Monday, July 20, 2009

Peter Singer on Rationing

In yesterday's New York Times magazine, Peter Singer presents a patient, lucid explanation of the ethical and economic necessity for health care rationing. (See here.)

If you've read any of my 37 previous postings on rationing you know that I see rationing as (1) obviously necessary, (2) done every day in our health "system," (3) mandatory for ethical health care in the 21st century, because (4) there are more potentially beneficial interventions available than we can afford. As Peter Singer puts it:
When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. 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?
Given the undeniable truth of Singer's conclusion, how do we account for the steady drum of histrionic rhetoric warning the public that health care reform will mean "rationing"? What comes to mind is Schopenhauer's famous comment on an arcane philosophical argument:
As a serious conviction it could be found only in a madhouse: as such it would then not need so much a refutation as a cure.
I don't believe that the conservative legislators and commentators who warn about rationing are mad. I assume they know that their pretense that rationing is evil and will only occur if President Obama gets his way is nonsense, and are simply playing politics. Alas, the "rationing" accusation is effective politics, and the disinformation it embodies contributes to the madness of our national discourse on health care.

So how can that madness be cured?

Lucid argument of the kind Singer makes is useful, if only to firm up the resolve of the choir to keep singing. But to move the general public we'll need a combination of political leadership and time. If I were a political advisor, which I'm not, here's the line of thinking I'd recommend:
1. Our health system rations now by not insuring close to 50 million and spending so little on primary care that many well insured folks can't get to a personal physician.

2. We know that at least 30% of what we spend on health care is unnecessary and possibly harmful.

3. We need to reform the system so everyone has insurance and can get good care. That reduces the amount of rationing that is going on.
4. We need to wring out the unnecessary clinical and administrative expenditures. By doing that we reduce the potential need for rationing.

5. By taking no action and allowing runaway costs to continue we ensure that more and more poorly thought out rationing will occur, as occurs at present.

6. In case rationing is ever necessary in a reformed health system, let's tip toe up to thinking about how it could be done in the wisest and most ethical manner.
There's so much to do to capture the low hanging fruit of clinical and administrative waste that trying to focus the public on the need to ration is a distraction. Better to use the spectre of rationing as a prod to ourselves and the health system to remove our enormous expenditures on things that aren't needed before we engage in the truly difficult debates about what beneficial interventions we will forgo!


Jim Sabin said...

For an excellent discussion of Peter Singer's article, see Bob Wachter's July 18 post on Wachter's World. There's a link to his blog on the right hand column of mine.

klacuff said...

When discussions are cast broadly about rationing it tends to invoke fear (no doubt intended by lobbyists) without necessarily promoting understanding.

As with many complicated concepts, "rationing" comes bundled with layers of meaning and it is often the case that people talk past one another. Is rationing saying "no" to a second MRI or for coronary bypass surgery or a knee replacement? Is it asking folks to wait for some procedures? The criteria are important.

One element adding complexity is that health and health care are themselves fuzzy concepts. And with new interventions minted weekly (note, I don't automatically say "advances"), these concepts evolve. All would agree, generally, with the need for emergency care, urgent care, and a wide range of surgical and medical interventions to save lives, prevent further harm, repair damage. Where it gets trickier is at the margins.

My 78-year-old mother is delighted with her two Medicare-financed knees and there is no doubt that the surgeries have improved her quality of life directly by removing the pain of arthritis but, also, indirectly by permitting her to remain active, engage socially, keep her weight down, etc. But, if she were 90 with other health conditions, perhaps weighing that decision more carefully is the responsible thing for our health care system to do. Or if she had to wait a year or two to get her knees so my neighbor could have basic health care, that might also be a wise decision.

She has also had her eyelids (droopy) done, also paid for by Medicare since they were (arguably) impeding her vision. Is this health? This procedure has not always been on the Medicare-financed list but many incremental procedures such as these are adopted each year. Is promoting the maximum quality of life medicine can provide what we are talking about when we talk about the goals of health care? Only with a very expansive view of what health is, I think.

I agree with Singer that we are already rationing by virtue of supporting the health insurance coverage of some but not all of our citizens (whether by tax incentives, payroll taxes, or general revenues). At issue is how can we reasonably assure access to health care services, promote health, and limit publicly supported services that provide insufficient benefit.


Jim Sabin said...

Hello Kate

Thank you for this extraordinarily thoughtful comment. The questions you raise are just the kind of questions that health systems, including ours, will ultimately need to address. And the spirit of thoughtful inquiry with which you raise the questions is the spirit a successful system will need.

The "droopy eyelid" issue shows just how complex governing a health system can be - discerning the difference between improved vision (clearly a health-related value) from improved looks (perhaps a source of personal pleasure, but not a goal for a health fund).

You might find the book Norman Daniels and I wrote on rationing ("Setting Limits Fairly: Learning to Share Resources for Health" - Oxford University Press, 2008) interesting. Our basic argument is that pluralistic societies do not have shared principles by which we can answer the kinds of questions you raise, with the result that we need a fair process. (The book delineates a view of what that process should look like.)