Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether an emergency review board should allow an ineligible Medicaid recipient to receive a novel drug.
If you were on the board, would you vote to overturn this case?
Yes: 56%
No: 44%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Healthcare rationing, in some form or another, is unavoidable. The alternative -- covering all possible healthcare costs for every living American -- would vastly increase the percentage of gross national product devoted to medicine at the expense of other vital budget items, such as education, defense, or consumer goods. Such a dramatic spike in expenditures would likely prove politically intolerable. Instead, as columnist David Leonhardt wrote in the New York Times, "The choice isn't between rationing and not rationing. It's between rationing well and rationing badly."
At present, our system rations badly. Princeton University's Peter Singer, in another New York Times column, compared the cases of patients refused extremely expensive kidney cancer treatments by their insurers, which drew national outrage, with that of a woman from Atlanta who suffered from a ruptured brain aneurysm because she could not afford a relatively inexpensive blood pressure medication. Common sense suggests paying for the Atlanta woman's medication before that of the kidney cancer patients' treatment.
Oregon implemented a "rational" system of partial rationing in the 1990s that remains in effect. Led by then-governor John Kitzhaber, a former emergency room physician, the state decided to expand the number of working-poor patients eligible for Medicaid. In order to do this with limited funds, the state stopped paying for certain expensive treatments under the same program. Healthcare economists estimated that, in the long run, this approach would save lives and improve overall well-being through increased preventive care and expanded access. However, such a system created "visible" victims, who suffered the short-term consequences necessary for society's long-term benefit.
In 2008, lung cancer patient Barbara Wagner's request for the costly drug Tarceva was rejected by the Oregon Health Plan. According to Oregon's rules, Medicaid "will not cover the cost of surgery, radiotherapy or chemotherapy for patients with a less than 5% expected 5-year-survival." The media and conservative organizations drew attention to the ironic fact that while Wagner could not receive cancer treatments, she was eligible for state-funded palliative care and physician-assisted suicide. (The drugmaker Genentech agreed to provide Tarceva for free; Wagner died in October 2008, shortly after her first dose.)
Other states have experimented with some forms of limited rationing. Massachusetts, in the 1980s, and Arizona, in 2011, denied funding for certain organ transplants -- until high-profile cases of people excluded, such as dying infant Jamie Fiske, pressured the states to alter their policies.
In Wilbert's scenario, he may have a compelling case for treatment, but if he is granted an exception to see the birth of his son, other patients will likely step forward with equally compelling cases. Helping these "identified patients" will -- in the long run -- cost the lives of others, like the Atlanta woman who suffered the devastating brain aneurysm.
In 1984, economist Lester Thurow explained the fundamental challenges of the U.S. healthcare system in the New England Journal of Medicine: "As libertarians, Americans are unwilling to deny any particular medication or procedure to wealthy people who can afford to pay for it on their own. Yet as egalitarians, once we allow some patients to obtain a medical intervention, we feel obligated to make that same treatment available to everyone -- regardless of cost. The results are rising expenditures and irrational forms of rationing that favor visible patients over invisible victims."
Carving out an exception to Wilbert's state's rationing system would produce precisely that unappealing trade-off.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Force Doctors to Remove Bullet From Robbery Suspect's Leg?