Rationing: Individuals vs. The Collective

Posted on September 18, 2009
Filed Under General Rationing Issues, Healthcare Reform |

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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.

Comments

5 Responses to “Rationing: Individuals vs. The Collective”

  1. ruralcounsel on September 19th, 2009 11:03 am

    I thought your review of American historical documents was well done. Though I might remind you that the Declaration of Independence was essentially a declaration of war between the colonies and the Crown under exigent circumstances, and despite some general principles articulated in the preamble, really had very little to do with the social contract between the citizens of this country and its government. Even so, that those signers all signed their own names, in fact, ought to clue you in to the idea that it was voluntary, and highly individualized declaration.

    The Constitution, the Bill of Rights, and the associated documents such as the Federalist papers is where you need to look if you want to study the formation of the trilateral contract between the people, the states, and the federal government.

    I think where we significantly part company is in the concept that healthcare ought to be a part of that contract. Indeed, if we accept your premise that there is a duty to sacrifice our individual freedoms for the “good of the country” for non-wartime activities like health care, there will necessarily be an allocation system that rations those finite resources. You may have faith that a system that is not inherently evil can be created; I don’t share it.

    But I don’t accept that basic premise that such sacrifices are required of us day-to-day, continuously, and for our entire lives. It is a far cry from a war-time draft to the idea that we won’t allow individuals to freely arrange for their own medical care ever again, in order to control the use of medical resources. You, as a medical doctor, are one of those resources. How much of your life are you willing to cede control over to the government, so that resource is most efficiently wielded? Should you let them set your hours, your fees, your geographic location, your area of specialization or even if you should be allowed to have one?

    The basic concept of a right requires that exercising that right does not require economic support from someone else. You should have a right to speak your mind, but I shouldn’t have to subsidize it. The lack of funds to publish your own newspaper isn’t a muzzle on your freedom of speech. The inability to pay for something does not impose upon someone else the obligation to pay for it for you. If that appears to be the case, then it wasn’t a right. It may have been a need, a desire, a want, but it wasn’t a right.

    So you see, I don’t believe that health care is a right. We can all agree that it is something that is good to have access to, and is downright handy to have in some circumstances. The same can be said for a lot of things.

    So today the issue of rationing is completely irrelevant. Because it doesn’t really happen. The government can’t ration what it doesn’t control. Some argue that healthcare is rationed now, by people’s ability to pay. We can argue the semantics, I suppose, but that isn’t true rationing. Pass a law saying no cancer treatments for anyone paying less than $25,000 a year in income taxes, and we’ll agree that there is true rationing.

    In our misguided attempt to make all healthcare accessible, regardless of one’s ability to pay for it, these government interferences will merely install a rigid system that by its very definition will fail to provide healthcare access to someone. I fail to see why we should let government be the mechanism for picking winners and losers. After all, they’ve done such a good job with financial accountability in the US Postal Service, Amtrak, Chrysler (Bailout II!) and General Motors, FEMA in New Orleans (remember the debit cards and uninhabitable trailers?), Fannie Mae and Freddie Mac, Social Security, …

    It merely becomes a question of who will not get care. Will it be the poor person who can’t afford it, or will it be the person who is denied it administratively? My instincts tell me that the poor person always has several options…seek charitable sources or find a way to become wealthier from their own efforts, whereas the person administratively denied from a rigid controlled system has no recourse. I find that reprehensible; far more so than todays systems’ inadequacies.

    I also don’t believe that our Constitution cedes such power to the government. If it choses to try and usurp such power, then it abrogates the social contract between itself and the citizens. I think people should give the potentially dire consequences of that a good deal more deliberate consideration than they seem to be doing.

  2. Guiac on September 24th, 2009 7:13 am

    Rural - what is your opinion regarding the right to an attorney? If you can not afford one one will be provided to you.

  3. Al Neustadter on September 24th, 2009 7:34 am

    However the pendulum swings, Borg or Federation, from where I stand the worst of all worlds is the one we live in now, where doctors with opaque loyalties practice covert rationing under the shadows and deprive people like my father of readily available and potentially life-saving treatment. I’m in favor of whichever “reform” reforms that.

  4. ruralcounsel on September 25th, 2009 4:28 pm

    The right to an attorney is a pretty fluid concept, and varies state by state. In some jurisdictions, it only applies if charged with a felony.

    My opinion of it?

    It is a relatively inexpensive counterbalance to the overwhelming power of the state in criminal trials. So it actually helps protect individual rights against the state, rather than helps consolidate state power. The PD doesn’t have a state crime lab working to exonerate the defendent, or a police force trying to gather evidence showing the defendent didn’t commit the crime. Given the many failings of those crime labs and police forces, its a wonder anyone innocent ever goes free.

    I’m in favor of it, if only because so many citizens are ignorant of their full rights and become entangled with the state police powers so easily, and unentangled with such difficulty.

    As for Mr. Neustadter’s comment, at least he’s honest in admitting he’s only looking out for himself and his own selfish interests. When a man is drowning, he doesn’t look too closely at who’s throwing him a rope. In this case, he doesn’t even care that the person throwing the rope had to mug someone else in order to get it. Until he’s the one that gets mugged, no doubt. Might I suggest, horrificly responsible though it may be, that he hold himself accountable for purchasing the “readily available” treatment for his father?

  5. Al Neustadter on September 26th, 2009 8:58 pm

    Rurelcounsel, I was not positing that the government can or should pay for everything. I do feel that in a country as great and as blessed as ours, all people within our borders should get some sort of minimum, base level of medical care. If we can afford to bail out corporate giants, and if we can afford the agriculture subsidy, we can afford that. I think we would all agree that in every society, whether capitalist or socialist, he who has the money and is willing to pay can buy more and better service. Except in this country, where we pretend that everyone gets all the care they need in the hospital, covert rationing notwithstanding.

    See my comment in the Ezekiel Emanuel posting. I would indeed have been willing to pay.

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