Not Your Usual Stocking Stuffer

Posted on December 18, 2008
Filed Under General Rationing Issues, Medical ethics |

Setting Limits Fairly - Learning to Share Resources for Health

By Norman Daniels and James E. Sabin

A book on how to ration healthcare may not be the first thing that comes to mind when you’re making your list and checking it twice, but think again.  DrRich is certain that you know a lot of people who would profit greatly from reading Setting Limits Fairly - Learning to Share Resources for Health, by Daniels and Sabin.  Just to name a few, there’s your stodgy great-uncle who believes that all we need to do is get the government out of the way and all will be well; your geeky brother who says the answer lies in sundry high-tech gewgaws such as electronic medical records, and Blackberries packed with medical guidelines and clinical decision trees; and your pudding-headed and fatally compassionate coed niece, who is convinced that simply making health insurance universal (and perhaps Buying the World a Coke) will fix everything. There are others to whom you also ought to give this book, but you get the drift.

As DrRich has been telling you for more than 18 months, healthcare rationing is unavoidable, no matter how we finally elect to “fix” the healthcare system, or whether the reform we finally adopt is affected by profit-mongering Gekkonians or power-mongering Wonkonians. Which is why the only appropriate response whenever Mr. Obama or Mr. Daschle (or, had things turned out differently, Mr. McCain or Mr. Romney) tell you they, at last, know how to fix our broken healthcare system is: “That’s swell! And under your plan how will the rationing work?”

If they begin their answer to you with anything other than, “Glad you asked. We’re going to conduct the necessary rationing in the following manner. . .,” they’re either lying to you, or are fatally naive about their own plan. Neither is a very promising prospect. It means their plan, whatever remarkable accomplishments it may include, will continue the wasteful, unfair, dangerous and destructive covert rationing of your healthcare, and it will do so whether or not they’re actually clever enough to realize it.

The thing DrRich liked right away about Setting Limits Fairly - Learning to Share Resources for Health is that the authors don’t waste any time or space trying to convince us that rationing is unavoidable. They just assert the obvious (so obvious that one would have to be a politician to miss it), then immediately move on to a fascinating and erudite discussion of how to do the necessary rationing fairly and effectively, and perhaps more importantly, how to accomplish it in a way that will be acceptable to our society.

Norman Daniels is a Professor of Population Ethics with an extremely impressive list of accomplishments, and James E. Sabin (in addition to being a fellow medical blogger) is a Clinical Professor of Psychiatry at Harvard Medical School and Co-Director of the Center for Ethics in Managed Care. (Ethics in managed care! Who knew?) While DrRich has had some harsh words for medical ethicists on more than one occasion, he wasn’t talking about these guys. These guys are not dissemblers, or utilitarians, or dunderheads, as DrRich has perhaps implied of other ethicists (fairly or not).

Daniels and Sabin face the problem of healthcare rationing squarely, and offer a realistic approach to solving it. When one faces the problem of rationing squarely, one simply cannot make all the pain go away. By its nature, rationing means withholding at least some useful healthcare from at least some people who would benefit from it. So no matter how we do it there will be winners and losers, and there will be pain. The authors own up to this fact up front.

Further, Daniels and Sabin recognize that there is no set of ethical principles, or practical rules, or clinical guidelines, that will just make everything come out all right, or even that will make the rationing decisions straightforward or deterministic.  One way or another the hard rationing decisions will have to be specifically deliberated, and somebody is going to have to make the call. And for every decision that is made, somebody isn’t going to like it.

The author’s treatment of this fundamental problem is enlightening and convincing.  Their basic theme is that any effective scheme for open rationing will have to adhere to what they call “accountability for reasonableness.” By this they mean that, under any acceptable system for open rationing, the large majority of the population will have to see the rationing decisions as being reasonable (whether they “like” all the individual decisions or not). Accordingly, fully transparent rationing processes must be developed, under which the decisionmakers can he held accountable to the standard of reasonableness.

There is plenty of theory in the book to support the “A for R” approach, but its major strength lies in the authors’ presentation of concrete examples, gleaned from other countries and even from within the U.S., illustrating how systems that provide accountability for reasonableness tend to be accepted within democratic societies, and even tend to produce favorable outcomes.

DrRich is particularly gratified that, at least as he sees it, the rationing system he proposed in his own book is fundamentally compatible with the “A for R” approach - though if he were to write a new edition of his book, having read this one, he might be inclined to change a few details.

Setting Limits Fairly is not exactly light reading, but anyone who has thought seriously about the American healthcare system will not have trouble getting through this. And anyone who thinks seriously about fixing American healthcare should read it.

At the Christmas dinner table DrRich plans not to make the same grave error he made at Thanksgiving. If “healthcare reform” once again becomes a topic of conversation, rather than holding forth himself (at the risk, once again, of alienating Loved Ones, or their Quite Significant Others, before he has even had a chance to get some pumpkin pie), he’ll just toss a copy of Setting Limits Fairly at the offending party, jovially wish them a Merry Christmas! (the utterance of which, to make it very clear, is considered an entirely acceptable emanation at DrRich’s family gatherings), and offer to discuss the matter further, if they wish, once they actually know what they’re talking about. Now, who can take offense at that?

Comments

3 Responses to “Not Your Usual Stocking Stuffer”

  1. Dr. Val on December 18th, 2008 11:44 pm

    “Not exactly light reading” - oh dear. That’s the problem with so much writing on important topics. As the 17th Surgeon General of the United States always says, “The health literacy of America is basically at the 6th grade level.”

    Keep fighting the good fight, Dr. Rich. Maybe you’ll get some pumpkin pie this time.

    Merry Christmas!

  2. Ku on December 26th, 2008 6:10 pm

    IMHO, it would be really nice to know what is/will be covered in advance, rather than going through the black box of the health insurance company and its seemingly random decision-making processes. J.Random Consumer should not be required to know ICD-9 and/or CPT coding to find out whether or not [fill in the blank] is covered. I speak from recent experience, in which my insurance carrier would not provide me coverage information until I could give them CPT code(s) for procedure(s) deemed medically necessary. Go figure.

  3. sayspine on December 28th, 2008 12:01 pm

    Do you have an opinion as to Medicare pursuing/utilizing Microvolt t-wave alternans as a tool to help eliminate some of the unnecessary ICD implants being put in today?

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