I want to ration your health care

I want to ration your health care. Well, I don’t want to do it personally, and not to you specifically. And that’s the problem. Policies on the individual and societal levels feel very different. We are not culturally prepared for “rational” rationing. We’re happy to do it irrationally; if you don’t have insurance, you’re probably not going to get proton beam therapy for your prostate cancer. Someone might be willing to chemically or surgically castrate you, though.

Even if you do have insurance, should you be able to get, for example, proton beam therapy? Therapies new and old are often available and used independent of how good they actually work and how cost-effective they actually are.  What if (and I’m making up the numbers here) proton beam therapy, which costs gazillions of dollars, decreases cancer recurrence by a few percentage points, and decreases impotence by a few more? Is it worth it? For you? For us?

I’m not beating up on proton beams; never pick a fight with ionizing radiation unless you’re sure you will win. The wider point stands though. In the U.S. we practice medicine with complete irrationality.  There are thousands of lives that can be saved by simple practices that so many of us ignore. There are thousands more that can be saved by the proper use of medications.

And yet we continue to pour money into a fantasy. We believe that a 95 year old with cancer just might be the one to survive the ICU, with just one more day on the ventilator, just one more round of dialysis. We believe that our own patient with pancreatic cancer might be the one who feels better on Gemzar. We believe we can cure our obesity-related disorders without exercise, without medicine, and without society-level interventions (it worked with smoking).

The American medical system is an irrational fantasy, one in which we swoop down and cure one person’s problem at a time, forgetting that the system as a whole is making us all sick and broke.

11 Comments

  1. On the other hand, not giving treatment to that 95-year-old seems like a really shitty thing to do.

    • Ah ha! It’s a matter of perception. “Not giving treatment” is very different than “giving appropriate treatment”.

      • I suppose. Still feels wrong to just let someone die without trying everything beforehand.

        • lumbercartel

           /  July 31, 2012

          Still feels wrong to just let someone die without trying everything beforehand.

          Even when that “something” closely resembles torture?
          Even when you could, no serious doubt about it, save hundreds of children’s lives for fewer expended resources?

          When we’re not letting children die or suffer the rest of their lives for want of inexpensive and reliable care maybe then we can talk about the ethical economics of “heroic” care for terminal geriatric patients. Until that time, I really don’t think we have much standing to speak.

          • I don’t think that treating this hypothetical patient needs to be at the exclusion of other patients.

          • lumbercartel

             /  August 1, 2012

            I don’t think that treating this hypothetical patient needs to be at the exclusion of other patients.

            Would that this were so, but there is never enough money for prenatal, perinatal, and early childhood care. At the same time there’s always enough money to keep terminal geriatric patients in ICU for weeks.

            Resources are always finite. Choose wisely.

    • lumbercartel

       /  July 30, 2012

      Why does “not giving that patient treatment X” sound so much like “not giving your 1963 Studebaker a new cylinder head?” The patient is not (or certainly shouldn’t be) a passive object of this care. And that’s aside from the question of “giving treatment X” vs. “paying for treatment X.”

      Every recent survey of physicians shows that they’d personally prefer far fewer end-of-life interventions than they normally give patients. Sounds like a failure to communicate, if nothing else.

      That’s why I have a rather detailed EOL directive (and I’m just 60.) It’s the same reason that my mother’s recent death was as drama-free as it was: she had planned for it and made her wishes (comfort care only, thank you) quite clear. So “not giving treatment to that 85-year-old” was not only sensible, it was what she wanted and what she had directed her family and caregivers to do.

  2. John M. Harris

     /  July 30, 2012

    Good grief, if grampa can pay for it, get out of his life!!!

  3. John, a few thoughts to consider:

    Grampa isn’t usually paying for it by himself. Whether it’s Medicare or private insurance, other people are paying for the bulk of it.

    When it’s Medicare, it is everyone that pays taxes paying for grampa’s minimally life extending treatment, and ultimately either taxes increase, the Federal debt goes up, or some other spending gets eliminated as a result.

    When it’s private insurance, it’s ultimately all the premium paying customers paying for it, usually resulting in higher premiums because insurance companies aren’t in the business of writing checks.

    Even if grampa was a multi-millionaire and paying for it himself, he is still consuming (and out competing others for) finite available medical resources. Another consideration might be, what kind of financial situation is grampa leaving behind for gamma as a result of this spending? Sure, that’s just between gramma and grampa to decide, but if gramma ends up broke and on Medicaid, it affects the rest of us as well.

    Nobody exists alone on an island, and many of our decisions have effects that extend beyond ourselves, even when those effects are not immediately obvious.

  4. John, a few thoughts to consider:

    Grampa isn’t usually paying for it by himself. Whether it’s Medicare or private insurance, other people are paying for the bulk of it.

    When it’s Medicare, it is everyone that pays taxes paying for grampa’s minimally life extending treatment, and ultimately either taxes increase, the Federal debt goes up, or some other spending gets eliminated as a result.

    When it’s private insurance, it’s ultimately all the premium paying customers paying for it, usually resulting in higher premiums because insurance companies aren’t in the business of writing checks.

    Even if grampa was a multi-millionaire and paying for it himself, he is still consuming (and out competing others for) finite available medical resources. Another consideration might be, what kind of financial situation is grampa leaving behind for gamma as a result of this spending? Sure, that’s just between gramma and grampa to decide, but if gramma ends up broke and on Medicaid, it affects the rest of us as well.

    Nobody exists alone on an island, and many of our decisions have effects that extend beyond ourselves, even when those effects are not immediately obvious.

  5. DLC

     /  August 4, 2012

    Cases like this, the Doctors don’t get to make the call, for a reason. If you start rationing care based on “how much longer is this poor old man going to live” what’s to stop you from descending from there into Euthanasia and Eugenics ? Why should anyone but the patient (or their family) be permitted that kind of choice ? We have the best healthcare delivery system in the world, at least in potential. It should not be a contest between the 89 year old guy whose lungs are failing and the 8 year old who has pneumonia. Oh, and yes, I encourage everyone to establish an end of life directive, or at least a DNR order. Make these hard decisions now, so that your family does not have to. Please.

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