Monday, July 20, 2009

Peter Singer on Rationing

In yesterday's New York Times magazine, Peter Singer presents a patient, lucid explanation of the ethical and economic necessity for health care rationing. (See here.)

If you've read any of my 37 previous postings on rationing you know that I see rationing as (1) obviously necessary, (2) done every day in our health "system," (3) mandatory for ethical health care in the 21st century, because (4) there are more potentially beneficial interventions available than we can afford. As Peter Singer puts it:
When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?
Given the undeniable truth of Singer's conclusion, how do we account for the steady drum of histrionic rhetoric warning the public that health care reform will mean "rationing"? What comes to mind is Schopenhauer's famous comment on an arcane philosophical argument:
As a serious conviction it could be found only in a madhouse: as such it would then not need so much a refutation as a cure.
I don't believe that the conservative legislators and commentators who warn about rationing are mad. I assume they know that their pretense that rationing is evil and will only occur if President Obama gets his way is nonsense, and are simply playing politics. Alas, the "rationing" accusation is effective politics, and the disinformation it embodies contributes to the madness of our national discourse on health care.

So how can that madness be cured?

Lucid argument of the kind Singer makes is useful, if only to firm up the resolve of the choir to keep singing. But to move the general public we'll need a combination of political leadership and time. If I were a political advisor, which I'm not, here's the line of thinking I'd recommend:
1. Our health system rations now by not insuring close to 50 million and spending so little on primary care that many well insured folks can't get to a personal physician.

2. We know that at least 30% of what we spend on health care is unnecessary and possibly harmful.

3. We need to reform the system so everyone has insurance and can get good care. That reduces the amount of rationing that is going on.
4. We need to wring out the unnecessary clinical and administrative expenditures. By doing that we reduce the potential need for rationing.

5. By taking no action and allowing runaway costs to continue we ensure that more and more poorly thought out rationing will occur, as occurs at present.

6. In case rationing is ever necessary in a reformed health system, let's tip toe up to thinking about how it could be done in the wisest and most ethical manner.
There's so much to do to capture the low hanging fruit of clinical and administrative waste that trying to focus the public on the need to ration is a distraction. Better to use the spectre of rationing as a prod to ourselves and the health system to remove our enormous expenditures on things that aren't needed before we engage in the truly difficult debates about what beneficial interventions we will forgo!

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