u
u Rationing
Rationing
Is Still
I was depressed by Peter Ubel’s essay “Why It’s Not Time for Health Care Rationing” (March-April 2015) for two reasons. The first was his contention that with a little of what he calls “rebranding” (sophistry over substance), there is no problem with rationing, and second was his contention that as far as medicine and its hangers-on (bioethicists) are concerned, rationing medical care is widely accepted. One would hope that practitioners of medicine (and maybe a few bioethicists) would have at least a few qualms about a process that assigns individuals to what we might call a “class” based on medical diagnosis and then denies some individuals (on the basis of class) medical treatment that would be expected to prolong or improve the quality of their lives. The first problem is Ubel’s sophistry about “rebranding.” He seems to think that stewardship of antibiotics is a form of rationing or triage. It is not. The point of antibiotic stewardship policies is to restrict the use of certain antibiotics in order to slow the development of antibiotic-resistant organisms. The assumptions are that most bacteria are still treatable with “usual” antibiotics, so the “restricted” antibiotics are not really needed, and that by using clinical or laboratory criteria, clinicians can recognize the patients who really need the new antibiotics. Patients benefit from this in several ways, including lower care costs, and because the overwhelming majority survive their infection, they are more likely to have good treatment for their next infection. Similarly, Ubel’s discussion about calculating the “quality,” “cost,” and “value” of each year of life gained by a medical intervention is unrealistic. July-August 2015
exchange
t
While you may be able to quantify the “cost” of a given series of medical interventions, both the “value” and “quality” of each is usually in the eye of the consumer-beholder as well as society. For example, Steven Hawking does not have a life that I would want, and he requires quite extensive medical treatments to maintain it. Nevertheless, he seems to regard his life as highly valuable, and society, in this case, seems to agree. In addition, measures of life years gained and quality of life are far from exact. The second problem is that rationing and triage fundamentally change the role of medical practitioners. In Western medicine, since the time of Hippocrates, physicians have been directed to place the interests of the patient above their own. Many or most of
Rationing or triage situations subordinate the interests of individuals to a perceived interest of some “group.” us still take the Hippocratic oath, and within the past fifteen years, the international boards of internal medicine have recommended a revision of it that instructs or commits physicians also to place the interests of the patient above those of multiple third parties as well. Rationing or triage situations subordinate the interests of individuals to a perceived interest of some “group.” The medical practitioner’s primary role is to use medical knowledge (as a diagnostician) to classify patients into groups that will or will not be treated and to provide treatment to them only if their class or group is “entitled” to it. Ubel’s discussion of bedside individual physician
“rationing” or parsimonious sharing of knowledge with patients with the goal of limiting the care they receive or the cost of treating them is an appalling breach of the guidance about the primacy of patient interest. It is one thing, near the end of a patient’s life, to lay out all options and then decide jointly with the patient and family that no aggressive treatment should be pursued. It is totally another to hide therapeutic options because you, as a practitioner, have decided it is time for your patient to go. At best this is paternalism, but a more honest description is a violation of usual ethical and moral principles of integrity (honesty) and respect for person (autonomy), the individual patient. As Ubel points out, it is hard to know what Sarah Palin meant when she talked about death committees. But as he also points out, the Affordable Care Act is alive and well and includes the Independent Payment Advisory Board (another example of the preference for sophistry in that it will be neither independent nor advisory), which will decide which treatments for which patients will be allowed (paid for). This appears to be the rationing board, and almost certainly, some of their decisions will adversely affect both the quality and quantity of some individuals’ lives. To me, this is a death committee. The economics of the situation continue to seem Malthusian. If the primary goal is to control costs, then the deaths of individuals (the ending of health care expenditures for them) are desirable. Hopefully in practice after a few avoidable deaths occur, some medical practitioners and maybe bioethicists will have a “what have we done” moment. • Robert J. Wells M. D. Anderson Cancer Center, University of Texas DOI: 10.1002/hast.462 H AS TI N GS C E N TE R RE P O RT
3
u Rationing
Rationing
Is Still
I was depressed by Peter Ubel’s essay “Why It’s Not Time for Health Care Rationing” (March-April 2015) for two reasons. The first was his contention that with a little of what he calls “rebranding” (sophistry over substance), there is no problem with rationing, and second was his contention that as far as medicine and its hangers-on (bioethicists) are concerned, rationing medical care is widely accepted. One would hope that practitioners of medicine (and maybe a few bioethicists) would have at least a few qualms about a process that assigns individuals to what we might call a “class” based on medical diagnosis and then denies some individuals (on the basis of class) medical treatment that would be expected to prolong or improve the quality of their lives. The first problem is Ubel’s sophistry about “rebranding.” He seems to think that stewardship of antibiotics is a form of rationing or triage. It is not. The point of antibiotic stewardship policies is to restrict the use of certain antibiotics in order to slow the development of antibiotic-resistant organisms. The assumptions are that most bacteria are still treatable with “usual” antibiotics, so the “restricted” antibiotics are not really needed, and that by using clinical or laboratory criteria, clinicians can recognize the patients who really need the new antibiotics. Patients benefit from this in several ways, including lower care costs, and because the overwhelming majority survive their infection, they are more likely to have good treatment for their next infection. Similarly, Ubel’s discussion about calculating the “quality,” “cost,” and “value” of each year of life gained by a medical intervention is unrealistic. July-August 2015
exchange
t
While you may be able to quantify the “cost” of a given series of medical interventions, both the “value” and “quality” of each is usually in the eye of the consumer-beholder as well as society. For example, Steven Hawking does not have a life that I would want, and he requires quite extensive medical treatments to maintain it. Nevertheless, he seems to regard his life as highly valuable, and society, in this case, seems to agree. In addition, measures of life years gained and quality of life are far from exact. The second problem is that rationing and triage fundamentally change the role of medical practitioners. In Western medicine, since the time of Hippocrates, physicians have been directed to place the interests of the patient above their own. Many or most of
Rationing or triage situations subordinate the interests of individuals to a perceived interest of some “group.” us still take the Hippocratic oath, and within the past fifteen years, the international boards of internal medicine have recommended a revision of it that instructs or commits physicians also to place the interests of the patient above those of multiple third parties as well. Rationing or triage situations subordinate the interests of individuals to a perceived interest of some “group.” The medical practitioner’s primary role is to use medical knowledge (as a diagnostician) to classify patients into groups that will or will not be treated and to provide treatment to them only if their class or group is “entitled” to it. Ubel’s discussion of bedside individual physician
“rationing” or parsimonious sharing of knowledge with patients with the goal of limiting the care they receive or the cost of treating them is an appalling breach of the guidance about the primacy of patient interest. It is one thing, near the end of a patient’s life, to lay out all options and then decide jointly with the patient and family that no aggressive treatment should be pursued. It is totally another to hide therapeutic options because you, as a practitioner, have decided it is time for your patient to go. At best this is paternalism, but a more honest description is a violation of usual ethical and moral principles of integrity (honesty) and respect for person (autonomy), the individual patient. As Ubel points out, it is hard to know what Sarah Palin meant when she talked about death committees. But as he also points out, the Affordable Care Act is alive and well and includes the Independent Payment Advisory Board (another example of the preference for sophistry in that it will be neither independent nor advisory), which will decide which treatments for which patients will be allowed (paid for). This appears to be the rationing board, and almost certainly, some of their decisions will adversely affect both the quality and quantity of some individuals’ lives. To me, this is a death committee. The economics of the situation continue to seem Malthusian. If the primary goal is to control costs, then the deaths of individuals (the ending of health care expenditures for them) are desirable. Hopefully in practice after a few avoidable deaths occur, some medical practitioners and maybe bioethicists will have a “what have we done” moment. • Robert J. Wells M. D. Anderson Cancer Center, University of Texas DOI: 10.1002/hast.462 H AS TI N GS C E N TE R RE P O RT
3
