Map of life expectancy at birth from Global Education Project.

Tuesday, October 25, 2011

Good problem statement, anyway

Lawrence J. Schneiderman offers up plenty of most excellent zingers regarding our cultural blindness about the nature of medical services and the ineluctable limits thereon. It's the sort of thing I keep saying here but he's more famous. A sampling of the good bits:

Throughout their exertions, members of Congress have been preoccupied with how to pay for health care. Hardly any thought has been given to what should be paid for—as though health care is a commodity that needs no examination as to what health outcomes should receive priority in a just society. "Priority in a just society”—those five words are encompassed and eclipsed by one word that was excoriated or indignantly tossed aside: rationing.

We will have to make tough choices, of course, but the choices will be based not on capricious gated communities of eligibility for limited, expensive, high-technology, life-sustaining treatments—for example, simply by reaching age 65 one suddenly becomes entitled to Medicare, which will provide substantial coverage for all sorts of organ transplants but sadly not a penny's help with walking, eating, bathing, and other daily tasks by qualified home health care workers, or even by family members who may have to give up their job to attend to these far more common elderly needs. These costs are a major source of bankruptcy and can amount to 10% of household income, causing severe economic, social, and psychological burdens on caregivers. Recognizing that there has to be a limit to the otherwise boundless demands that can be made on medical care, we must accept that medicine cannot serve every personal need, desire and good. Everyone is not entitled to everything. Everyone is entitled to a decent minimum level of medical care.

[T]he R-word, rationing, the proverbial third rail in the halls of Congress: Touch it and you’re dead. At least your legislation will be; witness the instant defeat of the mild effort to have Medicare reimburse physicians’ time to discuss end-of-life treatment alternatives, including advance directives. “Death panels,” shouted the opposition. “Pulling the plug on grandma!” “We cannot have rationing!” declare politicians who complacently enjoy their own medical insurance and overlook the irrational rationing that takes place all around them. Yet everyone who spends any amount of time thinking about this problem knows that rationing is ongoing and inevitable. As noted even in that champion of the libertarian free market, The Economist, “Every health system rations in some way or other; the demand for health care is always greater than the resources available. The question is whether rationing is done openly and as sensibly as possible—or done implicitly, through murky pricing, bureaucratic fiat or denial of care."

Alas, his solution I fear is too full of fuzzy logic and complex ethical judgments to advance the cause. Indeed, after reading the article carefully, twice, I'm not sure I understand it, and I don't consider myself a dolt. He attempts to apply a utilitarian ethic that weighs a combination of urgency of need, personal functional status, and social benefit. He tries to wiggle out of the accusation that his proposal values people's lives and health differently depending on somebody's evaluation of their relative worth to society, but alas, as far as I can tell, he wiggles futilely. Such judgments do appear to be lurking in the weeds of his garden, and he offers no clear and consistent way of making them, beyond a call for "transparency" and an appeal process. Not going to happen.

But, we sure as hell need to do something. The Republican solution is to champion injustice, exploitation, expropriation, waste and abuse. The Democratic solution is to wimp out and do nothing meaningful - including being too frightened even to make a clear statement of the problem. At least Schneiderman tries to give us that.


Anonymous said...

In Switzerland, it is possible for a family member (spouse, child, niece, etc.) who lives with an old-age pensioner who requires care, to get a salary from the State Pension Scheme. A typical situation: Mother Alzheimer, requires full time care, but not much medical (say district nurse / doctor once a month), living with daughter. Daughter would get the equivalent of old-age pension herself, but paid as a salary (thus making unemployment contributions and subject to tax.) Hard to say how much - but at least 1000 dollars a month. It is not uncommon for family members to club together and post one member with the aged parent, putting that person’s career or life on hold. The extra money makes it possible; and makes it an official life choice. Part-time is possible as well, for elderly ppl who are not 100% dependent.
Far cheaper and far kinder than any kind of ‘home’. No rationing involved. In fact, money is saved.


Dr Hulda Clark said...
This comment has been removed by a blog administrator.
Cervantes said...

Spam from a snake oil sales(wo)man. Has been terminated with extreme prejudice.

Thanks Ana. Schneiderman does propose something like that, which is definitely a good idea. Of course, not everybody has relatives who could do it even with financial help, but where the social context permits, it's much better than nursing home care.