Rationing Health Care

The distinguished utilitarian philosopher Peter Singer has written a bold and courageous piece in the New York Times entitled “Why We Must Ration Health Care.”  If you have not read the article yet, I strongly recommend that you spend the time do so.  Regardless of whether you agree with his ideas, it’s time we began a public discussion on how we will ration health care and Singer’s article offers an excellent starting point.The rationing of health care is currently a third rail in American politics: no politician will dare mention it.  Senator Max Baucus, the Democratic chair of the Senate Finance Committee and one of the most important Democratic leaders pushing health care reform, told CNSNews in April that “There is no rationing of health care at all” in his proposed reform.  For the American public at large, the rationing of health care conjures up images of soulless bureaucrats deciding who lives and who dies, which is why the practice has such a poor reputation in America. Almost all other developed countries with universal health care, however, engage in some type of rationing of health care.  In Britain, for example, the National Institute for Health Service, a government-financed but independently run organization, provides guidelines for the National Health Service to follow.  By calculating the costs and benefits (in terms of improving the quality of life and extending life) of different types of medical care, other countries with universal health care ensure that scarce medical resources are not wasted on expensive treatments with little chance of success.  Furthermore, the citizens of these countries are happier with their largely government-run and rationed medical systems than Americans are with our system.  Singer cites a Gallup poll in which 73 percent of Canadians and Britons expressed confidence in the “health care of medical systems” in their country, compared to 56 percent of Americans.  This difference is all the more revealing given that the United States spends much more, per person, on health care.

The only real alternative to rationing health care through a government-run public program that cost-effectively allocates medical resources based on need is to rely on how the private sector rations all other types of goods: rationing based on ability to pay.  As a staunch believer in the general efficiency and justice of markets, I’m happy to acknowledge that rationing based on ability to pay is the correct thing to do when it comes to goods such as televisions and concert tickets.  But when it comes to a good such as medical care, it seems proper that society should do more of its rationing based on need rather than ability to pay.  Keep in mind that countries that ration based on need through public-run health care systems, such as Britain and Canada, also allow private health insurance if individuals want more expensive care beyond what can be provided to all at the public’s expensive.

As Singer also mentions, a large reason government-sanctioned rationing seems so wrong is that we are fooled by the “identifiable victim” effect.  We hear stories about individuals in other countries harmed by a government’s decision to limit the cost of health care, but the people who die in emergency rooms because they lack health insurance are invisible to the public at large.  Rationing based on need would also help America make the sensible move to reallocate resources away from end-of-life care towards saving the lives of younger people.  It’s not that I don’t care about the lives of the elderly (my grandfather’s recent death has in fact put this consideration at the front of my mind), but, as Singer wisely argues, “If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.”  I have plenty of fierce philosophical disagreements with utilitarianism, but Singer’s rule-based utilitarianism for rationing health care seems quite persuasive at the moment.