Saturday, August 1, 2009

The r-word

The r-word is not “reform” as in health care “reform.” It’s health care “rationing.”

An argument for explicit rationing was made by Peter Singer in a recent New York Times Magazine (July 19). A Princeton professor and native Australian, Singer says the US should establish a treatment effectiveness review board to decide if Medicare (or any national payment system) should cover costs associated with specific medical tests and treatments.

On July 23 Peter Orszag, the White house budget director, was quoted in the New York Times as saying America needs “an independent commission that would measure the efficiency of specific medical providers and practices.”

Just the other day in the Wall Street Journal (July 30), there appeared an op-ed article by Myrna Ulfik, arguing against such a federal health review board. Ms. Ulfik, a cancer patient, said that to survive she must have “the freedom to choose my insurance, my doctors, and get the diagnostic scans and care I need.” Implicit in the freedom to choose, of course, is the ability to commit a government (or other third party) to paying the cost associated with such choice.

Ms. Ulfik argues that a government commission should not limit an individual's health care decision-making. Poignantly she says, "I am still here because my care was managed by doctors — not a government agency. My doctors do what the bureaucracy can’t: They see me as a human being.” By still "here" Ms. Ulfik means still "alive."

Ms. Ulfik's argument accords with that of the rabbi, as quoted by Dr. Singer: “if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally.”

"Patient-as-person will be a lost concept under the new health-care plan," writes Ms. Ulfik, "where treatments will be based not upon individual patient needs, but upon what's best for everyone."

Dr. Singer asserts that the government already weighs human life in economic terms. The Department of Transportation, he says, "sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million." He cites a similar value set by the Consumer Products Safety Commission. I have written about the value of life in a previous post.

How does one balance the appraising decision-making of Dr. Singer against Ms. Ulfik's moral imperative? Interestingly, such decisions may depend upon the part of the brain that’s doing the thinking.

Josh Green, a Harvard professor, has studied how the brain “lights up” under MRI examinations when individuals consider specific moral questions, such as how to balance the good of many against an individual good.

Dr. Green says moral decisions apparently emanate from different brain regions. When the ethical choice is, in effect, an accounting exercise (the greater good for the greater number, as in Dr. Signer’s argument), the brain reaches its decision in the region “behind the eyebrows.” When the moral problem is resolved by asserting basic human values, the decision apparently comes from deep within the brain, involving older brain structures that we share with our primate cousins. Dr. Green talked about this in 2006 on a WNYC radio science show called Radio Lab.

Considered morally, an individual life may have infinite value. This is how the life is seen by the individual, by the family, and by caregivers. They know, and worry about, and care for the individual person. When considered from the viewpoint of the government, however, a single life may have a finite value.

The government's job is to achieve the best results from limited resources. That is why it can train and send soldiers in harm's way. That is why it can set limits on health care spending. What are those limits? That is what the debate about health care reform is all about.

1 comment:

Julian Brelsford said...

Reality-on-earth rations health care (for society as a whole, if not necessarily for individuals).

There is no such thing as health care without limits - there are limits that come from technology and expertise. there are limits that occur when desired resources are impossible to obtain. It could be that there are three doctors who know how to do a procedure and none of the three is available to deal with an emergency on Wendesday in Minnesota; it could be that a particular medicine or piece of equipment can't be obtained during an emergency, etc. And it could be that our society can't afford to say "there is no limit whatsoever to the resources we'll spend on your health care".