Friday, August 6, 2010

The Ethical and Practical Problems of Medical Rationing

Bonjour mes amis!

We’re getting political today! Don’t let the med school committees get their grimy paws on this one!

My mother, a dietitian, recently directed me to an article published in Lancet 2009 titled "Principles of allocation of scarce medical interventions." It was written by Govind Persad, Alan Wertheimer, and Ezekiel J. Emanuel, who is the corresponding author and the brother of the current White House Chief of Staff. All three are bioethecists at the NIH. This and other publications by Emanuel became controversial during the battle over healthcare reform legislation.

The article specifically addresses such items as organs and vaccines that are, at least at present, scarce. However, the ethical principles involved could easily be extended to all medical care in a nationalized healthcare system. Although the article claims that application of these principles to the healthcare system as a whole would be “premature,” the recent debate highlighted the way that healthcare funding is, more and more, being framed as “scarce resource.” Note that, alongside organs and vaccines, ICU beds were listed as scarce in the introductory paragraph.

The article examines eight different possible approaches to rationing scarce medical resources, along with the United Network for Organ Sharing (UNOS) point system, a “Quality-adjusted life years” system, and the authors’ own proposed “Complete Lives System”. These can be roughly divided into three categories, with some overlap: indiscriminate, utilitarian, and justice-based. The indiscriminate category includes lottery and first-come, first-served systems. The utilitarian approach involves saving the maximum number of lives, life-years, or “quality-adjusted life years,” and also includes schemes that prioritize healthcare workers and the “sickest first” system, although the article argues against that system’s utility. The final subcategory, the justice-based category, includes rewarding donors and prioritizing the youngest first, not because of their good prognosis, but because they have experienced the least number of life-years and are thus the worst off.

The paper concludes with the “Complete Lives System,” which advocates for maximizing the number of “complete lives” lived. It incorporates elements of utilitarianism, justice, and social utility, prioritizing treatment of young patients (excluding infants) who stand to gain the most life-years and who have formed relationships with other people.

I will save an in-depth analysis of these various approaches for another time. Briefly, if you believe that a doctor’s fundamental goal is to uphold the dignity of each individual human life, then several of these ethical schemes are untenable. The “quality-adjusted life years” system can be rejected out of hand. As the authors themselves point out, a wheelchair-ridden person might value an additional year wheeling around as much as another person values a year on their feet. Doctors should not be in the position to dictate whose experience is devalued. I also don’t believe doctors have the authority to choose who “deserves” treatment more than others, and questions of social utility should only be relevant during acute national crises. Of the authors’ favored approaches, this leaves the utilitarian approaches of maximizing lives or life-years as the only ones that are mindful of the equality of human experience. I’m still wrestling with the idea that the young should be prioritized because they would have longer to live – I’ll be thinking on that over the next few weeks.

The “Complete Lives System” proposed by the authors is a Frankenstein amalgam that includes some of the worst ideas of the lot. It would prioritize care by age according to this graph:

The social reasons given for de-emphasizing infants reflect a clear philosophical break from the equal value of human life. According to the article, adolescents get priority over infants because they have “received substantial education and parental care, investments that will be wasted without a complete life.” Moreover, an adolescent has a “developed personality capable of forming and valuing long-term plans whose fulfillment requires a complete life.” This claim that education or – career plans – somehow dramatically increases the value of a person’s life is patently absurd.

Likewise, the “Complete Lives System” is driven by retrospective notions of justice that have no place in a doctor’s work, which should be concerned with what can be achieved for a patient prospectively. The idea is that a person who has lived a “complete life” deserves additional years less than a person who has not lived as long is an affront to the equality of human experience and individual perception.

This brings us to a larger problem with the application of the “Complete Lives System,” and most of the utilitarian ethical schemes, to healthcare as a whole: by lowering medical expectations, they would perpetuate and normalize the scarcity of the product (health care) instead of investing funds to keep pushing the boundaries of science. In the context of a utilitarian national medical system, the ethical definition of a "complete life" would be dependent upon changing government fiscal needs. A contraction of medical funding could be handled by simply contracting the expectations for medical treatment and research. This is already apparent in the “Complete Lives System,” which sees a marked de-prioritization above the age of 60, well below the current average US life expectancy of 78.

This is especially problematic because defining the point at which medicine is too costly as the point at which life no longer deserves medicine is an exercise in circular reasoning. Under the “Complete Lives System” proposed by the authors, the populations most poorly served by medicine – the elderly, the seriously ill – would, by definition, be deemed unworthy of treatment:

- “I’m sorry, but treating this person is too costly to be worth the effort.”
- “Why, Dr. X?”
- “Because they’ve already lived a complete life.”
- “What makes you think they’ve already lived a complete life?”
- “Because treating them is too costly to be worth the effort!”

By defining a "complete life," the government, which currently funds the most important research projects, would have no ethical imperative to continue paying for research targeted at elderly "undeserving" populations.

The current market system limits the ability of individuals to prolong life, but it does not introduce an ethical justification for that limit, let alone an arbitrary one dependent upon the government’s fiscal stability. It is this ethical and moral dimension that makes the “Complete Lives System” dangerous. Underachieving in healthcare is one matter; using that underachievement as a metric for the value of human life is quite another.

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