After lunch, a panel of experts and a concerned audience took on Arthur Caplan. It was quite a discussion:-)
The doctor on the panel said we should not talk about what we’re doing as rationing. In his view, we could save money if we quit spending it on the wrong things — treatments that don’t work and illegal immigrant care, for example. He also said that our technological improvements are the hidden costs in our patient care.
The nurse, Fran Roberts, said that nurses are on the interpretation and communication front line of rationing. They are the ones who tell the patient their care is over. Yet Roberts pointed out that sometimes withholding care is good. More treatment and procedures doesn’t mean better health care. She cited the example of her brother, who had terminal cancer, and whose oncologist wanted to keep on trying until she persuaded the family to opt for hospice and quality of life for his final days.
Joan McGregor, the philosophy professor (and a Canadian) believes that providing more care is not always to the benefit of the patient. In her eyes, getting rid of useless, potentially harmful last chance care is not rationing. Transferring people to hospice is not a money-saving tool — it’s a quality of life choice. Patients can decide not to have treatment. Not doing everything for everyone is not the same as rationing. There are many cases of medical futility.
The panel discussion brought out that there are three types of rationing:
1)Resource Rationing: has to exist for things like ventilators and ICU beds (we only have so many). It’s not just economic.
2)Economic Rationing. We also have to decide as a country how much of our resources do we really want to spend on health care? Is it the only good? What should NIH be working on? (Stem cell research will be very expensive and primarily benefit people at the end of life and only to people who can afford it) Shouldn’t we ask the government to concentrate on diseases that are more common and occur in younger populations.
3)Human resource rationing. Doctors don’t spend enough time with patients because there’s a shortage of doctors and nurses. Money doesn’t change this. Insurance doesn’t change this.
Suggestions were offered about ways to ration justly:
1)Shift reimbursement to primary care
2)Enact tort reform
3)Start a mediation system for malpractice
4)Re-certify doctors – 4% of doctors account for 80% of malpractice cases
5)Let doctors communicate about end of life decisions and communicate appropriate indicated care. Allow nurses and and doctors and pharmacists to say no without the threat of a lawsuit.
6) Adopt a single payer system (advocated by the ethics professor, who is Canadian)
7) Don’t allow people to profit by caring for the sick
Driving the health business by profit means there are more plastic surgeons than primary care physicians
8)Erase the large compensation gaps between primary care docs and surgeons
9) Make the insurance industry not-for-profit
10) Quit subsidizing all the world’s technological advances
11)Quit doing things because we can and only do them when they are effective
Update A reader emailed me the following:
Even politicians that say they are supporters of free markets are usually not fully consistent on the issue especially when it comes to health care. But that doesn’t mean that we should not be promoting the idea of getting the government out of health care. It needs to be a long term goal. It took about 100 years to bring us to this level of interference and it will take a while to get out.
A free market will bring costs down naturally and increase quality as it does in every other industry. This will make health care more widely available at the lower cost. For example you mention the scarcity of organs in the market today. In a free market there would be more organs available for transplants because there would be incentive for people sell their organs after death and leave the money to family members. Also, for kidneys people could sell one of their kidneys instead of having to give it away. This would bring more organs into the market and help more people. But the government forbidding the sale of organs keeps scarcity up.
As far as health care being a right, it can’t be. A right is something you have by your very nature as a human being and can’t require another person to provide you with something. That would be a violation of their rights. Just as an example, the rights mentioned in the Bill or Rights like the right to free speech or to bear arms do not mean that someone has to provide you with a microphone or a gun. That’s why there is no such thing as the right to a job, or the right to a living wage, or to affordable housing. These would require someone to give you a job, pay you more than your skills warrant or rent an apartment for less than what others would gladly pay. A right to health care would imply that you have the right to force a doctor to treat you or force someone else to pay for it.
The only moral system is a free market system. That’s why I’ve been writing my representatives and making that clear to them. I don’t expect to get a perfectly free market system now. But I expect them not to more closer to a system which violates more people’s rights and makes the system even worse.