Pushing Health Care Rationing by Not Discussing Health Care Rationing

The scent of health care rationing is in the air. But I have noticed lately that many who support the concept push the agenda by not actually discussing health care rationing. Case in point: Ellen Goodman’s fuzzy recent column, “A Rational Talk About Rationing Care.”

Goodman starts by citing an interview in the  New York Times  in which President Obama wondered whether society should have to pay for the kind of care his late grandmother received, that is receiving a hip replacement after a fall even though she was terminally ill.  From her column:

I was . . . struck by the way the president framed Toot’s [Obama’s grandmother] treatment as one of the “difficult moral issues” surrounding healthcare costs. Indeed, folks on the right saw this story as Obama’s warning about rationing ahead. But aren’t there places at the end of life where ethics and economics, compassion and cost, dovetail rather than conflict?

There are “difficult moral issues” ahead. But is this one of them? Is a healthcare system that offers “everything” to everyone—hip replacements to terminally ill patients—morally superior? Or suspect? Can’t we decide when more is not more?

That would seem to open door to discussing mandatory care restrictions. But instead, Goodman veers away:

I won’t second-guess decisions in those last weeks of Toot’s life any more than I would second-guess my own family’s decisions as the avalanche of choices rolled toward us in my mother’s last months. But I do think that what our system may need is not more intervention but more conversation. Especially on the delicate subject of dying.

I’ll brew the coffee. But “second guessing” by society is exactly what health rationing is all about. Goodman moves next to the subject of costs:

Today more than one-fourth of Medicare dollars are spent in the last year of life. Most people want to die “peacefully” at home but 80 percent die in hospitals. So, much of our money goes to the kind of death we don’t want.

I am not sure her statistics are right, but even if they are, receiving unwanted treatment—which is increasingly less common—isn’t rationing.

It’s true that the financial incentives of our medical system are geared toward intervention, but so are the emotional incentives. Doctors are in the business of fixing, trained to write “hope” on the prescription pad. These professionals are often uncomfortable amateurs in the business of talking about their “failure”: death.

Doctors should offer hope. Moreover, Goodman is behind the times about financial incentives. But again, what has any of this got to do with rationing? Ah, finally, here it comes:

In the wake of the Terri Schiavo case, the “living will” became a common document. On websites now, “The Five Wishes” are downloaded as family talking points that go beyond “pulling the plug.” But denial is still the default position. And maybe the destructive position . . . Recent research shows these conversations result in less aggressive treatment, lower stress, a better quality of life for dying patients and comfort for those who will mourn them.

If this is rationing, I call it rational.

But having “conversations” and willingly eschewing aggressive treatment explicitly isn’t rationing. Rather, rationing prohibits health care funders from paying for otherwise covered treatments, based on the patient’s age, state of health, disability, or perhaps, because the patient committed politically incorrect lifestyle crimes such as smoking or being overweight.

If and when Goodman really wants to have a direct discussion about the harsh and discriminatory realities of health care rationing and what it would mean to society’s most vulnerable populations, I’m game. But this column isn’t it.