- Those who charge that a nationalized healthcare system will "ration" healthcare, ignore fundamental realities about our current healthcare system;
- A national healthcare system that makes care available to everyone must make hard choices about what care is worth providing. Furthermore, the best way of doing that is through the use of QALYs--Quality Adjusted Life Years; and
- If those who have the means are dissatisfied with a nationalized healthare system's use of QALYs to apportion care, they should purchase supplementary insurance.
I'll have a few comments on this later, but I wanted to get this up quickly. Stay tuned....
Will QALYs cause doctors to balk due to their Hippocratic oaths? The "Do No Harm" is often taken to mean "Preserve All Life," despite what makes sense for Quality of Life. My 92 year old grandmother, who died recently due to complications from CDIF infection following knee surgery, probably would not have had the surgery under the QALY test. However, she could not survive without it. The decision was to do the surgery, despite the risk. I would not want to have the responsibility of decision makers, who must balance the needs of the patients against the needs of the shareholders.
ReplyDeleteI am not so sure that "Do No Harm" is equivalent to "Preserve All Life" by MDs or others. Palliative care, specifically in a hospice situation, is not about preservation of life, so much as it is about preservation of quality of life.
ReplyDeleteBut more to the point about your grandmother. First of all, I am sorry for your loss. I didn't know this had occurred.
Please do keep in mind that a system that takes QALYs into account would not prevent your grandmother from getting this care. Rather, if she wanted it/needed it, it would be available through supplemental insurance or as an out of pocket expense. Keep in mind as well, that you had the option in reality because you had insurance. This would be no different where QALYs were used to make a determination about a standard health insurance benefit.
D-Man,
ReplyDeleteI read this last week and thought about it all weekend. Glad you brought it to your forum, here.
One of the "fundamental realities" you refer to in your first bullet, above, I presume, is the deep-dark-secret that Healthcare is ALREADY rationed socioeconomically. By who can and can't pay.
I hope this message lingers, too, for others who read it and perhaps take for granted a standard to which we hold our caregivers (read: hippocratic oath; "obligations to ALL my fellow human beings"), but don't conceive of as our own burden of responsibility.
Time for some ch-ch-ch-ch-changes!
Griffin,
ReplyDeleteThanks for checking this out. And thank you for emphasizing that healthcare IS rationed in our system right now. But it is rationed on the ability to pay, instead of on other criteria--like benefit to society. Thus a wealthy retired person will get all manner of healthcare, but a poor, uninsured young person will not.
Unfortunately, for those of us with adequate insurance, this may mean having to give something up in the form of services that may NOT be covered by a basic plan. Of course, nothing would then preclude us from seeking supplementary insurance, should we so desire.
Thanks for your comment, and keep them coming!
I too thought Singer's piece was very good. Some rationing is of course essential and inevitable, as Singer argues. The question is how to begin thinking rationally about rationing.
ReplyDeleteIn general, when thinking about the American system of medical care, it is useful to begin with something that the US does much better than any other country. The United States has by far the best post-secondary system of education in the world. It achieves this relative excellence with a unique combination of public and private universities, colleges, and community colleges. This system might serve as a model for the American system of delivery of medical care. More detailed questions such as public or private (we need them both) or rationing (not everyone can go to Harvard) become clearer.
Take rationing. One key to a good system is that some education (and medical care) must be the best in the world. Harvard, Stanford, Berkeley, and Michigan are necessary to set the gold standard. Smaller units such as Haverford, Swarthmore, Amherst, and Bowdoin set the standards for teaching (patient care). But we cannot afford to give everyone an education at Harvard or Haverford. We can give everyone a good two year community college education.
What is the equivalent of a good two year community college when it comes to medical care. Certainly, basic care as a child and basic preventive care should be provided to all. On the other hand, expensive operations for someone my age (68) may have to be like a Harvard education. Either I have the money or I can get a scholarship, but I do not have a right to have the public fund such an operation.
What should be the criteria for scholarship aid if I don't have the money? Age?? Probability of success on the operation?? Singer begins the discussion of these interesting questions.
Richard Barron Parker