Obama health policy advisor on rationing

Tuesday, July 21, 2009 Comments

If Obamacare is implemented, it stands to reason that demand for care will go up while supply of care will go down. On the one hand, I believe that some doctors will choose to leave practice (and students will opt to avoid medical school) rather than work under even more government control than already exists. Aside from that, the government is fixated on "cutting costs" with regard to healthcare despite it's free-spending ways when it comes to everything else.

Such an environment will create a scarcity of care, much like what has already happened in countries with socialized medicine like Canada and Britain, which invariably leads to government rationing of care. Given that, it's worth asking how will care be rationed?

For some insight into that, we can look to the recommendations of Dr. Ezekiel Emanuel, NIH bioethicist (an ironic title IMO), Rahm Emanuel's brother, and most importantly, Barack Obama's "Special Advisor for Health Policy."

So, what are Dr. Emanuel's views on rationing of care? He recently coauthored an article on the topic, "Principles for allocation of scarce medical interventions," in the Lancet. While the article references specific care like organ transplants, kidney dialysis, and vaccines in the event of a pandemic, it is also clearly meant to apply any time there is a "scarcity" of care (which Obamacare would undoubtedly create).

After considering a number of possible rationing methods that could be used, Dr. Emanuel and his colleagues recommend a combination of criteria which they call the "complete lives system":

"It prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. ... also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants (figure)."

While I was disgusted to see the curve take a nose-dive around age 50, I can't say I was surprised, based on Obama's recent statement regarding the elderly, "Maybe you're better off not having the surgery, but taking the painkiller," (translation, go home and die?). However, I admit I was surprised (and appalled) to see babies and young children also targetted to be denied care. What would this mean for preemies? Would life-saving NICU care be deemed "too expensive" by the bureacrats?

It gets even worse when you see his justification for such discrimination against the "very young."

"Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfilment requires a complete life. As the legal philosopher Ronald Dworkin argues, 'It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does'; this argument is supported by empirical surveys. Importantly, the prioritisation of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo."
That paragraph is just wrong and abhorrent on so many levels. What parent considers their love and time spent parenting as an "investment"? What parent would consider the loss of a baby less tragic than the loss of an older child? What parent would agree that it is acceptable to let a baby or young child die on the grounds that they haven't "invested" much time in that child yet (or worse, that the state hasn't "invested" in their education yet)? And to say, "this argument is supported by empirical surveys"?! WHO THINKS LIKE THAT?!? It makes me physically ill. No wonder these people don't care to protect the unborn or even newborns. If babies, toddlers, and even children who haven't yet reached adolescence mean so little to them, surely an unborn child would be worth even less in their eyes. I guess that answers my question about preemies...

Here's more:

"A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern that disproportionately large amounts of resources will be directed to young people with poor prognoses."
And who determines prognoses? Something tells me it won't be doctors and families.

"When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated (figure)."
Attenuated. Good luck with that. How's that "hope and change" working out for ya?

As to potential objections that such a policy discriminates against the elderly, the authors have this to say:

"Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."
Sure, ok. Well, I feel better now. It's not like we'd be discriminating against anyone on the basis of age or anything. :rolls eyes:

On the need to influence public attitudes to accept such a system:

"the complete lives system requires only that citizens see a complete life, however defined, as an important good, and accept that fairness gives those short of a complete life stronger claims to scarce life-saving resources."
In other words, the belief in the sanctity of life in general must go, and be replaced by the notion that a "complete life" is more important than just any life, that some lives are more worthy of saving than others. If you're over 40, just accept that you need to step aside and not expect much care, someone younger has a "stronger claim" to that care. And if your child is not yet 15 or determined to have a lower "prognosis," accept that someone older or healthier has a "stronger claim" to care. Anyone else feeling outraged yet, or is it just me?

But, let's not be too hasty. They're not quite advocating this system be applied to the entire health care system, at least not until we take some other steps first:

"Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending."
Huh? I thought we were supposed to be making healthcare more affordable, not increasing spending... won't that just increase the cost to taxpayers under a government-controlled system?

Dr. Emanuel and his colleagues are careful to distance themselves from so-called "objective" methods of discounting the value of life on the basis of disability or "quality of life," but their objection is to the attempt to quantify it. They have no problem with more qualitative methods of taking "instrumental value" into account. The fact that they advocate only resorting to that in the event of an "emergency" might be intended to reassure us, except that our current government is in a constant state of "crisis."

So what do they mean by "instrumental value"?

"Instrumental value allocation prioritises specific individuals to enable or encourage future usefulness. ... Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation."
What exactly does "usefulness" mean? While they claim their system doesn't discriminate on the basis of disability, does anyone reading this really think that such language won't be used to discriminate against those with special needs if some bureacrat decides their "future usefulness" is less than someone else's? And how about anyone deemed "inconvenient" to society? What is the criteria for "usefulness," who decides, and why should it even matter? Can you imagine going to the doctor and being asked questions to determine your "usefulness" to society before being offered any care? The idea is unconscionable, and the sanctity of all life would be meaningless under such a system.

Where have we heard such notions before? I hate to bring up Nazi references but the similarities in thought are there. The Nazis also believed in "life unworthy of life" and saw the elimination of such people as a "healing" process for society as a whole. To be clear, Dr. Emanuel and his colleagues are NOT advocating killing anyone as the Nazis did, but denial of care via rationing would ultimately result in needless loss of life. Most importantly, it would result in loss of life that would not occur under our current system. Emanuel & friends obviously saw the potential for readers to see such parallels because they addressed it:

"Ultimately, the complete lives system does not create 'classes of Untermenschen whose lives and well being are deemed not worth spending money on', but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible."
Whew... I feel better now. Well, not exactly. Obamacare will CREATE "genuine scarcity" in many, many areas where it does not exist today, making such decisions more and more "necessary." And in reality, denying or limiting care is no less than a death sentence in many cases.


"To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo."
Interestingly, Obama tends to favor that term "status quo" also, and he uses it in a similarly derisive tone. Heaven forbid we hold onto a system that doesn't require rationing, especially centralized rationing, for the vast majority of care.

We keep hearing about how our current healthcare system is in a state of crisis. It's not. Are there some things that need to be improved? Of course, it's not perfect. But let's not burn down the whole town just to fix a few potholes in the road.

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