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[This is cross-posted on Doctors for America's Progress Notes and my blog.]

I wasn't planning on writing about rationing of health care again, since we covered it in my last post prompted by Don Berwick's resignation from CMS.

But two stories came up recently that prompt me to do it again. The American College of Physicians released their revised Ethics Manual this week, and included language regarding the use of cost effectiveness as a criteria for providing care, and even urged parsimony by physicians. In an accompanying editorial, Ezekiel Emanuel, lauds the ACP for this language, noting the physician's obligation to society as a whole, and not just to individual patients. (As we noted last time, the Charter on Medical Professionalism  and the AMA Code of Ethics emphasize the physician's duty to social justice in the distribution of finite health care resources.)

All well and good, but NPR did a story on the Manual, and out it came. Scott Gottlieb, MD, of the American Enterprise Institute noted the general acceptance of cost effectiveness data in medical decision making, but then followed up that parsimony "really implies that care should be withheld. There's no definition of parsimonious that I know of that doesn't imply some kind of negative connotation in terms of being stingy about how you allocate something." (The definition I linked to above notes that parsimony can mean simply being careful with money or stingy.)

Daniel Callahan of the Hastings institute also got the vapors: "If you say certain things will not be cost-effective, they're not worth the money, well that's rationing, particularly if some patients might benefit or simply some might desire it whether they benefit or not, whether it benefits them or not. So that's where this all becomes a real viper's pit."

As we noted previously, America rations health care ruthlessly, largely by income and inability to pay (yes, I know that's a link to an NPR story), but also on quality of insurance, most acutely with private health insurance and Medicaid. I won't run through all of this again, please reread the last post for the details, but I cannot help but find it exasperating that supposedly knowledgeable people, like Gottlieb and Callahan, act as if utilizing cost effectiveness strategies necessarily means "withholding care," and, by extension, that all care, effective or not, cost-effective or not, is beneficial.

But more irksome is the implication that we don't ration now, and that this new, threatened "rationing," is somehow anathema to America. Which brings me to the second story that came up this past week, concerning money troubles in the British NHS and a regression in some areas to longer waiting times for certain procedures. The NHS had done quite a bit to repair their reputation and significantly shorten waiting times, but are apparently losing ground due to governmental austerity measures that (surprise!) actually effect people in real life. I noticed that conservative web site covered the story as an indictment of all health care, all over the world (and, of course, missing the irony that conservative austerity measures were the source of the problem). I pointed out over there with a flurry of comments that we're not so hot on this score ourselves, but also noted that Germany and France, in particular, provide health care for all, far more frugally (parsimoniously, even) than we do, and have no waiting times, no significant rationing of services compared to us. We remain the only industrialized nation that thinks nothing of rationing health care - and I mean this more literally than usual - as many of us give no thought to those struggling and suffering and dying for health care.

A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy--a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper--has loyally  stuck with a health-care system that leaves its citizenry pulling out their teeth  with pliers.
                                                 - Malcolm Gladwell, The Moral Hazard Myth
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Comment Preferences

  •  We don't want to die, but letting someone we don't (0+ / 0-)

    know die is somehow different. (Yeah, that is pretty disgusting, but unfortunately, true.)

    1% of our population use about 49% of all medical services.

    We spend half of our lifetime medical expenditures after age 65.

    Quality of life differs from your point of view. Hawking is 70 years old and can hardly move at all, yet he's still alive and it looks like he'll continue to live for some time to come. Others with his same disease want to die before they are "a conscious but motionless, mute, withered, incontinent mummy of my former self.". The point is that some people want to live at all costs and others will willingly die if they can't live on their terms.

    Any real discussion of rationing brings in the wing nuts. It's despicable  they don't see denying care simply based upon the fatness of your pocketbook as rationing.

    I have no problem using prognosis, quality of life and efficacy as part of the rationing equation. I have a big problem with using the ability to pay for it as the only criteria for rationing medical care. I have no problem with using the same criteria for everyone, but from a political perspective in the U.S. we'll continue to allow people who can afford futile care to continue to buy it. That's part of the American Way.

    If a nation expects to be ignorant and free, in a state of civilization, it expects what never has and never will be. Thomas Jefferson

    by JDWolverton on Fri Jan 06, 2012 at 12:40:03 PM PST

    •  thanks for the comment ... (1+ / 0-)
      Recommended by:

      My experience in the icu for 25years is that much of the cost is for care that would be refused with truly informed patients. The way it is, patients are kept in the dark about their prognosis and so often agree to treatment they would not agree to if informed honestly.

      •  gosh, most of my experience with ICU pts is (0+ / 0-)

        that they are in no condition to consent to anything. Their families can't bear to let them die, so the treatments continue.

        After 25 years, I hope you have some better memories.

        If a nation expects to be ignorant and free, in a state of civilization, it expects what never has and never will be. Thomas Jefferson

        by JDWolverton on Fri Jan 06, 2012 at 06:28:43 PM PST

        [ Parent ]

        •  Both are true... (0+ / 0-)

          Often the patients, if able, will make decisions to forego aggressive treatments. Families will often not do this.

          The tack I take is to make it clear to the family that we are not asking them to decide, but asking them to tell us what the patient would say if they could. This helps sometimes, but as you note, many families still persist in wanting futile treatment.

          I have noticed some people and their attorneys putting in a line in their advance directive explicitly saying that the AD must be honored and that family cannot supercede their wishes. Smart.

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