I was fortunate enough to attend SLHI’s “The R Word event” today, at which Dr.Arthur Caplan, Director of the Center for Bioethics, Univ of Pa and arguably one of the ten most influential people in science, raised the questions President Obama has asked us not to mention: At what time do you put a price on a human life? Is it worth more to save the life of a fifteen year old than an 80 year old? Should we use public funds to pay for a $10,000 drug that extends life six months. Caplan believes we ration now: 25% of the population gets care only from the emergency room.

Right now, Caplan says we treat health care as a privilege, not a right, because health care is connected to employment. Most other countries believe health care is a righ, because we are a community and should look out for our neighbors (Canada and Britain); healthy workers are good for the economy (Germany and SIngapore); or health care is part of equal opportunity, like education.

But no country buys its citzens everything. There are limits to universal health care. In countries that have it, you wait, and if you want to jump the line you pay more. If you want specialists, you pay more. But you do get access to some level of care.

Here in America, health insurance doesn’t do you any good in getting health care if there’s no gynecologist in your rural or inner city neighborhood. Rationing because of scare resources is a daily reality even if you have insurance.

Caplan gave an example: the need to ration access to ventilators during a swine flu epidemic. The US has 30,000 ventilators, and all of them are in use every day. If more people suddenly need ventilators as a result of swine flu complications, who do you give them to? Older people? Younger people? (Doctors afraid of malpractice will not disconnect 89-year-old Fred to put on 25 year old Susie.)

In the future, we will be rationing not only because resources are scarce, but because as a country we can’t afford the costs. We spent $280 billion in drugs in 2006, most of them specialty pharmaceuticals used as treatments of last resort. As the population ages, the demand will escalate; stem cell research will also generate new costs, regenerating parts of brains, hearts and spines. Pharmaceutical costs for rare diseases can destroy an insurance plan; what about when they develop something for arthritis? Cancer?

The health care system now rations viciously by leaving out 25% of people. Caplan distinguished among three ways of allocating resources:
1)allocation – general distribution of any resource (make everyone’s share smaller)
2)rationing – distribution of scarce and highly valued resource
3)triage – rationing with an agreed upon goal

If you have to ration, there are many just ways to do it:
1)equal chance for all (draw lots)
2)equal outcome for all (give everyone the same survival odds)
3)help those who merit/deserve benefit (who can pay, who can stay healthy)
4)help those who have the greatest need (sickest first)
5)create most good for greatest number
6) save the largest number of lives
7_save the largest number of lives that will have quality of life

Organ transplants are always rationed because there are never enough organs. That’s why they are given to people who can pay (the wallet biopsy), are the sickest, and will have the best quality of life afterwards.

According to Caplan, as a society, we would do better if we acknowledged that rationing is going on, that in America money and access to primary care and age are already used to allocate resources. For what the participants thought, see the post below:-)