How to ration healthcare the American way

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

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.

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.

Establishing outer-sphere ethical precepts

The two precepts in the outer sphere, under any system of healthcare rationing, present us with an ethical dilemma. You cannot have both perfect societal beneficence and perfect distributive justice simultaneously. You've got to pick which one takes precedence.

Assuring fairness vs. maximizing good

If we have to ration healthcare, we want the rationing process to do two things. We want it to be fair (that is, we want to adhere to the precept of distributive justice), and we want it to yield the maximum amount of healthcare benefit for the dollar (that is, we want to adhere to the precept of societal beneficence.) Unfortunately, we cannot maximize both of these goals at the same time.

Consider the following illustration: Two men, both fifty, are diagnosed with the same rare form of cancer. A treatment exists to cure this type of cancer, but the healthcare system can only afford to treat one of these men. The first man is otherwise healthy and if cured can be expected to recover fully. The second happens to be bedridden with severe multiple sclerosis (MS); if he is cured of cancer, he will remain severely disabled and will probably have a reduced life expectancy due to that disability. To which man should society offer treatment?

Some would say that, obviously, society should treat the man who is otherwise healthy, as we would be buying him a high-quality life of substantial duration. If we treated the other man, we would be saving a relatively low-quality life, and for a shorter duration. Treating the otherwise healthy man would therefore clearly maximize the good (societal beneficence) society achieves with its money.

But others would point out that the second man (the one with MS) wants to live just as much as the first, that his life has the same intrinsic value as the other man's, and that withholding therapy from him just because of his MS would be unfair. Discriminating against people with MS-or any other disability-is a flagrant violation of the principle of distributive justice. Fairness dictates that all individuals should have an equal claim to the benefits of therapy.

It should be obvious that we cannot have it both ways. How we decide to distribute society's resources in this case (and in every case) depends on how we prioritize the two conflicting ethical principles. We might decide that maximizing fairness should predominate over maximizing good. The only way to absolutely maximize fairness, in fact, would be to withhold therapy from both men (this would be the only option that would equalize the results). But then both would die, and our adherence to strict fairness would reduce the amount of good we've achieved to zero. On the other hand, if we decide we want to maximize beneficence (the total amount of good we can buy with society's money), we would have to treat the otherwise healthy man. But by choosing to do this, we would be removing the patient with MS from consideration altogether, reducing fairness to zero.

Whatever we do, we cannot both maximize good and maximize fairness. So, if we're going to devise a scheme for the open rationing of healthcare, we have to choose explicitly between these two ethical precepts or decide specifically how to distribute our priorities between them.

The basic ethical dilemma inherent in devising a rationing scheme is of more than just theoretical importance. The way we balance fairness and good determines whether open rationing ends up being a significant improvement over what we have now or ends up as bad as many fear it might.

An argument for giving primacy to fairness

While we ought to get as much bang from society's healthcare buck as possible, that is, maximize societal beneficence, we should not do so by subordinating the principle of distributive justice. In rationing healthcare, we should avoid discrimination against individuals or groups by virtue of their race, sex, nationality, genetic makeup, or diseases and disabilities.

Why should assuring fairness predominate over maximizing good? Because if we agree to limit societal beneficence in the name of distributive justice, we will strive to expand covered medical services for everyone and thus to expand the overall good we're achieving. Our tendency will be to find new ways of biasing the total goodness upward (while maintaining fairness), by collecting better cost-effectiveness data, finding new efficiencies, discovering new treatments and technologies, or choosing to divert more funding into the healthcare system.

On the other hand, if we hold maximum good to be the dominant standard and treat fairness as a secondary consideration, we will always be tempted to bias fairness downward, that is, to expand the categories of patients whose lives are judged relatively valueless based on disease or disability, as this would be the simplest path to achieving more total good per healthcare dollar spent. Once we set a precedent of maximizing good at the expense of fairness it will be difficult to turn back but easy to advance. We should not assume that we will be significantly more resistant to such behavior than other cultures have proven to be.

Most of us, I think, would rather live in a society that takes the former path rather than one that takes the latter.

A proposed ethical standard for rationing

I propose an equal opportunity standard (EOS) for balancing the two ethical precepts in the outer sphere:

The EOS standard: All individuals should have an equal opportunity to enjoy the fruits of life, within the constraints imposed on them by nature.

This EOS is a reformulation of the principle of distributive justice, suitably bounded for the purposes of rationing. It says that, while we ought to let fairness (that is, distributive justice) predominate, we also ought constrain it to allow society to accrue a reasonably optimal amount of good.

The EOS gives primacy to fairness by recognizing that all individuals are of equal intrinsic worth, that is, all individuals should have an equal opportunity to enjoy the fruits of life. However, the EOS prevents the excesses of unfettered fairness in two ways.

First, the EOS does not insist that the principle of distributive justice requires equivalent outcomes among individuals. It strives only to gain for individuals an equal opportunity for those good outcomes. Not all opportunities, even equal opportunities, yield equivalent results. Given equal opportunities for a favorable result, some individuals will have good outcomes and others poor outcomes. The EOS accepts this.

Second, the EOS recognizes that not even equal opportunity is possible in all cases. Sometimes the vagaries of nature limit opportunities. A person's illness or disability may reduce their odds of responding favorably to a therapy. Under the EOS, society does not have to spend unlimited amounts to provide a therapy that is unlikely to yield a good outcome.

In rationing healthcare under the EOS, the distribution of resources would not be based on either attempting to maximize the overall good that accrues to society or attempting to equalize outcomes among all individuals. The EOS does not make the problem of maximizing fairness vs. maximizing good go away, but it changes the question. Instead of asking, Saving which of these two individuals will maximize overall good? or How can we guarantee equivalent outcomes for these two individuals to maximize fairness? we will be asking, Given these two equally worthy individuals, how can we optimize the opportunity for good outcomes for both?

The EOS-a statement of math as well as ethics

The EOS is a compromise between a strict beneficence standard and a strict justice standard. It reinforces distributive justice while helping optimize total societal good; and it offers sufficient flexibility for tackling difficult rationing problems.

The EOS, in addition to being a statement of principles, is a statement of mathematics. As we develop our scheme for the open rationing of healthcare, one way or another we're going to have to rank medical services by some numeric value. And the EOS shows us how to do the math.

In particular, there are four ethical questions that must be resolved before we can conduct the business of openly rationing healthcare, and the EOS leads us to specific answers to these questions.

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