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Symbols, Rationality, and Justice: Rationing Health Care

Published online by Cambridge University Press:  24 February 2021

Daniel Callahan
Daniel Callahan*
Affiliation:
The Hastings Center, Briarcliff Manor, New York; 1965, Harvard University
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Abstract

Proposals to ration health care in the United States meet a number of objections, symbolic and literal. Nonetheless, an acceptance of the idea of rationing is a necessary first step toward universal health insurance. It must be understood that universal health care requires an acceptance of rationing, and that such an acceptance must precede enactment of a program, if it is to be economically sound and politically feasible. Commentators have argued that reform of the health care system should come before any effort to ration. On the contrary, rationing and reform cannot be separated. The former is the key to the latter, just as rationing is the key to universal health insurance.

Type
Articles
Information
American Journal of Law & Medicine , Volume 18 , Issue 1-2: Rationing Health Care: Social, Political and Legal Perspectives , 1992 , pp. 1 - 13
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 1992

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References

1 See Mark, Pauly et al., A Plan for “Responsible National Health Insurance”, HEALTH AFF., Spring 1991, at 5, 20–21 (comparing experiences of the United States, the United Kingdom and Canada).Google Scholar

2 See, e.g., Robert J., Blendon, The Public's View of the Future of Health Care, 259 JAMA 3587 (1988)Google Scholar; Cindy, Jajich-Toth & Burns W., Roper, Americans’ Views on Health Care: A Study in Contradictions, HEALTH AFF., Winter 1990, at 149.Google Scholar

3 Cf David C., Hadorn, Emerging Parallels in the American Health Care and Legal-Judicial Systems, 18 AMJ.L. & MED. 73, 85Google Scholar (“The problem of rationing merely is another instance of the need to balance individual welfare and public good.“).

4 See, e.g., Joan, Beck, Oregon Health Plan Faces the Reality of Care Rationing, CM. TRIB., Mar. 2, 1992, at C15Google Scholar; Spencer, Rich, Advocates for the Poor Hit Oregon Health Plan: Governor Vows to Prevent Inadequate Care, WASH. POST, Sept. 17, 1991, at A3Google Scholar.

5 See, e.g., David, Lauter & Edwin, Chen, Health Care For All: Three Plans Compete, L.A. TIMES, Nov. 11, 1991, at A1Google Scholar.

6 See Kai N., Lee, Salmon, Science and the Law in the Columbia Basin, 21 ENVTL. L. 745, 776-77 (1991)Google Scholar (“[In] rationing lifesaving medical care … societies must attempt to make allocations in ways that preserve the moral foundations of social collaboration.“); Pascal, Fletcher, Feeding Family Food Basket is Frustrating Chore in Cuba, REUTER LIBR. REP., Sept. 30, 1991Google Scholar, BC cycle (“The authorities say the rationing system is the only way to ensure a fair distribution of scarce resources.“).

7 See GEORGE J., ANNAS ET AL., AMERICAN HEALTH LAW 121 (1990)Google Scholar (11.1% of GNP in 1987); Roberrt D., Ray, Health Tax Credits? A Sickly Idea: Here's A Plan That Won't Do Anything to Make the System Work, WASH. POST, Jan. 26, 1992, at C5Google Scholar (13% of GNP in 1991).

8 Robert J. Blendon, supra note 2, at 3588-90; Cindy Jajich-Toth & Burns W. Roper, supra note 2, at 153.

9 Daniel Callahan, Director.

10 This Article does not address the details of that kind of system.

11 118 CONG. REC. 33,004 (daily ed. Sept. 30, 1972) (statement of Senator Hartke in sponsoring the end-stage renal disease section of the Social Security Amendments of 1972).

12 See GEORGE J. ANNAS ET AL., supra note 7, at 890.

13 Health Insurance for the Aged Act, Pub. L. No. 89-97, 79 Stat. 290 (1965) (codified as amended at 42 U.S.C.A. §§ 401-426 (West 1991)).

14 John, Holahan & John L., Palmer, Medicare's Fiscal Problems: An Imperative for Reform, 13 J. HEALTH POL., POL'Y & L. 53, 77 (1988).Google Scholar

15 THE PEPPER COMM'N: UNITED STATES BIPARTISAN COMM. ON COMPREHENSIVE HEALTH CARE, 101ST CONG., 2D SESS., A CALL FOR ACTION 17 (S. Print 1990).

16 See Administration Health Care Proposals: Hearings Before the House Ways and Means Comm., 102d Cong., 2d Sess. (1992) (statement of Dr. Louis Sullivan, Secretary of Health and Human Services) (“Indeed, one of our principles is to increase the efficiencies in our system because of my belief that we already have enough dollars in the system, but we're not spending them wisely.“), reprinted in FED. NEWS SERV., Feb. 20, 1992.

17 See Amitai, Etzioni, Health Care Rationing: A Critical Evaluation, HEALTH AFF., Summer 1991, at 88–95.Google Scholar

18 Steffie, Woolhandler & David U., Himmelstein, The Deteriorating Administrative Efficiency of the U.S. Health Care System, 324 NEW ENG. J. MED. 1253, 1255 (1991).Google Scholar

19 See Leonard S., Weiss, Finding the Remedies for Ills in Health Care: They Don't Come Easy, but They Do Exist, NEWSDAY, Mar. 5, 1992, at 97Google Scholar (defensive medicine adds more than $18 billion to health care costs).

20 Cf Frank A., Sloan & Randall R., Bobvjerg, in Medical Malpractice: Crises, Response and Effects, HEALTH INS. ASS'N OF AMERICA, RESEARCH BULLETIN 43 (1989)Google Scholar (“Price rises for liability coverage and heightened fears of litigation with its many uninsured costs have surely affected the climate of American medical practice.“).

21 INSTITUTE OF MEDICINE, ASSESSING MEDICAL TECHNOLOGIES 211-27 (1985).

22 See George J., Schieber & Jean-Pierre, Poullier, International Health Spending: Issues and Trends, HEALTH AFF., Spring 1991, at 106, 114 exhibit 6.Google Scholar

23 Id. at 110 exhibit 2.

24 Diagnosis-related group, which is a Medicaid payment plan under which hospitals receive a lump sum payment on the basis of discharge diagnosis, without regard to actual treatment provided. See GEORGE J. ANNAS ET AL., supra note 7, at 215-16, 234-48.

25 Under a managed care system, the patient chooses, or is assigned to, a primary care provider who then controls the patient's access to hospitals and specialists. Under most plans, the provider's income decreases if the provider approves expensive specialists or hospital care. Id. at 784.

26 Under a health maintenance organization system, the patient pays a fixed sum and the organization promises to provide a defined package of inpatient and outpatient services. Doctors may be paid as salaried employees or on a fee-for-service basis. Id. at 774-75.

27 See DANIEL, CALLAHAN, WHAT KIND OF LIFE: THE LIMITS OF MEDICAL PROGRESS 76 (1990)Google Scholar.

28 Id. at 76-77. See also Sandra, Christensen, Did 1980s Legislation Slow Medicare Spending, HEALTH AFF., Summer 1991, at 135.Google Scholar

29 See Stuart M., Butler, Coming to Terms on Health Care, N.Y. TIMES, Jan. 28, 1990, at C13Google Scholar; Robert, Pear, Social Security Benefits to Go Up 3.7%, N.Y. TIMES, Oct. 18, 1991, at A10.Google Scholar

30 See Yesterday's Mirage: Why Britain's NHS Needs Competition, THE ECONOMIST, Apr. 28, 1984, at 26 [hereinafter Yesterday's Mirage]; see also DANIEL CALLAHAN, supra note 27, at 88-89.

31 See Yesterday's Mirage, supra note 30, at 26-30.

32 See GEORGE J. ANNAS ET AL., supra note 7, at 70-74, 104-06.

33 See Charles J., Dougherty, Setting Health Care Priorities: Oregon's Next Steps, HASTINGS CENTER REP., May-June 1991, at special supp. 1–16Google Scholar; Sara, Rosenbaum, Mothers and Children Last: The Oregon Medicaid Experiment, 18 AM. J.L. & MED. 97 (1992).Google Scholar

34 Sara Rosenbaum, supra note 33, at 104.

35 Act effective July 1, 1989, ch. 836, 1989 OR. LAWS 836 (codified as amended in scattered subsections of OR. REV. STAT. § 414 (1989)).

36 Pub. L. No. 89-97, § 1901, 79 Stat. 343 (1965) (codified as amended at 42 U.S.CA. §§ 1396a-1396u (West 1992)).

37 Id.

38 CHARLES J. DOUGHERTY, supra note 33, at special supp. 3-4. See also Daniel, Callahan, Medical Futility, Medical Necessity: The Problem Without A Name, HASTINGS CENTER REP., July-Aug. 1991, at 30.Google Scholar

39 For example, coronary artery bypass surgery for an elderly person, or resuscitation efforts with a very low birthweight baby.

40 OR. REV. STAT. § 414.720 (1991).

41 Lawrence D., Brown, The National Politics of Oregon's Rationing Plan, HEALTH AFF., Summer 1991, at 46–47.Google Scholar

42 Id. at 50.

43 See Daniel, Callahan, Ethics and Priority Setting in Oregon, HEALTH AFF., Summer 1991, at 78–87.Google Scholar

44 See Oregon Medicaid Rationing Experiment: Hearings Before the Subcomm. on Health and the Environment of the House Coram, on Energy and Commerce, 102d Cong., 1st Sess. 19 (1991) [hereinafter Hearings on Oregon Rationing] (statement of Jean I. Thorne, Director, Medical Assistance Programs, Dep't of Human Resources); id. at 83 (testimony of Tina Castanares, Oregon Health Servs. Comm.).

45 See id. at 65 (testimony of Rep. Les AuCoin) (“Oregon's health plan is a program of expansion, not of limits.“).

46 Lawrence D. Brown, supra note 41, at 50.

47 See Hearings on Oregon Rationing, supra note 44, at 157, 160 (statement of Sisters of Providence in Oregon).

48 See id. at 151 (statement of Peter O. Kohler, M.D., President, Oregon Health Sciences University); id. at 157 (statement of Sisters of Providence of Oregon).