Map of life expectancy at birth from Global Education Project.

Thursday, February 01, 2007

Rationing Rationally

One of the common objections we hear to single payer health care or other universal systems is that it will mean "rationing" of health care. To ration means "to supply, apportion, or distribute," and it's related to the word rational. Both are derived from the Latin word for "reason." So why is that bad?

People fear that it means they won't get services they need. They point to comparatively long waits for some elective procedures in Canada, and to the United Kingdom's National Health Service declining to provide certain procedures to people beyond a given age, or to pay for drug treatments that are approved for use in the United States.

Of course, we have rationing of health care right now in the U.S., but it's irrational rationing -- rationing by uninsurance. People with the right kind of insurance may get a heart transplant costing half a million dollars, whereas people with no insurance don't get basic care that can prevent heart failure. But is it wrong to set limits at all?

The UK has established an agency called the National Institute for Clinical and Health Excellence (NICE -- the "H" for health came letter and the old acronym is, well, nicer), which provides the National Health Service with guidance on what to pay for and what not to pay for. For example, here they recommend not giving memantine (brand name Nimenda) to people with mild or moderate Alzheimer's disease. This drug is approved and heavily marketed in the U.S. for just those people, so the drug companies are mad at NICE about this and other guidances.

And yes, in coming up with its recommendations, NICE takes cost into account as well as effectiveness. Measuring effectiveness is somewhat subjective, of course. Treatments can extend life, or relieve symptoms. Longer life can be of little value if people are in great pain, or severely disabled, or severely demented or even vegetative. So while there are methods for attempting to quantify the value of treatments, such as Quality Adjusted Life Years, public participation, openness, and political accountabilty are necessary, and NICE offers all of these. But the bottom line is that a day or a week or a month of life is not of infinite value after all. The money that might extend a very sick person's life could also feed a hungry child or nourish the souls of millions. Ultimately we must have a way of making these tradeoffs and saying that enough is enough.

So, there are many reasons why the UK and other rationally governed countries spend much less on health care than the U.S., but rationing, yes rationing, does contribute. Is this a terrible, immoral idea that our Culture of Life could not accept? What do you think?

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