The Corner

Greasing the Skids for Age-Based Healthcare Rationing

The big problem with Obamacare isn’t the exchanges for me. It is the centralized control. 

Once technocrats seize power over a sector, its political nature is to determine winners and losers, favored and disfavored, in-crowds and out-crowds.

That means rationing based on invidious determinations about whose lives matter more and whose less.

But Sarah Palin threw a wrench into those plans by coining the “death panel” descriptive, leading pro-rationers to loudly decry her as an alarmist and a paranoid right wing nut.

That led to the hilarious phenomenon, of which I have written often, of want-to-be rationers yelling, “How DARE you say we death panels!” and then whisper, “We need death panels.”

Meanwhile, in the professional journals–where such plans are hatched–the push for rationing continues. Latest example, a push for rationing the elderly from access to ICUs by Dr. Paul E. Marik in the American Journal of Hospice and Palliative Care.

First, Marik extols other countries for barring the elderly from ICUs. From, “The Cost of Inappropriate Care at the End of Life:”

The United States is in the midst of a health care crisis; health care expenditure currently accounts for 17.7% of the Gross National Product when compared to 6% to 11% for other Western Nations.1,2 Hospitalizations rather than physician and other services are the major contributor to health care spending in the United States.

 Elderly patients (older than 65 years) account for 11% of the US population yet they account for 34% of health care expenditure. The disproportionate usage of health care costs by the elderly patients is in striking contrast with that of other Western Nations.

The answer is to bar the door to some of the elderly, those in which wanted life-sustaining treatment “prolong the patient’s death,” a very slippery concept that turns what is actually happening–keeping the patient alive longer–on its head:

Almost all patients with serious and life-threatening illnesses in the United States regardless of their prognosis or prospect of recovery are admitted to an ICU, unless the patient or his or her surrogate specifically declines ICU admission. It is therefore exceedingly uncommon for intensivists in the United States to refuse ICU admission; if a bed is not immediately available, one is ‘‘made.’’

This contrasts to the situation in most Western nations in which not all requests for an ICU bed are honored. Indeed, refusal of ICU admission is common, with a rate that varies from 24% to 88%.

Marik decides that palliative care specialists decide who gets in, who doesn’t, and who gets kicked out:

A palliative care consult should be obtained as part of the time-limited trial. The patients preferences (or surrogates best estimate of the patient’s wishes) with regard to mechanical ventilation and other forms of life sustaining treatment should be considered in all triage decisions.

But they can be vetoed.

For dying patients with irreversible disease, admission to the ICU (or ongoing care) is frequently inappropriate and the care of these patients should be primarily focused on a palliative approach allowing a dignified death. A palliative care consult and an ethics consult should be considered in those circumstances, where the goals of the patient and/or family appear unrealistic and when long-term interventions such as tracheostomy and percutaneous endoscopic gastrostomy tube placement are being considered.

But that means imposing a conflict of interest upon doctors, requiring them to balance a purported duty to society with that of the patient. Moreover, in some cases, society prevails. So much for optimal care.

So much, too, for honoring patient wishes, which other medical technocrats are assuring us will be honored if we fill out advance directives and pay doctors to discuss our end-of-life wishes.

And indeed, in his conclusion, Marik uses the “R-word:”

The reality is that although we are the richest nation on the Earth, we need to ration health care; this should however be done fairly, justly, and equitably.

Rationing, by definition, isn’t that. It is invidious when it judges the value of some lives as having greater societal value than those of others.

But Wesley! We have to limit costs. 

Indeed. But coercion is not the answer. Education is. Treat people like adults. Patients and families need to be told about how onerous some of these interventions can be.

Moreover, I point out that as we are discussing cutting access to wanted treatment for some patients, we are expanding the scope of what constitutes required care for others. As just one example, Medicare now pays for sex change surgery and other interventions for gender dysphoria.

If we are going to ration care, it should start with procedures that are elective and/or not essential to maintain life and physical health. 

 

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