Defined at a high level of abstraction, rationing is inevitable in medicine. Not everything that might be in a patient’s best interest can be done in a world of finite resources, and some constraint has to limit his treatment. Thus the left-wing jibe that the market features “rationing by price.”
But there are many good reasons to prefer rationing by price to other forms of rationing, which is why we use it for most products and services. Those reasons are not limited to efficiency, though they include it. The rationing involved in a free market is decentralized, creating more room than a bureaucratic system for people to make different trade-offs. Hence most people do not think of it as rationing at all.
It follows that it is a deep mistake to imagine the wonders of greater government involvement absent rationing. Greater government involvement necessarily means that the government will play a larger role in the allocation — the rationing — of care. In a pure government monopoly, for example, where getting care outside the system was either illegal or only a notional possibility, the monopoly would have to turn down some requests, and so some medical interventions would go undone. Even in a mixed system with a large governmental role, the government’s decision not to pay for a treatment — again, a decision that must inevitably be made many times — will have the practical effect of denying care.
The trade-offs should be made, as much as possible, by the people who are most affected by them. Liberalizing health markets, by reducing the obstacles that governments have placed in the way of the development of a large market in individually purchased insurance, is a practical method of facilitating that decentralized choice for all but the most indigent. But nobody should be under any illusions that the trade-offs can be wished away.
Anyone who thinks rationing by government is something to be feared has reason to worry about the health legislation being discussed in Washington. The president has many times said that cutting costs is the goal of health-care reform and mused aloud about denying services to the elderly as a method of doing so. It is in this context that the controversy erupted over the proposal, now withdrawn, to pay for end-of-life counseling sessions. It was only reasonable to suspect that this proposal was included to encourage people not to get treatments they otherwise would get. (It’s not as though it moved us toward universal coverage.) The proposal to form a board that could recommend against Medicare payments for various procedures, with Congress required to fast-track its advice, raises the same concerns.
Baleful trends among bioethicists should heighten those concerns. The view that medical care should be withheld from people based not merely on the likelihood of success or the cost but on judgments about the quality of their lives is no longer held only by a fringe. Practices that are at best close cousins to euthanasia have become widespread. And as anyone familiar with the work of Wesley Smith knows, inquiries into patients’ intent are not always fastidious.
To conclude from these possibilities to the accusation that President Obama’s favored legislation will lead to “death panels” deciding whose life has sufficient value to be saved — let alone that Obama desires this outcome — is to leap across a logical canyon. It may well be that in a society as litigious as ours, government will err on the side of spending more rather than treating less. But that does not mean that there is nothing to worry about. Our response to Sarah Palin’s fans and her critics is to paraphrase Peter Viereck: We should be against hysteria — including hysteria about hysteria.
The state remains a dangerous servant and a terrible master, all the more so when it is also our HMO.