Covert rationing and end-of-life healthcare 

In the last two sections we have surveyed how covert rationing corrupts the actions of managed care organizations and of the regulators, all of whom are supposed to be (and insist to us they are) protecting the health and welfare of Americans.  In this section we'll look at an aspect of covert rationing that may be even more disturbing and ultimately more consequential than either of these.

The issues surrounding end-of-life medical care are of vital importance both to individuals and to society. Perhaps more than any of the other issues we have discussed, the way we handle end-of-life care will determine what kind of a people we will become in the 21st century.

There are actually three areas of hot contention related to "end-of-life" medical care - these issues are advance directives, physician-assisted suicide, and medical futility. In my book The Grand Unification Theory of Health Care, I discuss all three end-of-life controversies. On this website I limit the discussion to the most contentious one of the three - physician-assisted suicide.

All three areas of end-of-life controversies involve legitimate ethical dilemmas, about which respected ethicists have argued and continue to argue on either side.  In each case the ethical point of contention is the same - that of individual autonomy versus the needs of society as a whole.  In essence, all three ask this question - how much authority will a patient be permitted in gaining some control over the events that surround his or her own death?

The autonomy of the individual - a person's right of self-determination - is a cornerstone of the American belief system.  Yet, individual autonomy is not perfect even in concept; it has inherent limitations. In the individual's pursuit of life, liberty and happiness, no person has the right to limit or jeopardize the rights or welfare of other individuals (i.e., of society).  This limitation creates an unavoidable tension between the rights of an individual and the needs of society.  Indeed, the general problem of how to protect individual autonomy without sacrificing the legitimate needs of the collective accounts for many of the domestic conflicts that have taken place during our nation's history.  

Not surprisingly, the issue of autonomy is central to the end-of-life disputes. Acknowledging that the dying patient has the right to make critical healthcare decisions often provides a final measure of control and dignity to his or her life.  To those in the "end-of-life" movement, the battle is for affirmation of the individual autonomy of the dying patient, and against the technocratic, unfeeling healthcare machine that is too intent on following its own rules and procedures.

There might be no conflict at all if the individual's end-of-life desires did not place certain demands on society.  But when dying patients ask that their own death be hastened, a certain tension is created. The tension arises from the fact that our society, as a requisite check on the sovereign authority (that is, the authority which has the ultimate power to assert its will over all other authorities, whenever necessary, by the use of violence). In American society this sovereign authority (the government) is obligated to jealously honor and protect the physical life of individuals. So when individuals demand that healthcare providers stop protecting their physical existence or even act to end it, and further, that the state embrace those demands, a potential conflict is created. And it is necessary to consider whether such demands might begin to erode an essential aspect of our social contract.

This question is difficult enough on its own.  It becomes virtually unsolvable when put into play in a milieu of covert healthcare rationing.

Central to the end-of-life disputes, though not often openly discussed, is the issue of cost.  In virtually every plea for the expansion of end-of-life autonomy is an aside (often in parentheses) as to how much money is being spent today caring for patients in the last few months of life.  Up to 35% of Medicare expenditures in any given year, we often hear, will go to the 6% of enrollees that die within that year.  The clear implication is that, by honoring individual autonomy, as a bonus we also stand to save countless millions of dollars. There is an undeniable and increasingly compelling financial incentive for society to yield on its jealous protection of individual life. It ought not to be surprising, in this light, that those who cut the checks, the health insurers and the government, have generally expressed great sympathy and support for at least some aspects of the end-of-life movement.  

And as we will see, covert rationing turns the issue of end-of-life autonomy on its head. For, under a system of covert rationing, placing the autonomy of the dying person above all other considerations will ultimately devalue the worth of the individual.