OP-ED

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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Guest

This can be done through managing stress, reprogramming your subconscious, creating new habits – even something
as simple as counting sheep. Acute or Short Term Insomnia:
In this type of insomnia the symptoms last for several weeks.
Stress is one of the most disastrous problems that can easily run down your immune system, cause sleep problems such as insomnia or over-sleeping, cause
gastrointestinal issues such as ulcers and much more.

waist flab
Guest

Excellent article with lots of food for thought. Glad to see you back to work on your blog. It’s one of the few blogs that constantly inspires additional reading and thought.

Florida health insurance
Guest

In the competitive world today people spend more than half of their lives working day and night for some or the other reason. Though it gives them good financial rewards and gratification of their desires yet what suffers a big setback is their health. This is because individuals fail to pay significant heed to health, the most crucial aspect of their lives. But being occupied is not the only factor in deteriorating health. Reasons like environment, epidemics, natural calamities etc. also contribute largely to fading human health.

Robert
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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

MG
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MG

“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.

exhaustedMD
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exhaustedMD
bev M.D.
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bev M.D.

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

Elaine Schattner, M.D.
Guest

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… Read more »

Vikram
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Vikram

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… Read more »

Gary Lampman
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Gary Lampman

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… Read more »

Peter
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Peter

“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.

Nate
Guest
Nate

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.

Thomas S.
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Thomas S.

Eff Obama.

Thomas S.
Guest
Thomas S.

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… Read more »

Margalit Gur-Arie
Guest

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.