Rationing

The latest recommendations to decrease screening of breast and cervical cancer and the introduction of a health care bill that seeks to expand care without costing more has created a fear that we will end up rationing care. We're afraid that medicine will put a dollar value on a person's life and if saving them is too expensive, we won't do it. American society is terrified of rationing. We want to believe that modern medicine will go to any extremes to take care of our health.

I argue that this is a moot point. We are rationing. We have always been rationing and we will always continue to ration care. Resources are finite, and possibilities are endless. By deciding how many doctors to train, how many hospitals to build, how many clinics to fund, how many public health measures to support, and what research to underwrite, the government is rationing resources. By deciding how many patients to see a day, when to go home, how much overnight call to take, a physician also rations his care. We would love to have hour long doctor's visits, same day appointments, immediate access to world-renown specialists, clinics and emergency departments within 5 miles, free medications, and cures for every disease, but we recognize that such ideals are simply not possible. Our system now rations care. True, it is far more indirect than telling someone they can't get a test because it's too expensive, but the principle is the same.

If it would cost taxpayers a million dollars to extend someone's life an additional month, some of us might not choose to break the bank. There's some limit to what's reasonable or not. But how do we finesse that balance? I think that if we educate physicians to be socially conscious, that will be sufficient to control costs without plunging into the dreaded nightmare of "rationed care." Physicians make a commitment to care for a patient and they will do right for that patient until that competing interest of social or economic feasibility balances it out. In medical ethics terms, there's always a competition between beneficence - doing what's best for a particular patient - and justice - equitable distribution of resources. I believe we can train physicians in these ethical principles so that they do what is appropriate and right.

But on a systems level, who should make the calls? Should hospital CEOs decide what tests need prior authorization because of the expense? Should public health officials decide how to distribute a limited supply of vaccines? Should academic department chairs decide what research to focus on? Should the government issue blanket statements like "routine mammograms between 40-49 are not recommended?" These are much harder questions, and I don't have answers. However, I do want to point out that the mammogram recommendation was based completely on an assessment of risks and benefits to the patient rather than a cost-effectiveness analysis, and as a result, is not an example of rationed care but rather rational care.

In the end, I believe the ethical competing interests of beneficence and justice exist on a dynamic and evolving spectrum. The question of how to ration care is very real, and we need people from all backgrounds: patients, ethicists, public policy makers, and physicians to weigh in their input so we do what's sustainable for our system and what's best for each individual person.