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Healthcare Rationing: When Is It OK?

In his last post, DrRich considered the differences between a system of healthcare rationing in which individual autonomy is honored, and one in which the good of the collective takes precedence. DrRich concluded that the former is more desirable than the latter, since the latter would amount to throwing aside the Great American Experiment. In response to this post, an astute reader calling him/herself Jupe wrote:

. . in the case of a limited supply of an effective vaccine during a deadly epidemic, it doesn’t weird me out to think of docs and nurses being prioritized over, say, me. Or a hypothetical situation of military leaders being prioritized in the event of bio warfare  So it’s not that collectivism inherently offends me across the board.

In my mind there seems to be some sort of invisible line in there somewhere, but I can’t identify what it’s based on or exactly where it’s at, or why. I just know when it’s been crossed.

Jupe then continues, quoting Ezekiel Emanuel on setting rules for healthcare rationing. Emanuel says, “. . .Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.”

Jupe continues:

[That] just screams “line WAY WAY WAY CROSSED! HOLY CRAP!” to me. I know (well, deeply suspect) there actually is a fundamental difference between “doctors, nurses and military first to be immunized in the event of a bio-warfare attack” and “no antibiotics for the feeble minded” but I can’t pinpoint it outside of “it just intuitively seems right/wrong”.

DrRich interprets Jupe’s question as follows: Why does it intuitively seem OK to ration healthcare in the manner described in the first instance, but not in manner described in the second?

The most obvious answer would be that in the former case there’s an emergency, and extraordinary times call for extraordinary measures. For instance, in times of a war that threatens our survival, most of us would agree that a military draft – perhaps the ultimate sacrifice of individual rights for the good of the collective – is appropriate. And Lincoln, who was fighting a war whose explicit purpose he defined as upholding the Great American Experiment (i.e., to see whether a nation “conceived in liberty and dedicated to the proposition that all men are created equal could long endure”) was himself quite willing to violate individual freedoms to achieve that goal. For instance, he was willing to suspend habeus corpus and jail newspaper editors for sedition.

In other words, throughout our history we have sometimes declared it necessary to suspend individual liberties in extraordinary times, when it has been deemed critical to do so in order to preserve a system that – in usual times – celebrates that same individual liberty as a chief operating principle. Some have asserted that we must do such things on occasion to prevent our Constitution from becoming a suicide pact. (We Americans, in essence, engaged in this very debate during the Bush administration, and are doing so today, regarding questions as to whether such things as Guantanamo, water-boarding, etc. are really necessary to fight a clear and present existential threat.) The theory always has been that once the crisis has passed, and we are back to a stable, civil society, then individual liberty can be placed back on its pedestal.

DrRich is not happy about this, and he is not sure it is ever the right thing to do. It is certainly almost always not the right thing to do. So DrRich is not endorsing this practice, but is merely describing what he thinks he has seen. So far, it generally has worked out all right, as evidenced by the fact that (despite everything) we are still here.

But there are risks each time we take such drastic actions, that ought to make us extremely reluctant to take them. Each time we do this, it becomes that much easier to do it again the next time, and for a “lesser” threat. And each time we do this, it becomes a little easier to “forget” to restore all the suspended liberties once the threat is gone.

One of the big problems DrRich has had with the last few administrations (especially Bush 43 and Obama) is that they have seemed very quick to declare various crises (such as the terrorism crisis, financial meltdown crisis, healthcare crisis, and global warming crisis), which they claim to be the equivalent of those existential emergencies that threaten our survival, and thus claim a justification for suspending individual liberties of one sort or another. This, DrRich thinks, is the subtext behind Rahm Emanuel’s declaration that one must not “waste a good crisis.”

What DrRich sees going on is crisis creep.  We can argue, of course, whether the past few administrations have been intentionally pushing us toward “socialism.” DrRich would rather not engage in this argument. Who cares if it is intentional? The condition in which we now find ourselves – fighting all manner of “existential crises,” one after another, and often two or more at the same time – is inexorably pushing us toward permanent collectivism, whether it’s on purpose or not.

So the first example Jupe gives for healthcare rationing may seem acceptable partially because an emergency is present. But this answer is not entirely satisfactory. In general, suspending individual liberties during a time of crisis is simply a dangerous game for us to play. But more specifically, in this instance this explanation does not go far enough. Because (as DrRich has pointed out innumerable times) healthcare rationing is unavoidable today, even in normal times, even when there is no “emergency.” So to say that it’s OK to ration only in an emergency would leave us in an untenable position.

A better way to answer Jupe’s question would be to point out that in the first instance, the rationing is consistent with fundamental American principles, while in the second instance it is not. And this (DrRich asserts) is what makes the rationing “feel” OK in the first instance but not in the second.

But how can this be? As Jupe points out, even in the first instance, where the rationing passes the smell test, individuals are being sacrificed for the good of the collective. How can this be consistent with the basic American ideal of individual freedom taking precedence over the needs of the collective?

Indeed, this is the crux of the entire rationing problem in America. Rationing healthcare, no matter how it’s done, inevitably asks (or forces) individuals to sacrifice themselves for the good of the whole. How can we ever reconcile healthcare rationing in a culture that honors the primacy of the individual – in a culture that recognizes each human life to be of equal worth – without abandoning that fundamental principle?

As it turns out, it is indeed possible to accomplish this feat. DrRich has described how, in excruciating detail, elsewhere. Here, he will limit himself to attempting to explain why “American rationing” – healthcare rationing in a way that still honors the primacy of the individual – is even possible.

The Declaration of Independence is frequently cited by conservatives as the most important American document ever written. This is because it establishes the very rationale for our nation. It establishes that all people are created equal, and that they are endowed by their Creator (that is, by some entity that surpasses all human institutions) with certain inalienable rights, including life, liberty and the pursuit of happiness. Our government is explicitly called into existence by human creatures for the express purpose of protecting those inalienable individual rights. A government that fails to execute this task, or that asserts for itself the ultimate authority to determine which individual rights are and are not inalienable, is an abomination, and renders itself illegitimate.

So there.

What is less often noted by conservatives, or anyone else, is that the Declaration of Independence also establishes the importance of collective action. It is an explicit call to a concerted struggle. The document is itself an assertion that individual liberties – while the primary organizing principle of our new nation – must sometimes be subsumed for a particular greater good. That greater good, of course, is the establishment and the maintenance of a government dedicated to preserving individual liberty.

So, while the birth of the United States was predicated on the principle of individual freedom, it was also predicated on the success of a high-risk collective action. The signers of the Declaration of Independence committed the 13 individual colonies to work in concert. (”United we stand, divided we fall” is itself a collectivist slogan.) Further, by the very action of signing that document, these Founders each pledged their personal fortunes, their liberty, their sacred honor, and their very lives to the outcome of this collective struggle (whose odds of success couldn’t have seemed very high at the time). If the struggle failed, each of those individual signatories knew, they had just signed their own death warrant. They took on this risk as an unavoidable part of the “deal” they all agreed to, as the price of individual liberty.

By extension, all of us who enjoy the fruits of our forefathers’ efforts are parties to the same deal.  Freedom is never free, and in every generation, Americans have fought and died to preserve it. It’s usually a pretty good deal. 99% of the time we enjoy the pure fruits of individual freedom. But 1% of the time we must put our individual interests aside for the benefit of the whole. Most commonly this sacrifice comes in the form of military service, where life and limb are placed in harm’s way for the sake of everybody else’s individual freedom. The duty to occasionally sacrifice our individual liberties, for the sake of continued freedom for everyone else, has been part of the American Contract from the instant of its birth.

DrRich would argue that this duty might extend to healthcare rationing. To the extent that providing healthcare is deemed to be a collective enterprise (that is, to the extent that providing healthcare to all is determined to be vital to maintaining the American Contract), then in addition to accruing the benefits from such a collective healthcare system, we as individuals would also assume a duty to abide by the rules of rationing. This duty would be analogous to the duty to serve in the military if called – the duty to put oneself in harm’s way in order to help preserve the American Contract for everyone else.

(DrRich hastens to add that if we are to agree to a new healthcare system that relies on open rationing, we will be obligated to design that system in such a way as to minimize, to the fullest extent possible, the harm that comes to individuals due to that rationing. There are several ways to accomplish this, and, once again, he has described them in detail elsewhere.)

But for such a system of rationing to be legitimate in a United States dedicated to the proposition that all people are created equal, the rules of rationing themselves would have to be consistent with foundational American principles. That is, the rules would have to recognize the essential worth of every human life. And this brings us back to Jupe’s question.

The first example Jupe gives is of a dire medical crisis – an anthrax terrorist attack or a deadly influenza pandemic – where many thousands of people are going to die, and there are not enough remedies (vaccines, ventilators, etc.) to treat everyone. Jupe agrees that it seems to make sense to give priority to those whose survival can increase the number of people in our population who will ultimately survive – doctors, nurses, paramedics, pharmacists, police, military. Saving one sick person saves one sick person, but saving someone in one of these special categories may result in saving many sick people, and will minimize the overall mortality from the crisis.

DrRich would add that there is additional triaging that makes sense here as well, from the same standpoint. If we have two people whose survival depends on a ventilator but we have only one ventilator, it makes sense to give the ventilator to the one who is more likely to make a quick recovery – because that would give us the best chance of being able to “recycle” the ventilator for another patient more quickly. Choosing the patient who will need the ventilator for only a little while is another way of engaging a “multiplier” effect, similar to treating doctors and nurses first.

DrRich suggests that the reason these rationing decisions seem to make intuitive sense is that these decisions are founded on the idea that all human lives are intrinsically of equal value. So, choosing which individuals would be asked to step aside in this instance is not predicated on some assessment of their intrinsic worth to society – such as, age, gender, mental capacity, disability, or body mass index – but rather, on features that would tend to maximize the overall number of equally worthy individuals who would survive. So medical personnel might take priority (due to the multiplier effect), and so might the people who are objectively most likely to respond favorably to the limited medical services.

In contrast, the second instance Jupe provides comes in the form of a quotation from Ezekiel Emanuel, regarding utilitarian rules of rationing. This kind of rationing invariably points to some central authority (possibly his own FECCER panel) which would assign to various classes of individuals certain values reflecting the panel’s assessment of their potential worth to society, and then distribute healthcare resources according to those centrally assigned values.

While acknowedging that all healthcare rationing is bad and ought to be avoided as much as possible, the first instance at least recognizes the essential worth (and fundamental equality) of all individuals, while the second instance instead recognizes the primacy of the collective, and awards to a central authority the right to determine who is a worthy individual and who is not.

In DrRich’s way of looking at the problem, that is the bright line difference between the two examples.

And how we resolve this question – on which basis will we choose to ration our healthcare? – will go a long way toward determining what kind of society, and what kind of people, we will finally turn out to be.

*This blog post was originally published at The Covert Rationing Blog*

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