How to Ration Health Care

Suppose you were in a triage situation and you had to choose between two patients, deciding who lives and who dies. Are there any principles you could rely on to make your choice?

Alex Tabarrok had an interesting post the other day at Marginal Revolution in which he asked readers to imagine standing behind a Rawlsian veil of ignorance. This is a thought experiment in which you are about to be born into a world, but you don’t know which person in that world you will be (e.g., you could be born smart, dumb; rich, poor; black, white; etc.). You can decide the rules governing the world you are about to be born into, but you must make your choice “position blind.”

What decision rules would you choose?

For his part, Tabarrok focuses on how to allocate kidneys among transplant prospects and his own solution is: allocate scarce organs so as to maximize remaining years of life:

In the current system, a 60-year-old patient can be given a 20-year-old kidney — that’s a waste because the life expectancy of the kidney is longer than that of the patient; it’s like putting a new clutch in a car that is rusting away.  If we had 20-year-old kidneys to spare, this wouldn’t be a big problem.  But we don’t have 20-year-old kidneys to spare, so we also give 20-year-old patients 60-year-old kidneys which means the kidney is likely to die early, taking the patient along with it.  If we want to maximize total life expectancy, younger people should get younger kidneys.

There are other good sentences, followed by comments — some of which dispute Tabarrok’s understanding of organ survival — and there are previous Marginal Revolution posts on this subject worth checking out.

Consider, however, the broader issue. Is maximizing years of life really the best standard? In general, such a standard implies that we should choose younger patients over older ones. But this conflicts with a long-standing view that everyone should have equal access to care.

Suppose you were an emergency room physician on triage duty and chance forced you to choose between saving one of these two patients:

  • (a)    A 40-year-old college graduate or a 20-year-old high school dropout?
  • (b)   A 50-year-old scientist or a 30-year-old derelict?
  • (c)    A brain-damaged child or a healthy young adult?
  • (d)   A 40-year-old successful entrepreneur or a 30-year-old day laborer?
  • (e)    A 30-year-old concert pianist mother or a 20-year-old welfare mother?

Triage decisions in which life and death hang in the balance must surely be agonizing. I for one am glad I have never been forced to make one. But suppose you had to. Would you choose the patient with the most remaining expected years of life? Or would you make these choices by flipping a coin (thereby giving each patient equal opportunity)? If you could dictate a decision rule to all emergency room doctors, would you insist that others decide by coin flipping? My own criticism of the coin toss approach is here. But if not by age and not by randomization, how should rationing decisions be made?

I believe that most people, most of the time would choose to save the patient who is likely to make the greatest contribution to national well-being. That is, most people will allocate care in order to maximize national output broadly defined. (Broadly means, considering not just GDP, but also things that aren’t well measured by GDP, such as contributions to the arts and sciences.)

But before I send this idea out to all the ERs in the country, we will give readers a chance to comment.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis.  He is also the Kellye Wright Fellow in health care. The mission of the Wright Fellowship is to promote a more patient-centered, consumer-driven health care system. Dr. Goodman’s Health Policy Blog is considered among the top conservative health care blogs on the internet where pro-free enterprise, private sector solutions to health care problems are discussed by top health policy experts from all sides of the political spectrum.

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  4. Shouldn’t we choose the patient who is most likely to benefit from a new kidney? This is a factor of patient’s age, health status and compatibility with the available transplant organ. If those factors are equal, which is difficult to believe, the next decision criteria need to be clear and defined. Perhaps, the choice should be made based upon age and ability to contribute to society. Even if a patient is 20 and the kidney is 60 years old, the patient can always undergo a second transplant. In any case, it is a difficult decision. http://medspanresearch.wordpress.com

  5. “Nature has answered this question for every other inhabitant. The strong survive. Any other method is arbritary and placing the power of God in a human’s hand. We all know what terrible things happen when people place them self next to god in power.”
    Nate, did you lift this from a 19th century book on eugenics? Certainly reads it and it is wrong. There has been plenty of work in evoluntionary biology in the past 20-30 years that has debunked the claims of ‘the strongest organism’ always survives.

  6. Dr. Schattner:
    Precisely my point – this post was framed as political commentary from the start. Thus, no honest discussion can be had here.

  7. The problem with rationing according to the sorts of decisions you offer is not so much the rationing itself (which may be necessary) but the language of the post which suggests that the author does not sufficiently respect some people who are different from him.
    Including the concept of “black” vs. “white” in the introduction shocked me – that the issue even crossed the author’s mind. And then to refer to a person as a “derelict” conveys a lack of respect for a fellow human. (A good physician would never refer to a patient using that term, should never even think that of a person under her care.) As to the point of wanting to assign relative values to the lives of the entrepreneur, day-laborer and mother who’s not also a pianist, I guess or hope I missed that one.
    If we are to move ahead in rationing – in deciding what’s money well-spent in health care and what’s not – we have to take care in how we frame the discussion from the start.

  8. As pointed out, we may not have exactly these kind of rationing choices. And if we had, we chose one who shares something with us. Nate shares nothing with me. He is not going an eyelid before he takes his decision.
    Practical rationing decisions are- what procedures works and what doesn’t. What doesn’t is decided to be thrown away. It is not that some will get benefit and some will not.
    The problem with that approach as I see that is it is medicinally less effective though fair it maybe. I haven’t done research on this but I see more and more types of disease, more drugs being useful only to smaller population, more rare diseases etc and so more personal medicine. I believe global synthesis of food chains, international travel, stronger antibiotics are helping in evolution of new pathogens.
    Procedures & drugs that were effective in past may not just work in future or may work with a subset. Procedure based rationing does have drawbacks.

  9. Profit Driven Medicine is only respectful of those who’s status lords above them. A field derived from need has become a product, sold to the highest Bidder.
    Sure,we can repudiate such claims by showing the humanity of treating the less fortunate. At least their dead corpses are not scattered thru out our Communities. However, taxpayers subsidize these institutions to provide indigent services. So the idea of free care is a misnomer.Someone always pays!
    The Fact that these new reforms will make deadbeat business’s provide health insurance for their employees has been long overdue.
    Your Death Panels have always been Denial of Services and /or extremely excessive cost. Which dictates a persons ability to live or die. Yep! Insurance has had alot of experience in deciding who dies. If your health insurance profit and loss sheet starts running in the Red. Pulling the plug to save investor profits. Its a NO BRAINER!

  10. “rationing is a sad reality of life. It should never be in the hands of government to decide who gets it and who does not.”
    Yes, give it to the insurance companies, they know how to make life and death decisions better than anybody.

  11. rationing is a sad reality of life. It should never be in the hands of government to decide who gets it and who does not.

  12. Why Does The U.S. Have Such a Lousy Health Care System ?
    1) Because its not fair that the hardest working of us have private coverage which is superior to the health care offered to those who dont work, paid for by the tax-payer (in addition to the hard working taxpayer’s own deductibles…..nevermind – we should all be the same, regardlesss if some of us work harder than others). The problem is Capitalism.
    2) Because Health Care is a basic human right which should be offered by the government (who can always be trusted to ensure fairness) – just like driving priviledges are. Health Care should be just like the DMV – where we all take a number and wait on lines, regardless if your liver falls out in the meantime – and this way there will be nobody to sue, or to hold accountable when the mind numbing beuocracy f*cks up your life, literally.
    3) Because the fact that the state doesnt own your health gives people far too much freedom to choose – its not fair that some of us can afford quality care, while others cant. So, naturally – the only solution is to spread the misery around equally (the inherent virtue of liberalism) and make sure that EVERYBODY is subject to the same lousy DMV-Style health care that only congress-people are exempt from.
    Screw you Obama, we all know that socialized medicine has been the holy grail of the left since 1960, and that you are finally trying to make this a reality – it has nothing to do with health care, and everything to do with power. Who the hell will speak out against, or vote against, the party who decides who gets to live, and who gets to die ? Its got nothing to do with Health Care, and everything to do with power.

  13. Very well. For starters, Nate, I don’t quite understand if you are pro or against rationing. You keep referring to Liverpool as a bad thing, but then it seems that you would like to somehow ration care based on multiple criteria. So I guess I’m asking for clarification.

  14. death panels are a legit concern and worth debating. I rather debate death panels prior to a US version of Liverpool care pathways then after.
    If Medicare had been debated prior to its passage it wouldn’t be here today. Not going to let that mistake repeat its self.
    Whats been uncivilised on this post? Your the one tossing around double ?s. That was a needless escalation of the rehtoric, one ? would have amply conveyed your point.
    I haven’t seen any proposed solutions from the left, just attacks on John’s oddasity to use a loaded metaphor.
    Never to late to start what, are your ideas Margalit? We can start honest and respectful debate from there and see how it goes. Put down your ??s and I’ll leave my CAPS and !s at home.

  15. Really, Nate? Really?? Why don’t you try a honest conservative POV without death-panels, Obamacare, Communism, elitism, etc. propaganda, and see what the responses are?
    I consider myself exceedingly liberal, and yet I have a huge problem with rationing of any kind and another huge problem with the individual mandate. I presume my preferred solutions to these problems are very different from yours, but nevertheless, we can certainly discuss these things in a civilized manner.

  16. Honest discussions require both sides to be honest, while there are a few people more then capable of having an honest discussion and leaving the politics out that will never happen on THCB. This is an overtly liberal political blog with a couple loud mouth people from the right fighting a losing fight. Someone with a conservative POV couldn’t post an honest non political piece on here and last past the first comment.

  17. Nate;
    You misunderstand me; I am not one of those who thinks we should spend everything on everybody. I am simply objecting to this particular author, whose political leanings are well known, titling a post as he did, with a currently politically incendiary word. Metaphorical or not, his point is political, just like saying ‘death panels.’
    Many physicians agree that we already ration health care. Dr.Berwick says we do it on the basis of access, others say we do it on a case-by-case, irrational basis.
    Health insurers already ration care.
    But let’s have an honest discussion about it, not play to the fears of the elderly who really don’t understand the issues. This post is a particularly slick and subtle way of doing just that.

  18. The “Rationing” debate is purely hypothetical and based on false premises with its only purpose being electioneering propaganda.
    We spend too much on health care because hospitals, insurers, pharma & device and large physician groups are gouging prices. We also spend too much because we’re too lazy to prevent fraud and abuse, mainly in the public sector. And finally we are wasting resources left and right because we are unwilling to redesign the delivery system to maximize operational efficiency.
    If we fix all of the above and it still turns out that we don’t have enough money to take care of everybody, then, and only then, Rationing will need to be considered.
    Shouldn’t we Ration Wall Street’s profits before we Ration people’s lives? Or is that not an option any longer in our morally bankrupt governance system?

  19. There is are many differences among rationing (policy-based and prescriptive), triage (knowledge based and restrictive), allocation (economics-based and restrictive), accessibility (reality-based and restrictive), and opinions. It’s hard to compare the fruit in this basket, except to note that opinions seem to dominate the fruitful choices.

  20. terrible if you actually posted something productive Peter. Care to expand on why I would want to further research qualifications? I am already quit familar with them.
    When you comment it is usually a good idea to include a point, a purpose for the comment.

  21. “Did we eliminate Medicaid and no one told me?”
    You might want to research State income/asset qualifications for Medicaid.

  22. Bev MD is it possible his triage examples where metaphorical? If you all really want to get so literal about everything then answer this triage question;
    You have a population over 65 consuming 1 trillion a year in healthcare and a poor population consuming 500 billion. You only have 1 trillion to spend who do you cut off and how?
    You have a population of educated consumers who shop for the best value and spend an average of $3000 per year each. You have a medically similar population who show no regard for spending costing you $5000 per year each. With a limited budget you need to reduce spending 20% do you take it from both equally? How do you reduce your cost?
    c) is a legit question as written, Indian Health Services already deals with this every year, they have in effect a 6 month health plan, get sick by June or don’t get treated. Are limited resources being best allocated, some might deem it fairly allocated but is that best?
    All of these were legitmet examples, I think the real problem is no one wants to have to make the hard decision. It is much easier for certain people to promise everything and let tomorrow worry about the bill. Now that they are literally worded how do you solve the problem?

  23. Organ allocation does not have to be a zero-sum game. Some allocation methods can increase the supply of organs.
    There is a simple way to increse the supply of organs — allocate organs first to people who have agreed to donate their own organs when they die.
    Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren’t willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.
    Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at http://www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition. LifeSharers has over 14,000 members, including members in all 50 states.

  24. Mr. Goodman accomplished his objective in writing this post by getting the word “ration” in its title; the rest is mostly nonsense. As Barry correctly points out, the triage decision set forth is based on false pretenses and would likely never occur in real life.
    Beware of people trying to suck you in to their political aims.

  25. “evolutionary theory does not show that the strong survive. It shows that organisms that can cope with the environment they find themselves in survive.”
    I would disagree Esther. Within a species the strong and fit survive. The disabled,, old, weak, are usually the first to fall prey. When comparing species against other species yes those that cope survive. I beleive the original question was intended to be rationing amoungst humans not how do we outlast ants and their uberefficient health system.
    “Just curious, what prompted this particular conversation at this particular time?”
    We can’t engage in the occasional surreal conversation to break the dolldrums of wonkish debate in which we usually sludge?
    Is there ever really a right time to tell your kids you really do love one of them more then the other?

  26. I would think that someone close to death with little chance to recover would NOT be the person saved. Aside from that,value judgments really don’t belong. For instance, a scientist might beat his wife, a day laborer be very important to his community. We should mostly be going for chances for survival in the immediate circumstances. We cannot evaluate the lives of old vs. young, educated vs. not, street person vs. priest so easily.
    By the way, evolutionary theory does not show that the strong survive. It shows that organisms that can cope with the environment they find themselves in survive. Thus, in a way too simplistic example, an 82 year old man who crashed his car who is lucky enough to find himself in a hospital with the organ he needs as a result of the crash will survive where a young woman who is a paragon of strength who falls hiking and severs an artery and does not have immediate access to a blood transfusion will not.

    How much $$$$ is spent on problems due to SMOKING, dope, over-eating, booze and “extreme living?”
    Why does the public have to pay for that STUPIDITY? Which, BTW, would probably pay for FIVE “reforms.”
    We’re our brother’s keeper.
    And stupidity, SLOB-LIKE LIVING, incompetence, waste, fraud, theft, feather-bedding, and BLANK CHECKS do NOT have to be involved.

  28. …and if your house was on fire, and you could only save one child, which one of your children would you save?
    Just curious, what prompted this particular conversation at this particular time?
    I understand the need to keep the specter of Big Bad Government rationing alive and well, but this is surreal.

  29. InfoMark, you sound like a politician, you talked a lot but you haven’t answered the question. Two people are in front of you, which lives and which dies and why? It is very easy to say your on the high road when you haven’t moved.
    Speaking of limited resources and use there of;
    82 year old man drives into the ER, gets out of his car, and shoots himself twice. In this case the hospital managed to save his life. He is still 82, still suffers from what drove him to this point in the first place, and likly is near death anyways. Was this a good use of resources? It could be said with confidence that money spent on prenatal programs could have saved a dozen of new borns. Either or how do you not spend that money on babies who each have 70 years ahead of them? 800 years of life compared to 1-2.
    The easy answer is to be liberal and say raise taxes on the rich and save all of them but sooner then later even they will learn that is not always an option.

  30. Ah Nate, sounding like a Dickens character. “Are there no prisons? Are there no poor houses?” Medical advancement inevitably impacts the balance of nature, the question here is when resources are scarce what should govern the access to those scarce resources – that may determine life or death. There is nothing natural about the “free market” or wealth, these are all societal creations – nothing devine about Adam Smith. And government subsidies aren’t natural either.
    There is a reason that bioethics courses are taught in medical Schools. Until the political structures craft regulations to make these decisions – which in this country, for pragmatic reasons, dosen’t overly frequently occur, lets hope or clinical decision makers learned something in their bioethics and mal-practice seminars.

  31. Organ transplants are one area of medicine where we have rationed care for a long time using well established criteria other than ability to pay. Beyond that, I think the triage concept rarely comes into play. It is more likely to be associated with a terrorist event, a wartime mass casualty event or the rapid spread of an infectious disease in a specific geographic area.
    In end of life situations especially, common sense and cost-effectiveness should shape how we define good sound medical practice. People should have medical options explained them including the quality of life implications of each and the cost even if insurers or taxpayers are paying most of it. The idea that people should be entitled to any medical service, test or procedure that has even a tiny chance of benefitting them and that someone else should pay for it has no place in our world of finite resources and skyrocketing debt.

  32. Nature has answered this question for every other inhabitant. The strong survive. Any other method is arbritary and placing the power of God in a human’s hand. We all know what terrible things happen when people place them self next to god in power.
    Is it a good solution, by no means at all, any preventable death is sad. But it is the fairest solution. It also doesn’t mean we should stop doing everything we can to minimize such decisions but must admit they are decisions that must be made.
    “We ration care today, those who can afford it get, those who don’t, do without.”
    Did we eliminate Medicaid and no one told me? Quick search on the intertubes says millions of people who can’t afford care are getting tens of billions of dollars worth. Maybe we could do away with the sound bites and try using facts for a change?

  33. I’d say base it on urgency and appropriateness of care. Then first-come-first served, other factors being equal.
    Social or economic value decisions are simply not something physicians are trained in. They are as fallible and biased as the rest of us. And think of the litigation than might come from such decisions.

  34. The answer to this outside the U.S. has been teletriage. It is interesting you started with a triage example. If the patients are on site the the Decision Support Software can be used then too. This is how it is done in the UK and Canada and now pilots are being launched in Emergency dispatch in Richmond, Houston, Seattle, Philadelphia, and Louisville. For reference info on this see: http://www.lifebot.us.com/teletriage
    Roger Heath

  35. John, Interesting choices and perhaps false choices. But in your scenario people at least make it to the ER in reality some folks don’t make it that far. The responsibility of decision making is handed to the ER physician, why does he/she get to decide? How does he/she know enough about the “value” of a person.
    This of course where we need to consult our death panels isn’t it? Paging Sarah Palin! Don’t we get to call CMS and ask our local bureaucrat to send us the American value matrix to aid the decision making.
    Perhaps we should start the discussion on rationing about access to basic care and not trauma care and care proven by scientific research to have value and not just generate income for providers.
    We ration care today, those who can afford it get, those who don’t, do without. Try to get on the organ transplant waiting list without a substantial cash deposit, Medicaid, Medicare, or the right insurance coverage. Be Steve Jobs and have access the transplant hospitals with the shortest waiting list.
    In your cost benefit analysis, who is more valuable the investment banker or the poet? The garbage collector or the lawyer? The have or the have not?