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The open rationing of healthcare - specifically, adopting an official public policy stipulating the rationing of healthcare and adopting a transparent methodology for conducting that rationing-is a scary prospect. It certainly scares the starch out of the public officials who ought to be discussing it with us. It may not be long, however, before some smart politician figures out that the roiling discontent with our healthcare system is caused by the covert rationing that's already occurring and that an increasingly angry public may be ready to listen to a straight and logical explanation of what's really going on.

When people come to understand that rationing is already occurring and will continue to occur no matter what, they may listen to a proposal for reforming our healthcare system that includes open rationing. Gaining public support for such a thing will take more than appeals to reason, more than convincing the public that our current system of covert rationing is bad, more than listing the advantages that might accrue from a healthcare system that includes open rationing.

To sell open rationing to the public, we have to paint an accurate picture of what our system of open rationing will look like. We're going to have to show them exactly how we propose to do it. That is our goal here.

Establishing an ethical basis for rationing

Earlier we outlined the six principles that ought to guide our creation of a new American healthcare system. The last of these principles is that we need to base our open rationing (a necessary component of that larger system), on ethical precepts. Let's consider what those ethical precepts should be.

Fundamental ethical precepts for rationing

One of the main themes of my book and this website is the conflict between the needs of the individual and the needs of society. Any stable society requires a system of ethical norms for resolving these individual vs. society conflicts. In socialist societies, such ethical norms are pretty straightforward, because individuals are expected to subsume their own needs to the greater good (a requirement that helps explain why these societies tend to fail).

But in the United States, a society founded on the principle of individual autonomy, the ethical norms governing conflicts between the individual and society tend to be more complicated. Especially in an arena like healthcare, where individual needs and societal needs cannot both be fully served, ethical norms must be in place to balance competing interests.

To visualize the problem, think of the ethics of healthcare as being organized into two concentric spheres. The outer sphere holds the ethical precepts adopted by society to guide the behavior of the healthcare system for the benefit of the entire population of patients it serves. These outer-sphere precepts help ensure that the needs of society as a whole are addressed in an ethical manner by the healthcare system.

Contained within (and thus subject to) that outer sphere of ethical precepts is an inner sphere, which defines the ethical norms that govern the behavior of the healthcare system for the benefit of individuals. Inner-sphere precepts help ensure that individual needs within the healthcare system are addressed in an ethical manner-yet in a manner consistent with the outer-sphere (societal) precepts. So, while the physician's primary concern must be for the welfare of the individual patient, and while physicians must operate according to ethical principles that reflect this duty to individuals (the inner-sphere precepts), their behavior must also conform to the ethical constraints imposed by society on the entire population (the outer-sphere precepts).

Because individuals operating within the inner sphere must honor the outer-sphere ethical precepts, you might surmise that the needs of society always take precedence over the needs of the individual. And to some degree, this is the case. But it is more useful to think of the inner-sphere precepts as immutable ethical beliefs that serve the autonomy of the individual and the outer sphere as a coating, fashioned by society and therefore changeable, designed to protect (and not usurp) that inner core.

The Inner Sphere - ethical precepts for individuals

The inner sphere of ethical precepts-the core-tells the physician to place the interests of the individual patient above all else, within the bounds imposed by society. Classically, this inner sphere consists of two ethical precepts: individual beneficence and individual autonomy.

Individual beneficence requires that doctors always strive to assure that their activities benefit their individual patients.

Individual autonomy requires doctors to enable their patients to exercise their right to self-determination regarding their own medical care. That is, the patient has a right to know, and the doctor is obligated to inform them, of any information that might help them make decisions about their healthcare. (Covert rationing requires the medical profession to abandon this core obligation.)

But while individual autonomy is critical, it has its limits. When a patient or the patient's proxy demands that everything be done, they are exceeding the bounds of autonomy if doing "everything" means that some other individuals would be deprived of what otherwise would be rightfully theirs. These bounds of autonomy are defined by the outer sphere.

The Outer Sphere - ethical precepts for society

Under any equitable system of rationing we are going to have to carefully define our outer sphere of ethical norms, because those are the standards that bound and govern the inner-sphere behaviors of individual physicians and patients. The outer sphere, like the inner, consists classically of two ethical precepts, in this case societal beneficence and distributive justice.

Societal beneficence requires the healthcare system to maximize the overall public good realized from whatever resources society expends on healthcare. Societal beneficence is not the same as individual beneficence, because what is optimal for an individual patient may reduce the overall benefit to society, and vice versa.

Distributive justice requires the benefits of the healthcare system to be distributed fairly, that is, in a way that does not discriminate against individuals or groups based on who they are. Any system of open rationing requires us to make difficult decisions. For example, are the aged, the disabled, the genetically disadvantaged, or any other definable groups to have more, fewer, or the same healthcare opportunities as everyone else?

Healthcare rationing and the spheres

Now we can see why the American healthcare system is inequitable and unethical. A hallmark of both our recent Quadrant IV Tooth Fairy healthcare system and our current Quadrant III healthcare system is the lack-thanks to our culture of no limits-of effective outer-sphere, societal norms that would bound the appropriate behavior of individual doctors and patients. This lack makes it possible for some patients to soak up a disproportionate share of healthcare resources, while others are left with next to nothing. Inequity, sanctioned and sustained by formal Wonkonian or Gekkonian policies and procedures, abounds.

Reestablishing equity should have nothing to do with adjusting the precepts of the inner sphere. Individuals (to paraphrase the Declaration of Independence) have self-evident rights to their individual autonomy. Inner-sphere precepts are granted us by natural law, or by the Creator, or by the Magna Carta (depending on your personal views). As Americans, we should avoid modifying inner-sphere precepts except under extreme duress. Outer-sphere precepts - the mechanism by which we can legitimately limit the scope of inner-sphere behaviors - are negotiated by society and are therefore subject to change. To develop an equitable system for openly rationing healthcare, it is the outer sphere that we must address.

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