Rationing and Indication

I'll let y'all in on a secret: I'm writing a book. It's basically everything you need to know, as a citizen, taxpayer, consumer of medical services, friend or family member of consumers of medical services, and just plain person, about health and health care in the U.S. For some reason I haven't much connected the work on the book to this blog -- there is tons of materials I could have lifted from my book chapters and posted here for your delectation and delight. I'm not sure why I haven't been doing that, and maybe I will.

Anyway, the previous post creates an occasion to discuss a matter that seems pretty obvious to those of us who work in public health and health services research, but seems to seriously confuse a large segment of the population. This is the allocation of medical resources. Here in the U.S., we have two big problems: many people can't get health care that they need, mostly because they can't afford it but also in some special situations because of fundamental scarcity of resources; while many other people get a lot of medical services that they don't need  and aren't good for them.

When we talk about "rationing" health care people go ballistic. It's a fundamental human right! You can't ration it, that's some bureaucrat deciding who lives and dies! Death panels! Discrimination!

Well, obviously we do ration it, because of problem number one. People who can't afford what they need don't get it. But even if we had a universal system like all civilized countries, we'd still need a way of allocating resources fairly and efficiently. That's because we don't have infinite money to spend on health care. We need to spend on food, shelter, clothing, and the infrastructure to provide them; and most people want some money to spend on the finer things in life. In fact health care doesn't have more than a small amount to do with how healthy people are and how long they live -- it's deprivation in other areas that shortens our lives. Yet here we have people demanding that because "human life is infinitely precious" we need to spend a million dollars to give a terminally ill cancer patient a chance at a few more weeks of life, even as other people die because they can't get much less expensive but more beneficial health care, or they can't afford an adequate diet, or they breathe polluted air, or the don't get an adequate education. In fact with that million dollars we could vaccinate a hundred thousand children in poor countries against diseases that kill one of them every five minutes. But nobody seems to be screaming for that.

The problem of allocating donor organs is complicated. It touches on some of the bigger issues I just mentioned. There are inequities, for example Black people wait longer on average for kidneys. But inequities or not, there aren't enough to go around. So one criterion is to give them to people who have the best odds of a good outcome. We want to maximize the years of quality life we can give people and that means we don't want to give the organs to people who are less likely to benefit. That's more or less equivalent to the more general problem of spending scarce money to get the maximum benefit.

Unfortunately, this often means that the sickest people are not at the top of the list. Being seriously overweight is a counterindication for kidney transplants, so people may be required to lose weight. That doesn't mean they don't get the best possible treatment for their diabetes in the meantime, but they aren't the best candidate for a transplant. People whose hearts are in poor condition so they might not survive the surgery are also at the back of the line. And so are people at high risk of infection, because drugs that prevent organ rejection also compromise immunity against infection. At one time, HIV infection was a counterindication to organ transplantation, although thankfully today because of effective antiretroviral treatment people with HIV can have perfectly intact immune systems. 

But being fully vaccinated against diseases people may be exposed to is also a requirement. People are free, of course, to refuse vaccination. But doctors are ethically bound to allocate the scarce resource of donor organs to people who are most likely to benefit. That is not discrimination. It isn't discrimination to deny drivers' licenses to blind people or not give me a million dollar contract to play in the NBA. Sometimes what makes sense for some people doesn't make sense for others. Furthermore, doctors have to weight the benefits of any procedure against the risk. Since giving you a kidney transplant requires that we suppress your immune system, if you refuse to get vaccinated we'll just be killing you by another means, not saving your life. That seems a very weird demand.

On the other hand, when unvaccinated people do present with Covid, they actually get preferential access to scarce treatments, because they are more likely to benefit -- vaccinated people don't need the treatments as much. Many people resent that, and I think there are arguments on both sides. But medical ethics is complicated. People think about it a lot, and they do often disagree about one or another matter. But that's because they are trying their best to do what is right.

Update: If you are interested in the details of how donor organs are allocated, you can read all about it here. It's operated by the Health Services and Resource Administration. The rules have been updated a few times, through the rulemaking process which is completely transparent and invites public comment. It's pretty complicated, as there are a lot of interests to balance, and obviously people can disagree about details. But it is not the case that the people who harvest the organs decide where they go. Physical distance is part of the equation -- it matters because the organs have to get where they are going quickly so they'll be fresh. And as I say, characteristics of recipients and of the donor organs that affect the likely outcome are part of it. But it's not a secret and it doesn't involve favoritism.