Imagine that someone took you into the woods with three other people. The three other people were a young child of no particular distinguishing characteristics, a middle-aged drunkard with a family, and a 75-year-old Nobel Prize winner. They then told you that you had to shoot and kill one of those three people, and that, if you did not do so, the person who gave you the gun would go back and kill your child. What would you do?

Ethicists of Professor Brock’s ilk apparently could go through all sorts of analyses of the relative costs and benefits from a social or moral perspective of killing each of the three suggested victims. The child has more quality-adjusted life-years, multiple lives depend (not very well) on the drunkard, the Nobel Prize winner has made huge contributions to society but may not have much longer to contribute. But I have to wonder if they would see the quite logical answer:

Shoot the guy who gave you the choice. Then they can’t go back and kill your child, and the rest of you can all go home.

I feel this way when someone talks about the great need to ration healthcare. They are either making an obvious but trivial point, or totally ignoring an entire moral and practical dimension.

The United States spends 16% of GDP on its health care, and there is good reason, from looking at other countries’ systems, to believe we could provide not only as much health but essentially the same basket of services, to all our citizens, for maybe 12% of GDP, if we had financing and payment arrangements more similar to the international standard.

The most fundamental ethical conflict in our medical system isn’t which care to provide. It is the clash between the self-interest of sick people and the self-interest of all the individuals who make money from the health care system. Yes, resources in the form of money to pay for care are limited. But that does not mean the only choice is to ration care. It can mean that the right thing to do is to pay less to many of the people who are making so much money from the system.

Some surely deserve their current levels of income. But some of the incomes in our current system provide no social value at all; and others are quite likely significantly higher than they need to be. If we ignore the option of reducing the payments for care, including eliminating the unnecessary non-care, then we are allowing all the people who make those inoomes to tell us, essentially, “shoot the patients but keep us whole.”

Personally, I find an analysis that ignores this dimension morally reprehensible. It takes for granted the distribution of power and income in the system, assumes it is inviolate, and moves on to which patients to hurt. I don’t see how that is wise or ethical.

Now, ARE there medical services that should not be provided to some people, at some times? Sure. Any system is a system of social sharing. In that system, we make (or should make) decisions about what services we consider so important that they should be available to all fellow-citizens according to their need. In a decent society (which apparently does not include the United States) there is some guarantee of care to all who need it. But that does not include anything anyone can imagine — cosmetic surgery for vanity purposes for example, or abortion. Any definition of a benefit package “rations” in the sense of deciding what to share, and no benefit package is infinite. In that sense the claim that we need to “ration” is trivial.

Nor is there anything wrong with saying that care must meet some threshold expectation of actually doing some good in order for it to be the subject of social sharing. The ethical failure occurs when analysts claim that the cost control problems come from failure to “ration” in this sense. If that were true, one would expect the United States to have more physician visits and hospitalizations per capita than is the norm in countries that spend less (all other countries). But that’s not the case.

Public distrust of “rationing” therefore has three logical bases. The first is a presumption that, if care is really not helpful, it will not be prescribed. That presumption is false in some cases. But, in order for it to be false, one has to have a caregiver who is making a mistake. That brings us to the second factor: the need to choose between trusting one’s caregiver, or trusting some overseer — whether that be a government overseer or a private insurance overseer. The average patient starts out by investing trust in their caregiver, trusting him or her to do all sorts of invasive things, literally putting the patient’s life in the caregivers’ hands. Not surprisingly, the average patient therefore is disposed to, in some ways must, trust the caregiver more than any overseer. The third factor is, the average patient, or at least the average voter, knows full well that there are other ways to save money. The fact that ethicists and many health services researchers do not seem able to recognize that there are alternatives doesn’t mean the public is wrong. So people don’t want to hear about rationing because they don’t like the power relationship it implies and because they don’t think it’s the only option. And they’re right.

Can we get to a point where “rationing” in the form Professor Brock has in mind may be the best way to control costs? Sure. If we ever get to that point I will be extremely happy (and I should live so long). As it is, there are so many better ways to reduce costs, that it is simply immoral to insist that rationing useful care is the way to start.

Best,
Joe White

First, do we have any empirically-grounded evidence of what laypeople think “rationing” means in the health care context? The clearest examples of rationing in American memories are ration cards going back to WWII and gas rationing from the 1970s.
I don’t think most ordinary folk (those terrified by politicized use of scare words) view “rationing” as fundamentally equivalent to “allocation”, or view “rationing by price” as a form of rationing. I suspect many are just confused about what the word means, or might mean, in this context.

More specifically, I rather doubt that most non-experts are aware of the degree to which decisions by insurance companies about what they will cover–not to speak of implicit value judgments by physicians about what treatment options they will offer tp patients in particular circumstances–are themselves forms of rationing that are pervasive in contemporary health care (just as many who are terrified about “government bureaucrats” getting between doctors and patients don’t fully realize that the government bureaucrats will have to oust the platoon of insurance bureaucrats currently in place to find room for themselves…).

It is a rather sad reflection on our politics, and on society’s state of (im-)maturity on these issues, that straightforward, adult conversation on the ruinous implications of pursuing very high cost, very low efficacy medical interventions is (and has been, for decades)so difficult to conduct. Perhaps those with expertise in behavioral psychology and economics could find a better way to frame these issues so that more rational discourse could take place in the public realm.