On Rationing

Consider the case of Ted, an 82-year-old widower who lives on an annual fixed income of $24,000. He has developed cancer of the liver, which has spread to his lungs. His doctor recommends a new drug that, while not offering a cure, has the potential of extending his life anywhere from six months to two years. The cost of the drug is $8,000 per month of treatment.

Now, Ted happens to live in a parallel universe where every U.S. citizen is required to sign up for Medicare, which operates under a strict national budget and pays for a defined package of services with co-pays based on personal income and financial assets. Publicly financed services are rationed on a transparent and explicit set of criteria derived from mountains of cost effectiveness research, physician input and oversight, consumer town halls and surveys, and a regulatory and appeals process crafted by lawyers on steroids. It’s generous, but it has its limits: it won’t cover expensive medications that do nothing to restore health, it won’t pay for hip transplants for 85-year-old golfers, it won’t pay for intensive life support in cases that are determined to be medically futile, and so on.

Of course, people are perfectly free to pay for these services themselves – and many do.

Some may view this as a “rational” approach to health care rationing. We can’t continue to do everything for everybody, resources are finite, families have to live within a budget, and so must government. Better to be open, transparent, and fully involve the public and all of the “stakeholders” in setting the scope and limitations of what will be provided at the taxpayer’s expense, rather than to leave those decisions solely to patients and their physicians, who often don’t have the slightest idea of what things cost or where the money is going to come from.

On the other side, the very idea of government rationing health care is an anathema to those who champion the sanctity of individual freedom and the ability of patients and providers to come together in free markets and make their own decisions about what will — and will not — be provided. When government runs the show, you queue up in long lines for necessary services, lose physicians and other clinicians who seek more autonomy in decision making, and potentially get substandard care. Patients and their providers should be making health care decisions, not government.

In Ted’s case, a majority of taxpayers would likely concur with the marginal utility of spending public funds for an expensive cancer drug that merely prolonged life over a matter of months but did nothing to cure the disease. Presumably fewer of them would think to question why the drug cost $8,000 a month in the first place, the salaries of pharmaceutical CEOs and scientists, the salaries of physicians that are 10 to 15 times what Ted lives on, the profits of health plans and makers of dialysis equipment, or tax subsidies for tobacco growers.

All of these things, by the way, are the result of public policy decisions as well as market forces. Ted is merely a nit on the carcass of a huge and immensely profitable industry. If we were really intent on reducing public expenditures for health care through explicit rationing, there are bigger targets we could begin to scrape off.

All such targets, of course, are well organized and politically powerful. Ted and other patients like him are not.

The ethics of health care rationing lead down a slippery slope. That’s no reason not to take the journey, but it is a fair warning to those who would have us live and die by cost effectiveness research, quality-adjusted life years, and marginal utility rates alone. Ethics in health care are ultimately grounded in the ethics of human community, where people live together in the cracks, and not on the theoretical surface, of human experience. If we fail to come together now of our own free volition to develop and internalize the norms of social reciprocity, caring and compassion that define a free and just society, then the system builders and technocrats will bind us in a straightjacket of well intentioned but externally imposed rules and procedures, and few of us will like the results.

As for Ted, he didn’t get the new cancer drug, but he did become very close to the nurse who cared for him in his final days, and died peacefully in her presence. That was the greatest blessing of all.

Feedback? Send it my way: Roger.Hughes@slhi.org.

*The Drift reflects the views of the author, and does not represent the official view of SLHI’s Board of Trustees and staff.