Map of life expectancy at birth from Global Education Project.

Wednesday, August 26, 2009

On rationing

Obviously -- and I mean, like duhhhh -- we ration everything. Resources are finite, and rich people have more than poor people, including the stuff we usually think of as necessities -- more and better food, bigger houses (some people have none at all), more and better clothing. Their kids get more and better education, they travel more, they go to more shows, they have boats and horses and they have more fun, they even generally speaking have a wider choice of sex partners.

Conservatives mostly think this is just fine, it's the way God planned it. However, we do still have a pretty broad social consensus -- excluding the radical "libertarians" who seem to have gotten especially noisy lately -- that endorses the Rule of Rescue. Samuel Sessions (in a review of Leonard Fleck's book "Just Caring: Health Care Rationing and Democratic Deliberation" in the new JAMA), gives a succinct illustration of the rule:

Most would consider it morally objectionable for someone driving down a country road not to take a severely injured hiker to a hospital merely out of concern that bleeding would cause $200 damage to the car's upholstery. Many would not find it objectionable, however, if that person chose not to donate $200 to a charitable organization for hunger relief overseas.

So, even conservatives accept the Rule of Rescue in social policy. People who become too disabled to work receive a tiny pension which is sufficient to keep them alive. I haven't heard anyone clamoring to repeal it. Children who are neglected and starved by their parents are rescued by the state, and people get really angry when the state fails in that responsibility.

Food in this country is so abundant and so cheap that soup kitchens and charity food pantries are actually sufficient to keep people from starving to death on the streets; and until recently, at least, most of the visibly homeless have manifest mental illness or substance abuse disorders such that people can rationalize turning away, saying, "Gee that's tough but what can you really do?" There is a broader group of people who don't really have homes but they're managing to get indoors at night one way or another so they don't quite qualify for the Rule of Rescue. As for the Bushville tent cities that sprang up during the recent unpleasantness in the job market it's been possible to ignore them for the time being and anyway, the people have tents and even cars so their basic needs are met, they aren't dying of exposure.

Now, liberals don't think this is the way it ought to be, but I'm just getting inside the heads of conservatives here. If they didn't endorse the Rule of Rescue, they could not possibly show up at civic meetings screaming invective about "rationing" of health care. Of course they are diametrically wrong on the facts: under the current system it is much more likely that someone will be denied desperately needed health care services than it would be under the proposed reform legislation. But facts have never meant anything to conservatives in this country. My point is that they do accept an ethical principle that people in dire straits should be rescued.

Now, obviously they only apply this rule to U.S. citizens, which does not seem very Christian of them, but that's their moral compass, you can't argue with it. But just as obviously, they haven't thought this through very far, in several respects.

The first is drawing the line as to where the Rule of Rescue kicks in. By the time people are dying of, say, kidney failure, they've usually had a long course of diabetes or hypertension of lupus or whatever the underlying cause is. Shouldn't we have started to rescue them long before? The same goes for cancers that can be treated better if detected early (actually a debatable proposition but I'm a contrarian on that one), heart disease, stroke, and so on.

The second is drawing the line on futility. Remember, they aren't talking about people spending their own money, they are talking about the pooled resources of people who pay insurance premiums, or taxpayers who pay for Medicare. Should we pay $10 million for a one percent chance of prolonging somebody's life by one week? Again, obviously, they are wrong on the facts, we don't do that right now. But the point is, conceptually, we have to draw that line somewhere and we always will draw it. Humans are mortal, and there comes a time when we have to surrender to Thanatos.

There are other respects in which they have failed to think this through, but I'll stop there for now. What troubles me is that no prominent figure -- be it politician or pundit -- is willing to say these things in public. The fact is, reform or no reform, these problems are with us, will always be with us, and are much better discussed in public, acted upon democratically, and dealt with openly and transparently. That's how they do things in the civilized countries. That's how we ought to do things here.

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