The trouble with rationing health care

November 12, 1996|By Alfred Sommer

IN HIS KEYNOTE speech as the Johns Hopkins School of Public Health launched its year-long series of symposiums exploring the health-care revolution, Colorado's former governor, Richard Lamm, an acute observer of the medical scene for more than 15 years, highlighted once again the growing disparity between expenditures on health care and those being sucked out of other sectors of the economy meant to serve broad public goals.

Governor Lamm pointed out that when he began his political career in 1955, expenditures on health care were equivalent to those on education. By 1995, health care cost as much as education plus defense plus farm subsidies plus food stamps plus foreign assistance.

He, like others, has called for reining in health-care expenditures by concentrating -- as a traditional market economy does -- on those services that provide the greatest return on investment. These primarily relate to preventive services rather than curative; and curative services that have a high likelihood of success, particularly among individuals who are still capable of leading a ''quality'' life.

While investing in services that provide the ''highest return'' sounds fine in theory, it confronts us with a Hobson's choice. Mortality rates are ultimate 100 percent: We will all die one day. TC Confronted with our mortality, human beings in general and Americans in particular, want everything done that could possibly help, regardless of cost or likelihood of benefit. The threat of pain, disability and death holds us hostage to extortion as fiercely as if we were in the grips of a desperate kidnapper.

One could make a sound and rational case -- one the public is increasingly hearing -- that enormous sums of money should not be spent on ''the last few days of life.'' It not only is a waste of resources, but also often prolongs a patient's agony and strips him of dignity. The problem, of course, is that we rarely know when it is one's last few days, months or even years of life; and even if we did, months -- to those in sound mind -- can mean a great deal; if not to them, then to their loved ones.

As a society we could (and probably should) concentrate health-care resources on preventing premature morbidity and mortality -- illness, disability and death before the end of the biblical lifespan. Other societies have made just this decision as they've gone about rationing health services to the elderly.

Who would choose?

A stronger case can perhaps be made for rationing care according to an individual's potential for profiting from successful extension of life, in terms of intellectual capacity and the sheer pleasure of being alive. But who could or would wish to face the ethical dilemma of choosing to help some but not others?

For example, recent research suggests those whom we might think have the least ability to appreciate life -- individuals born with severely limited mental capacity -- have sometimes shown remarkable feelings when techniques are used to delve below the surface of their limited ability of expression. By the same token, the disabled commonly consider their disabilities far less limiting than the non-disabled suppose they are.

Hence, the continuing moral and practical dilemma. Yes, we are increasingly discussing -- even condoning -- physician-assisted suicide, even while moral tenets and explicit practical guidelines for invoking such actions on a society-wide scale remain obscure. Even so, these will have only a marginal impact on health-care costs, since religion, philosophy and emotional reasons will keep the numbers small.

The quandary is stark. Do we adopt policies from other countries that set arbitrary limits on the age at which expensive procedures will be performed (often regardless of a person's capacity to be a person)? Or do we adopt a version of the originally-proposed Oregon health plan, paying only for those services providing the greater good until some arbitrarily determined funding cap is reached?

At least we should learn from other countries how they reached a social compact that sanctions the rationing of health services, and then go about doing what Americans are uniquely good at doing, improving upon them.

Alfred Sommer is dean of the Johns Hopkins School of Public Health.

Pub Date: 11/12/96

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