This coming Sunday’s The New York Times Magazine, July 19, will have a fascinating article on the rationing of health care authored by Princeton University’s Ira W. DeCamp Professor of Bioethics Peter Singer. The article is HERE —“Why We Must Ration Health Care.” It seems that the web version of The New York Times is now taking to publishing some articles in advance of their paper publication dates. One other illustration is that presented on the Mirror of Justice several days ago regarding the early release of the substantial interview with Justice Ruth Bader Ginsburg that was released a number of days before the confirmation hearings of Judge Sonia Sotomayor for her consideration as an associate justice of the United States Supreme Court. [HERE for more information]
I find it interesting that as the Congress appears to be pushing through legislation on expanding health care coverage—a fine idea in principle—we are treated with this remarkable essay in public policy that advocates rationing health care by Professor Singer. As some readers of MoJ may recall, Peter Singer is an advocate for many problematic positions such as granting “personhood” to animals while at the same time arguing for the justification for the killing of newborn human babies; but he has also advocated on behalf of “ethical” eating by people—so if carnivores eat meat, what do humanitarians eat? But I digress.
In the article to which I have given the link, Professor Singer is not questioning if health care should be rationed, he is advocating that it be rationed. As an aside, I wonder what kind of health care plan he is on at Princeton, but I digress again.
Singer is astute enough not to raise questions that are too personal. Moreover, he offers some insightful points regarding particular issues. He supports allowing a person to spend his or her individual resources on expensive health care, but he poses his argument in the context of how someone with a questionable longevity because of serious illness who is a member of your health-insurance fund should be treated by the fund to which you, I, and anyone else may also contribute. As it turns out, he is not asking how much should the fund spend on caring for this individual; rather, he is asking how much is this person’s life worth? But he cleverly poses the issue this way:
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much? If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
He then launches into the current debate in the Congress over “health care reform” and adds that the term “rationing” has “become a dirty word.” He notes that this is what “sank the Clinton’s attempt to achieve reform.” And so, he promotes a questionable method of calculating the value, and therefore the worth of saving specific human lives. In essence, the approach he utilizes to do this is a utilitarian one. As he argues:
multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.
But is he really talking about reform, or is he, in fact, determining that someone else—be it individuals (e.g., Peter Singer), lobbies, medical insurers, the government, etc.,. will be authorized and empowered to make decisions on whether an ailing individual shall receive some, any, or no health care if that someone else decides that the individual’s—that your life—is not worth living or at least not worth prolonging.
I frankly think that most people today voluntarily chose not to prolong unduly this physical life by long-term and expensive therapies that have little promise of success. They recognize that their life in this world is coming to an end and, for many, it is now time to go home to God. I find myself frequently addressing this very issue. But this is not something of which Professor Singer takes stock since his approach disregards the possibility that people realize that while their life is valuable, it does not make sense to pursue costly therapies and medications that offer little hope for benefiting their physical life. For him, their moral agency appears not to exist, and if it does, it does not mean much to him. Not only does he want to be the moral agent for himself, he wishes to be the “moral” agent for everyone else from what he says. Here is how he begins to pitch his argument regarding this:
Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price.” The man’s response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?
But we are not talking about jokes, as crude as the one that he uses. We are talking about human life and why it is worth protecting in conformity with the wishes that most people are able to make in reliance on what good moral medical advice that is not swayed by monetary loss or gain advises. Indeed, health care can be an expensive resource, as Singer adds. But human life is a precious one that should never be discarded. The fact that the violent-prone person may find human life cheap does not mean that the rest of humanity should follow suit, especially when they hold distinguished chairs in bioethics at influential universities.
It becomes evident that Professor Singer is inclined to ration health care for some—especially the poor or the uninsured. The fact that one is poor or uninsured does not support the conclusion that they have nothing to give others. Thus, the professor reminds us that for many who are not “poor,” health care is paid for or substantially co-paid for by employers for whom contributions are tax-deductible. But for the unemployed or those employed but without employer-paid benefits including medical insurance, Singer is most willing to ration health care without hesitation. If you doubt this, here is what he says:
The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare’s trustees warned that the program’s biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation... President Obama has said plainly that America’s health care system is broken. It is, he has said, by far the most significant driver of America’s long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 25 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.
But, is this really true? Do other nations in fact have better health outcomes? Elsewhere, Professor Singer questions his own assertion by stating that while rationing is practiced by other industrial nations whose practices the American people and its servant government should admire and emulate, he admits that there are significant problems in these other systems. Getting good value for professional services and medications is not the issue. What is the issue is really identified by Professor Singer: what will the market bear in providing a service or a medication?
As he concedes,
Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE [the British government-financed organization that provides national guidance on treating illnesses].
It would seem from what Professor Singer concedes that the problem is not the need to ration health care. The problem, rather, is this: why does the cost of health care in one venue dramatically differ from another venue for the same service and the same medications. Perhaps the question that Congress should be really focusing on is just that, and it would be better off to put aside the arguments for rationing. Rationing is a device used when goods and services are in short supply. Rationing is not a device that should be used when goods and services are available but their costs are based not so much on reason but on caprice or the whims of a particular market. I would think that Catholic Legal Theory is very much interested in how laws are made and why they are made in the fashion that they are. In the context of what Congress is now doing regarding health-care in the United States, the question should not be on availability but on the pricing mechanisms that have a disproportional impact on what determines the cost of services and medications that are available but may or may not be affordable.
As I have mentioned, Professor Singer’s concern is really not with any of this but with what he views as the value of human life. As he reaches the end of his essay, he states:
The dollar value that bureaucrats place on a generic [my emphais] human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question “How much are you willing to pay to save your life?” — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. [As I have stated earlier in this posting, I question the validity of this claim.] So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives.
I think most people do make these kinds of decisions with regard to some issues but not when it comes to the major question about the end-of-life that emerges from realizing the inevitable destiny we all face. Singer attempts to cast his argument not as an economic one but as an ethical one. But he fails in this regard when he tries to distinguish between the teenager who is a violent criminal and the octogenarian who is still a productive member of society. As he asserts: “But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.” Professor Singer tries to get around this problem he has generated by concluding that health care is more than just saving lives; it is about reducing pain and suffering. His solution: ration health-care.
I for one believe his solution is flawed and that the Congress must recognize that rationing is not the solution but a problem that is easily avoided. The real issue that must be acknowledged and addressed is that the pricing schemes for medical services and pharmaceuticals; and the solution rests with bringing reason and fair pricing to what is charged for them to the person who can pay, the person who can pay with insurance, and the person who cannot pay but relies on public or charitable assistance. Regardless of who the individual is, he or she has a life that is worth living. If the treatment is available and will do good for that person, it should be made available. But if the treatment is one that will provide little benefit, the patient himself or herself, with objective medical counsel and support of fellow human beings and the availability of palliative care will probably reach a judicious decision and prepare to meet the one from whom his or her life was given.
RJA sj
