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Chapter Twelve: Rationing
of Care
The Honorable Ms. Derrickson, State Senator from East Carolina
stood before the state senate: "If we had enough money to pay
for every health care need that we have, this job would be easy,
but obviously we do not. Our committee has thrashed this around
for weeks, and the only solution that we can propose for the current
health crisis in East Carolina, is some thoughtful form of rationing.
They have already done this in Oregon, and now it is our turn to
do it here."
"How dare we take such a drastic step?" interrupted her
fellow-senator, Mr. James, from the back of the auditorium. "If
we do this, we will never be able to look our constituents in the
eyes."
Ms. Derrickson snorted in exasperation. "Are you kidding?
May the record show that every single state and federal agency in
these United States already rations health care. Whether we ration
is not at issue. What is at issue is the exact manner in which we
will ration-that is, choose to allocate our limited resources."
The Health Care Budgetary Guidance Committee brings a unanimous
opinion forward to the senate. It is our deliberated opinion that
unless a task force is appointed to address this rationing issue
immediately, we as a state are doomed to repeat our cost over-runs
in health care again this year. We predict that our yearly health
care budget will be entirely consumed by mid-August. This year's
budget is a farce, in light of exploding health care costs. Unless
we act immediately, next year's budget will be ruined as well."
After less than thirty minutes discussion the speaker entertained
a motion to call the question. By a margin of 74 to 12 East Carolina
approved the appointment of a task force to bring an initial proposal
to the senate by its next seating, to outline a rationing plan that
would stem the burgeoning health costs for the state.
Audrey Perlstein had an intractable seizure disorder. She had
been tried on eight different anti-epileptic medications with seemingly
little improvement. She had frequent, moderately severe complex
partial seizures that essentially made her unemployable, and consequently
totally disabled. She often fell down and injured herself during
her seizures. She had broken several bones, and had had numerous
visits to the local Emergency Department to repair large lacerations
on her forehead and posterior head from falls associated with her
seizures.
But now, on the television, she was seeing something beyond her
wildest dreams. A center in California was evaluating patients for
a special kind of surgery. If the surgery was successful, seizure
frequency and severity could drop dramatically. One person highlighted
on the show went from two severe seizures per day, to two small
seizures in the last fifteen months. Audrey couldn't believe her
eyes.
The next day she called her family physician, Dr. Drew Fancil. Dr.
Fancil agreed to meet with her later that week to discuss her concerns.
She could hardly wait, knowing that soon, with the proper intervention
she might be seizure-free.
On Thursday, when Audrey told Dr. Fancil about the TV show, he just
nodded.
"I thought that you would be flabbergasted and delighted,"
said Audrey. "Instead, you don't even seem surprised. What
gives? If you knew about this all along why didn't you tell me about
it?"
Dr. Fancil looked tired and sad. "The concept of these seizure
surgeries has been around for years. It is a proven remedy that
really does change the lives of some patients. I have sent seven
patients for surgical evaluation in the last three years, and four
of them received the procedure, and had excellent results. The reason
that I didn't send you is that due to a senate bill passed a few
years ago in this state, this type of surgery is no longer covered
on your Public Assistance card. Most commercial insurance does cover
this type of evaluation and surgery, but your card won't help you.
If you have to pay out-of-pocket the cost will probably run between
$30-40,000. I knew that you didn't have that kind of money, so I
didn't bring it up so you wouldn't feel any worse than you already
do."
Audrey shook her head slowly. "You mean to tell me that because
I have epilepsy and can't hold a job, and can't get insurance, that
I cannot get the surgery done that might give me back my life? What
a scam! This is terrible! How can they do this to me?"
"I agree," said Dr. Fancil quietly. "It is terrible,
it is a shame, it seems just plain wrong, but there is nothing I
can do about it. They can do it to you because they just don't have
enough money to go around. They have to make terribly difficult
choices, and people like you sometimes get left in the lurch."
Audrey brushed tears from her eyes as she walked to the pharmacy
to pick up her generic medications. So close and yet so far, her
solution was just beyond her grasp.
Betty Ferguson had delivered a strapping ten-pound baby boy twenty-seven
hours ago, and now she was checking out of the hospital. She still
felt pretty sore, and very tired, but rules were rules. From now
on mothers with routine deliveries, who were covered by the Purple
Star Intermountain Health Plan were to be discharged within less
than 36 hours, or they could personally pay the difference.
What happened to the days when a new mother typically spent six
days in the hospital after delivery to regain her strength, learn
about her new baby, and have someone else help with those first
fitful days? Who knew? She guessed that there was no use complaining.
She just hoped that little Bobby would be all right. If he wasn't
and they had to come back into the Emergency Department at night,
she would have a co-pay of $50 for each visit. As a recently divorced
mom her budget was pretty tight. She thought wryly, "I guess
I am pretty fortunate to have insurance at all."
In some political settings the buzz word "rationing"
has been used to imply an evil process where no one receives appropriate
medical care. As can be seen from the above vignettes, however,
health care rationing is already with us all throughout the U.S.
and the world. No one except the very rich are getting all the services
they want, whenever they want, at no additional cost. So, the real
question, as the fictional Senator Derrickson, above, pointed out
to her colleagues is "How are we going to thoughtfully proceed
with the rationing process?"
A number of answers to this question are already in place in different
venues. Some of these may seem reasonable at first blush, but on
closer examination most come up short. In Life on the Line, Dr.
John Kilner, (see full reference below), devotes ninety pages (plus
notes) to rationing, beginning first with rationing processes currently
being used and their shortcomings, followed by his proposal for
a Christian rationing process.
Age, length of medical benefit, quality of medical benefit, likelihood
of medical benefit, psychological ability, ability to pay and a
number of other criteria are examined and found to be wanting. All
are fraught with the inherent difficulties of attempting to predict
an uncertain future, and weighing highly subjective value-laden
bits of information in an attempt to allocate limited resources.
Decisions based on these tenuous efforts will allow some to live
and cause others to die.
Within the context of 1) God-centered, 2) Reality-bounded, and 3)
Love-impelled ethics, he proposes six criteria to consider in rationing
decisions:
1) Is the patient in question, willing and interested in pursuing
the proposed therapy?
2) Is the patient likely to receive significant medical benefit
from the intervention?
3) Is priority granted to those facing imminent death?
4) Is the selection process impartial, avoiding favored group
status and prejudice?
5) Are patients who require fewer of the limited resources being
given priority over those who might require extensive resources?
6) Are those whose lives are truly indispensable (a rare thing)
to be given priority?
He summarizes his approach (a direct quote from page 223) to resource
allocation:
1) Only patients who satisfy the medical-benefit and willingness
criteria are to be considered eligible.
2) Available resources are to be given first to eligible patients
who satisfy the imminent-death, vital-responsibilities, or resources-required
criterion.
3) If resources are still available, recipients should be impartially
selected, generally by lottery, from among the remaining eligible
patients.
What does the Bible have to say about rationing of resources? Let's
look and see.
Scripture and Discussion Questions
Matthew 18:1-4
Matthew 22:34-40
Matthew 25:14-30
Acts 6:1-6
1Timothy 5:1-8
James 5:13-16
Leviticus 19:9,10,15
1) Jesus instructs his disciples in Matthew 18 about the importance
of a child-like faith and humility. Does this passage offer you
any guidance as you consider rationing?
2) If we are to love our neighbor as ourselves (Matthew 22:34-40),
how would this affect our rationing decisions?
3) Matthew 25:14-30 tells about three servants who were entrusted
with finite, limited resources. The master praises the servants
who take care to use the entrusted resources in a worthy manner.
Elaborate what bearing this could have on different rationing considerations.
4) Acts 6:1-6 relates a particular food rationing welfare system
present in the first century church. Does the manner in which these
early Christians resolved their dilemma help us today?
5) In 1 Timothy chapter 5, Paul instructs Timothy in the area of
respect for all others, but he particularly points out the needs
of the elderly men and women. Is there a trend in our current bioethical
milieu to foster disrespect for the elderly? Give examples for your
answer.
6) (James 5:13-16) Should the Christian community have a different
manner in which they solve their health care shortages? Do you know
of any examples of this in practice today?
7) We have looked at Leviticus 19 before as we considered general
welfare in Chapter One of this study guide. Why might we want to
consider these same verses again in a discussion of rationing?
8) What other Bible passages shed light on this complex discussion?
9) In the United Kingdom, patients above certain age limits do not
receive specific therapies unless they can pay for them out of their
own pockets. Is this a Biblical concept?
10) The U. S. government, in an attempt to control costs will only
pay fixed amounts for given procedures, surgeries, and therapies-regardless
of what these actually cost. Some doctors and hospitals actually
lose money for every Medicaid patient that they treat. Is this Biblical?
11) Other doctors and clinics refuse to treat welfare patients at
all, based on the above statements. Is this a Biblical way to act
toward suffering persons?
Comments
1) By some estimates, up to forty million Americans are medically
uninsured. We have a long history of providing care for the extremely
poor, but the working middle class often are uninsured or underinsured.
2) The amount that Americans spent on prescription pharmaceuticals
doubled between 1994 and 1999. Estimates are that the cost will
double again by 2003.
3) Insured Americans have access to the best health care in the
world, but we also spend a higher percentage of our gross national
product on health care than any other country.
4) British healthcare is high quality, but patients must wait long
periods of time to receive surgeries and diagnostic tests that Americans
can have performed relatively quickly.
5) Costly, high technology interventions such as bone marrow transplants
are sometimes performed on patients when there is no convincing
evidence that they will be efficacious. The attitude sometimes seems
to be: "Well, nothing else has worked, and it is possible that
this might help." A new movement in medicine, called "Evidence-based
medicine" is an attempt to bring more rational proof to medical
decision-making.
6) Many Americans concede that it is wrong for so many people to
be medically uninsured, but nonetheless will not vote for measures
that would increase taxes to provide the care needed. (If this is
to be paid for, should this be done on a local or national level?)
7) In the second vignette, Audrey thinks that if she had the surgery
to cure her seizures she would be able to get back to work. Studies
show, however, that once a patient has been on disability for over
one year, for any reason, chances are very slim that they will ever
return to work. Most patients with seizures who make good recoveries
from their surgeries and have a significant decrease in their seizure
frequency still do not become employed.
8) Many rationing plans employ a utilitarian approach. If one person
would likely receive twenty years of improved life versus another
person that would likely receive ten years of benefit, the first
person would be given priority. This assumes that our predictions
of the future are valid. This also is prejudicial against older
patients.
PRAYER REQUESTS: As you close today's
lesson together, pray that God will help you to be wise, loving
and generous as you consider health care, food, clothing, shelter
and job needs in your community. Pray that the Holy Spirit will
enlighten you regarding ways that you might be part of the solution
in this important area.
For Further Reading:
The most important background for the didactic portion of this
lesson is from:
John F. Kilner, Life on the Line-Ethics, Aging, Ending Patients'
Lives, and Allocating Vital Resources (Grand Rapids, Michigan: Eerdmans
Publishing Company, 1992). See comments from Chapter Six. Dr. Kilner
offers Christian wisdom to ponder, on some important, controversial
topics.
Paul Ramsey, The Patient as Person-Explorations in Medical Ethics
(New Haven, Connecticut: Yale University Press, 1970). Dr. Ramsey,
an early Christian medical ethicist provides a classic exposition
on some of the important pitfalls of resource allocation in Chapter
Seven of his book, entitled "Choosing How To Choose: Patients
and Sparse Medical Resources."
American Medical Association, Code of Medical Ethics-Current Opinions
with Annotations (Chicago, Illinois: American Medical Association
Press, 1997). Offers two rather succinct statements regarding organized
medicine's official position on rationing in
sections 2.03 and 2.095.
John F. Kilner, Robert D. Orr, and Judith Allen Shelly, eds., The
Changing Face of Health Care (Grand Rapids, Michigan: William B.
Eerdmans Publishing Company, 1998). This book is devoted to analyzing
"managed care, resource allocation and patient-caregiver relationships."
Under the broad category of Justice, Thomas L. Beauchamp and James
F. Childress, in Principles of Biomedical Ethics, 4th ed., (New
York, New York: Oxford University Press, 1994), look at the topic
of resource allocation (rationing) from the perspectives of egalitarianism,
communitarianism, libertarianism and utilitarianism.
Judith C. Ahronheim, Jonathan Moreno, and Connie Zuckerman, Ethics
in Clinical Practice (Boston: Little, Brown and Company, 1994).
This is primarily a case book of ethics, but begins with 83 pages
of overview and general principles. Pages 34-39 have a concise overview
of rationing under the heading "Justice: Allocating Resources."
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