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Rationing of Healthcare in America

By Dr. Christopher Hughes

“The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

This quote from Don Berwick, now the former head of Medicare, along with other quotes praising the effectiveness and efficiency of the United Kingdom's National Health Service, prevented him from being confirmed in the US Senate for the permanent chief of Medicare job. It seems that many members of the Senate, in spite of seeking to cut costs in the Medicare program, reject outright the concept of "rationing" health care in any manner. They also apparently reject the idea that a country (i.e., the UK) that controls costs in its health care system has anything to teach us - about anything.

Rationing is the controlled distribution of scarce resources, goods, or services. Health care services are inherently scarce: money for services is not unlimited, facilities for delivering services are finite, and health care professionals are limited in time, geography, skills and capacities, and so on.  Berwick correctly notes that rationing is not the question - we already ration - but rather how we do it versus how we should do it. We currently ration almost exclusively by income. As Uwe Reinhardt has noted, in America, if you are uninsured, you have the health care system equivalent of a third world nation - you only get the care you can afford (unless you are "lucky," and are sick enough to require Emergency Room care and federal law requires you be given enough care to make you less critically ill). We also ration within our insurance systems, be they private or public. Private insurers routinely decide which providers, institutions, medications, and procedures will be paid for, and which will not. Our private insurance packages have limits, qualifications and armies of bureaucrats charged with limiting spending on health care to ambitious targets (the "Medical Loss Ratio"), and Medicare and Medicaid have significant limits as well. So, in spite of a large cohort of Americans believing to the contrary, we do routinely and ruthlessly ration care here in America, in a manner unthinkable around the world.

The professional ethic in medicine has traditionally been to provide all services to the patient in front of us, without restraint on any resource. In fact, fighting for resources for a patient is still considered highly admirable, no matter the financial or other costs to society.

The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups, and to advocate for their patients’ welfare. - AMA Code of Ethics. (AMA, 2001.)

Straining against this moral imperative, however, is the more recent rise, signaled by a new Charter on Medical Professionalism (ACP, 2002), but also found in the same AMA Code of Ethics, that the medical profession must strive for a fair distribution of scarce resources, and that physicians must take responsibility for advocating for this social justice. (ACP, 2002)

This conflict between advocacy for the individual patient and advocacy for equitable distribution of resources is not lost on the profession, and is explicitly acknowledged in both the Charter and the Code. The conflict in this discussion rests entirely on the role of justice, specifically social justice, as it applies our conflicting roles. Physicians will generally accept the other major ethical questions as a given: do good (beneficence), do not harm (non-maleficence), and respect patient (and physician) autonomy.

From my perspective,  physicians fall somewhere along a continuum of strict advocacy for the patients in front of them without regard to allocation of resources, to strong advocacy for social justice and fair distribution of resources. But this dichotomy, of course, oversimplifies, and all physicians seem to have the capacity to place importance on both, while leaning one way or the other overall. George Lakoff might call us all "bi-conceptuals" in this area.

The typical argument by physicians largely opposed to the social justice argument, and consequently opposed to expansion of health care coverage by non-market-based methods, is that they personally take care of all patients who present themselves. Not only do they care for these patients, but they advocate for them - better operating rooms, better hospital amenities, better nursing and ancillary care, longer stays in the hospital, as well as better reimbursement for themselves and their peers, as this will increase the "resources" available for patients. They usually point out that their practices include a certain amount of care for the indigent, thus fulfilling their dual duties in this ethical conflict: serving the patient in front of them and performing a social justice role by taking care of an otherwise un-served patient.

On the other hand, physicians like me argue that taking care of the patients in front of us and advocating for them is the minimum we can do as physicians. It is not far off from what any member of society does - do the job at hand, get paid for it, and give some money or time to charitable efforts. It is quite comforting to go about the practice of medicine, and not look at our society as a whole, and acknowledge, at the very least, the major disparities in health care in America.

Our role as physicians, certainly those in leadership, must go beyond this minimum. Our professional role - that is, our role, collectively, as a profession - cannot simply be our practices.  We are also tasked with a public health role and a social justice role.  

I believe this is why, nearly unanimously, every major specialty medical society and the AMA adopted the Charter on Medical Professionalism, including its strong emphasis on social justice and fair allocation of limited resources and strong commitment to universal access to health care. It is one thing to be a practicing physician and merely argue for resources for the care of our own patients, it is another to be a leader in medicine, and abdicate these core professional responsibilities. The ethical balance of advocating for the individual patient ("patient welfare") versus advocating for fair allocation of resources and care for all persons (social justice) falls heavily to the latter when one is a leader in the profession.

But even so, there is not necessarily an insurmountable dichotomy in these conflicting ethical imperatives. Clearly, physicians in systems with an over-riding ethos of social justice still advocate for the patients in front of them. Their advantage is that the "general welfare" of the population is assumed to be the primary system value, whereas here in the US, we are still fighting about this politically.

Which brings us back to Don Berwick's apostasy, as seen from the view of conservative Americans. His sin is the recognition that we do ration care, it is right in front of us, it is fixable, and that we might have something to learn from other health care systems that are not our own. Or, perhaps better stated, he recognizes that the "Emperors" declaring that we do not ration care, we have the best healthcare in the world, and that we have nothing to learn from other nations except how not to provide healthcare, have no clothes.

"It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein."- Theodore Roosevelt


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