with disabilities are first and foremost people.
Mr. Singer himself nails the real sticking point in this rationing debate when he says:
...but if there is a social consensus that we should give priority to those....
The point is that there is no social consensus on this idea of rationing. That's why it's so contentious. And that's why trying to do it should wait until there is a consensus, or at least the beginnings of one. That will require a debate that we haven't had yet and that we may not even be ready for. The current crisis it that the Obama administration is full of people who want to force their views on everyone, because they think they know better.
Well, Mr. President, know this: How you and your people want to ration medical care is NOT how I would do it. And how I would want to do it is NOT how you, my good reader, would want to do it. How do I know without asking you?
Simple. We are nowhere near a consensus on this.
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