The Grand Unification Theory of Health Care

Section 8 - Fixing our health care system

               Guiding principles: A proposed ethical standard for rationing
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Grand Unification Theory of Health Care

- Contents -


SECTION 1 - The importance of the doctor-patient relationship and why we can't have it anymore 

SECTION 2 - The truth about health care rationing

SECTION 3 - Health Care 2000 - how it got this way

SECTION 4 - Secrets of  managed care 

SECTION 5 - Portrait of a modern HMO

SECTION 6 - The Clintonians Strike Back

SECTION 7 - Rationing and Death - Covert rationing and end-of-life care

SECTION 8 - Fixing our health care system

APPENDIX - Devising a methodology for open rationing

The FCEO standard

We would like to propose, in light of the foregoing, an ethical standard upon which to base our rationing decisions.  We will call it the Fair Chance, Equal Opportunity (FCEO) standard:

All individuals should have a fair chance for an equal opportunity to enjoy the fruits of life, within the constraints imposed on them by nature.

This proposed ethical standard is a reformulation of the principle of distributive justice, dressed up for the purposes of rationing.  It is designed to allow us to optimize the good we obtain for our health care dollar, but only within the constraints of fairness.

Thus, while we ought to let “fairness” (i.e., the needs of the individual) predominate, we also ought to constrain it to allow society to accrue an optimal amount of good.  The FCEO standard constrains the individual’s claims on society in the following ways.

It acknowledges that the principle of fairness does not require equivalent outcomes (i.e., equivalent enjoyment of the fruits of life) among individuals.  It strives only to gain for individuals an equal opportunity for those good outcomes.

Further, it recognizes that not even an equal opportunity is possible among all people.  Opportunities are limited by the vagaries of nature.  A boy born with a shriveled arm does not have the same opportunity to become a major league pitcher as a boy born with two normal arms. If the one-armed boy decides to become a pitcher, we can encourage him and cheer him on, and if he succeeds we can rejoice with him. But we are not obligated to change the rules of baseball to accommodate him, nor are we obligated to divert whatever health care resources we must to provide him with sufficient physical compensation to allow him to compete effectively. Similarly, there will be circumstances where a person’s illness or disability will significantly reduce their opportunity to respond to a therapy.  Society is not obligated to spend whatever it must to provide them with such a therapy.

Finally, equal opportunities are limited by chance.  A person born in Watts certainly doesn’t have the same opportunities in life as a person born in Brentwood.  But society is not obligated to move the child from Watts into Brentwood, or the child from Brentwood into Watts in order to provide equal opportunity.  What society is obligated to do is to offer a fair chance (not an equal chance) at an opportunity to enjoy the fruits of life. Thus, for instance, society is obligated to assure that both children have access to a reasonable public education.

In summary, under this formulation of distributive justice, a system of health care rationing is not obligated to assure that all individuals have equivalent outcomes, or even that they have equivalent opportunities, but merely that they have a fair chance at equivalent opportunities within the constraints imposed on them by nature.  In rationing under the FCEO standard, then, the distribution of resources would not be based on either attempting to maximize the overall good produced to society, or attempting to equalize outcomes among all individuals.  Instead, it would be based on attempting to attain a reasonable equalization of opportunity for individuals.

Thus, while we should aim to optimize the opportunities of those who are burdened by disease or disability, we are not obligated to strive to return them to “normalcy” at any cost.  On the other hand, the presence of a disease or disability does not diminish in any way their claim to a fair chance at an equal opportunity to optimize their enjoyment of life, within the constraints of that disease or disability.

The FCEO standard would imply, for instance, that if we were able to restore eyesight to a blind woman, but only at a cost equivalent of performing coronary artery bypass grafting on twenty others, we are not obligated to do so.  We are only obligated to consider it fairly, as we would any other medical procedure.

The FCEO standard does not make the problem of maximizing fairness vs. maximizing good go away, but it changes the question.  Instead of saying, “Saving which of these two individuals will be better for maximizing overall good,” we will be saying, “Given these two equally worthy individuals, how can we best achieve a fair optimization of opportunity?”

Some implications of the FCEO standard

The FCEO standard would also present us with other opportunities, admittedly controversial, to optimize beneficence without compromising fairness. 

For instance, we may decide that patients whose diseases or disabilities are self-induced have a less compelling claim to health care resources than those whose illnesses are caused by “nature.”  Patients who choose to smoke, for instance, choose an action that predictably will require expensive medical care, thus potentially causing other patients who chose not to smoke to forego beneficial care. It would not be unethical, therefore (nor a violation of the FCEO standard) to ask smokers to sacrifice a degree of their priority for medical care.  Such a provision, if chosen, to be fair would have to be enacted prospectively – that is, we may choose to apply it, say, only to smokers born since 1985, so they would most likely have plenty of time to “unchoose” smoking before they developed smoking-related illnesses.

Even more controversial, but still consistent with this principle, would be to use age as a factor in determining priority for health care resources.

The use of age as a rationing parameter has been widely debated among ethicists. Most who argue for it base their arguments on the principle of maximizing public good. The duration of benefit of a life-saving procedure, they would say, would be greater in a younger patient than in an older patient (since saving the life of a 70 year old might “buy” only 10 years of additional life, whereas saving the life of a 20 year old might buy 60 years of life at the same cost.)  This reasoning, clearly, is in violation of the FCEO standard.  It also opens up the slippery slope argument – if you can devalue the elderly in the name of maximizing good, then you can devalue the handicapped, the chronically ill, and virtually any other group you can think of in order to maximize public good.

Yet, the FCEO standard still allows a rationing system to prioritize according to age.  Under this standard, saving the life of a 20 year old might take precedence over saving the life of a 70 year old not to increase overall good, but simply because the younger person has had relatively little opportunity to enjoy the fruits of life - an opportunity we should strive to optimize.  By giving priority to the younger person, we come closer to achieving a “fair chance for an equal opportunity” between these individuals than if we had given priority to the elder.

Further, the “discrimination objection” to age-based rationing does not hold here, because under the FCEO standard, every individual should have a fair chance at an equal opportunity to enjoy the fruits of life, and the 70 year old has already had 50 more years of opportunity than the 20 year old.  Nor does the slippery slope argument hold. That argument, you will recall, says that if we differentiate between individuals based on age, we can differentiate based on anything we choose. But under the FCEO standard, rationing by age does not, in fact, differentiate among individuals at all. What it does do is attempt to equalize opportunities between individuals over the course of their lives.  Thus, each individual, during the course of their lives, will at some point enjoy the priority of the young, and (if they are lucky) also the priority of the old.  Unless early death ensues, every individual over the long term will share the same distribution of age-related risk. 

We are not saying here that we must use age as a factor in determining rationing priority, or even that we should.  While my own belief is that optimizing “fairness” implies taking age into account when rationing health care, we are merely arguing here that we could use age as a factor if we chose without violating the principle of distributive justice as formulated under the FCEO standard – and without starting down a slippery slope.  The Appendix shows how the FCEO standard can be used in calculating priorities for health care services.

Next: What would our rationing system look like?

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