Rationing and Redefining Personhood
On October 10th, as part of Chicago's annual "Ideas Week," I participated in a debate on health care rationing hosted by "Intelligence Squared." My partner was Sally Pipes of the Pacific Research Institute, and our opponents were Peter Singer, infamous Princeton professor of bioethics, and Dr. Art Kellermann of the RAND Corporation. Properly framed, the issue was whether the government should ration health care at the end of life. As actually framed, the proposition was: Ration end-of-life care. Our opponents argued government should ration such care, our side said no.
The audience voted overwhelmingly in favor of rationing at the end of the debate. I believe this outcome is a symptom of the general confusion that surrounds the issue of who has the responsibility for health care in America and the shift from a sanctity-of-life ethic to a quality-of-life ethic in this country.
In arguing against the proposition that government should ration end-of-life health care I sought to communicate three basic points. First, since health care is largely a personal matter and should be tailored to the individual, medical decisions at the end of life should be determined by the patient in concert with his or her doctor and family. The patient is primary, of course, and his or her desires will help to frame the input of the doctor and the family. Does the patient want to explore all avenues of treatment, want to fight until the very end, or does he feel comfortable letting nature run its course and simply wish to be kept as comfortable as possible for the remainder of his life? With this information in hand, physicians at the bedside can then take into consideration proper approaches, be they aggressive or palliative. They can evaluate what treatments might be necessary, which are clinically indicated, and whether the cost of such treatments are reasonable compared to similar services available in the community. Families can take comfort in the knowledge that it is their loved one, not a faceless bureaucrat remote from the bedside, that is guiding the course of his treatment. In this scenario the dignity of the patient is preserved and the value of his life is respected.
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This brings me to my second point. Government-led rationing of health care inevitably invokes utilitarian criteria which cut against the sick and dying. When couched in purely economic terms, the elderly, the handicapped, and the terminally ill are "resource hogs" whose useful life is over and who now cost more to maintain than they produce. They are "takers" and not "makers." This attitude utterly rejects the sanctity-of-life ethic that has long prevailed in this country, which maintains that every human life is precious and ought to be respected and protected under the law. This ethic advocates equal protection for the very old, the very young, the handicapped, and everyone in between. Mr. Singer and his disciples of death maintain that government would be ethically justified in using generically crafted quality-of-life calculus and functional capacity studies to decide, in essence, who lives and who dies.
The problem is that the elderly, the demented, the handicapped, and other vulnerable demographics do not score well using quality of life calculus and functional capacity assessments. They will inevitably fail such tests and their right to treatment will be inevitably be diminished as their faculties decline. It bears pointing out that Mr. Singer derives his theory of health care rationing from the same ethical basis that shapes his belief that newly born infants do not qualify as "persons" because they lack the capacity for rational thought, are not autonomous, and fail to appreciate their continued existence over time. Singer maintains that until infants mature to the point that they acquire such capacities, their parents should be free to obtain a "post-birth abortion" – should be able to kill them. Of course, many of the very old, the very ill, and the demented often lack those same capacities; hence, they would not qualify as "persons" either using Singer's definition. They, therefore, could be deprived of health care resources with impunity.
In addition to the ethical problems inherent in government-managed health care rationing, there are other objections to be made. Rationing is, quite simply, a lazy way of balancing the health care budget. Rather than taking on the rampant fraud, waste, and abuse that characterizes the federal government's management of taxpayer money – rather than doing the hard work of cleaning house and reforming a broken system – our elected officials would rather balance the budget on the backs of the frail and sick who don't have PACs, can't speak up for themselves, and are unable to get out and vote. It's far easier to pinch pennies in the name of "comparative effectiveness" than to wrest money out of the hands of the special interests in Washington. Then there is the issue of basic fairness. How fair is it to pay into something all your life only to be told when you are ready to draw on your investment that you aren't worth the money, that the tax dollars you paid into the system would be better spent on a younger person who doesn't cost as much to fix? This is what rationing would do for the elderly.
As the old saying goes, "He who pays the piper gets to call the tune." This is the danger of ceding to government control over health care. As we know from countless horror stories emanating from Canada, the U.K. and other countries with centrally-planned health care policies, government-run health care results in a loss of freedom and autonomy for the patient. Patients under these schemes have no recourse if they are deemed "unworthy" of needed health care resources. The government makes its determination, and the decision is backed by the force of law.
In theory, rationing health care might appear the necessary and logical course for a nation facing a looming entitlement crisis. Ideas have consequences, however, and the consequences of calculating the value of human lives according to a utilitarian construct would be dire. What would it profit a nation to save a few bucks at the cost of its soul? This is a question we must ask ourselves before we plunge headlong down a very dangerous path.
