Four critical questions for rationing

Question 1: Is it ever appropriate to ask about an individual's intrinsic worth?

Under the EOS, all individuals should have an equal opportunity to enjoy life. So all individuals are of equal intrinsic worth. The answer to Question 1 is No.

Question 2: Is it appropriate to account for underlying medical conditions that objectively reduce an individual's chance of responding to a medical therapy?

For example, the presence of severe chronic lung disease significantly reduces the chance that a patient will realize a good outcome with coronary artery bypass surgery. Should this reduced probability of a good outcome be a factor in determining whether the individual ought to be offered the surgery? The EOS recognizes that constraints of nature will sometimes limit an individual's opportunity to enjoy life. The answer to Question 2 is Yes.

Question 3: Should a person's age be taken into account?

Whether to use age as a factor in rationing healthcare is a contentious issue among medical ethicists. Most who argue for it base their arguments on the principle of societal beneficence-maximizing public good. The total good derived from a life-saving procedure, they would say, is greater in a younger patient than in an older patient (because saving the life of a ninety-year-old might buy only two years of additional life, whereas saving the life of a ten-year-old might buy seventy years of life at the same cost). This reasoning sacrifices fairness (that is, the equivalence of two human lives) in favor of overall public good. Like all procedures that maximize good by assigning different values to various classes of humans, it leads to the slippery slope argument. That is, if you can devalue the elderly in the name of maximizing public good, then you can also devalue individuals on the basis of disability, illness, intelligence, sex, left-handedness, or race in the name of maximizing public good.

On its face, the EOS would seem to support those who insist on not taking age into account when rationing: If all individuals are of equal intrinsic worth, then ninety-year-olds ought to receive the same rationing priority as ten-year-olds. However, a closer look at the EOS can lead us to the opposite conclusion.

Under the EOS, saving the life of a ten-year-old might take precedence over saving the life of a ninety-year-old, but not because it would maximize overall good. Instead, the younger person has had relatively little opportunity to enjoy life-an opportunity we should strive to make equitable. By giving priority to the younger person, we come closer to achieving an equal opportunity between these two individuals-over the course of each of their lifetimes-than if we had given priority to the elder.

The slippery slope argument does not hold here because we are not setting a precedent by discriminating on the basis of some inherent difference between two individuals. Instead, we are saying that every individual should have a fair chance to enjoy life, and the ninety-year-old has already had eighty more years of opportunity than the ten-year-old. So under the EOS, rationing by age does not assign different values to individuals at all. What it does do is attempt to equalize opportunities between equally worthy individuals over the course of their lives. Thus, each individual will enjoy both the priority of the young and, later (if they are lucky enough to become elderly) the reduced priority of the old. Unless early death ensues, every individual over the long term will share the same distribution of age-related risk within the system of rationing.

Prioritizing by age under the EOS constitutes a special case, because equalizing the lifetime opportunity to enjoy life actually requires factoring age into the rationing decision, and doing so sets no precedent for rationing based on any other inherent differences among individuals.

While, admittedly, the EOS could be used to argue either point of view on the age issue, I personally believe it more correctly supports taking age into account, and I also believe this to be the more equitable position. For at least the purposes of this chapter, the answer to Question 3 is Yes.

Question 4: Should diseases or disabilities produced by the actions or choices of the patients themselves be taken into account?

In other words, should patients whose medical disorders are at least partly related to lifestyle choices (for example, smoking, obesity, riding motorcycles without a helmet) receive a lower priority in a rationing scheme?

The argument for assigning lower rationing priority to individuals whose medical conditions that are partially self-induced is one of equity. By making poor lifestyle choices, the reasoning goes, these individuals are choosing to soak up some of the healthcare resources that might otherwise accrue to people who themselves have chosen healthy lifestyles. A lower rationing score for those who make poor lifestyle choices would tend to equalize the playing field.

While there is nothing in the EOS that would preclude our adjusting the rationing priorities of those who make poor lifestyle choices, doing so would be problematic. Judging which medical conditions are due to lifestyle choices and which are not (was this man's heart attack caused by his chronic failure to exercise ninety minutes per day?) and deciding which self-induced conditions (obesity? alcoholism? drug addiction?) are due to individual choice and which are mediated by genetically determined tendencies would create significant, ongoing, systematic tensions that would tend to disrupt and undermine the entire rationing system.

For these and other practical reasons a rationing system under the EOS should not specifically account for conditions that we think are self-induced or partially self-induced. We should treat all underlying diseases or disabilities, whether mediated by lifestyle choices or not, as constraints imposed by nature.

This does not mean that individuals who habitually make bad personal choices will automatically soak up more than their rightful share of healthcare resources. Many self-induced illnesses (alcoholic cirrhosis, for example) objectively reduce an individual's odds of responding favorably to many therapies. In these cases, the therapy might be withheld anyway, because offering it would not improve their opportunity to enjoy life (see Question 2). In any case, for the purposes of this chapter, the answer to Question 4 is No.

The mathematics of rationing

Showing the actual mathematics of rationing is well beyond the scope of this website.  I give the actual calculations, and a system under which they could be implemented, a full and detailed treatment in my book, Fixing American Healthcare. What we just accomplished, however, is to answer the basic ethical questions that will allow open rationing within a healthcare system that is compatible with the foundational American precept of individual autonomy. The rest, dear reader, is just math.

Next: Catalyzing a healthcare reformation