All things excellent are as difficult as they are rare.


15 January 2014

Rationed Health Care

Death Panels.  Hmmm.  I've got some thoughts about those.

Ann Althouse gives us a very insightful comment on the phrase, one that both recognizes that the ACA isn't about ushering in Logan's Run and that there are genuine concerns behind the heated political rhetoric:
[W]e need to distinguish the form of expression from the substance. "Death panels" was a hotly emotional way to express concern about something that was real — that there will have to be rationing and denials of expensive treatments to some older/sicker patients.
I was thinking about this issue just yesterday, and I realized that what I don't like about the notion of any sort of centralized social health care rationing is the crass opportunism of it all.  Let me see if I can explain, bearing in mind that this is just a blog post written over my morning coffee and not a formal academic piece of work.

Let's imagine that we're living in some psycho-conservative's fever dream for a moment, and that the government has total control over who lives and who dies.  The whole thing is run by some wiz-bang technocrat utilitarian who correctly notes the following:
  • There are only enough resources* to do one appendectomy this month.
  • If it is given to Grandma Miller, she will likely live another two to three years in her nursing home.
  • If it is given to Johnny the Twenty-Year Old, he will likely live another 50 years doing mostly economically productive things.

Our wiz-bang utilitarian decides that the surgery will go to Johnny, who has his entire life before him.  It seems like a no-brainer in the face of scarce resources, right? 

Well if you were just nodding in agreement just now, then you might just be a crass opportunist. 

There's an expression that perfectly describes the deliberation that's going on here, and it's not a flattering one.  It's "What have you done for me lately?"  It's an expression that is attributed to people who lack loyalty, who lack a sense of the past, whose only concern is for how much they can get right now.

It's an expression that is attributed to those we see as crass opportunists.  And what bothers me about the purely utilitarian analysis here is that it looks at everything that Grandma Miller may have done in her life as a "sunk benefit."  But maybe, just maybe, if we ever find ourselves at the point of rationing our medical care through panels convened for this sort of thing, we might want to think that maybe the past matters, and that what Grandma Miller has done in her life (let's assume it's admirable and noteworthy) isn't a "sunk benefit" but proof that, so long as we're in the business of deciding these things, she has earned our efforts to prolong her life.

There are, of course, other arguments that might be made for choosing Johnny over Grandma Miller.  We might think that there's some strange principle of justice that mandates that, to the extent possible, everyone gets equal "time" on Earth.  We might be in a REALLY tight situation where the fate our people (whoever they are) depends on taking extreme measures and leaving the sick and old to die -- though I mean something like the Terminator Apocalypse, not the Great Depression.   And whatever those other arguments are, they might prevail over what I'm saying here.

But the standard sort of utilitarian analysis makes me queasy, because as an attorney working in the Greater Los Angeles Area, I've met lots and lots of people whose loyalties are as flexible as their memories are short.  They're jerks, and I don't think we should take their thinking as emblematic of how we should run things.

* I've always been on the fence about referring to health care services as a "social resource" in some Rawlsian sort of way, because those services aren't like water and oil and fresh air.  Those services are very explicitly the labor of doctors and nurses, and it's not clear to me that our concerns about where their services are needed should trump their preferences.  Of course, if you take the Queen's Shilling, I suppose you have to do what the Queen says.  But that's another issue for another day.

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