How to Ration Health Care – The Health Care Blog

Commentary by John C Goodman

Source: The Health Care Blog

Suppose you were in a triage situation and you had to choose between two patients, deciding who lives and who dies. Are there any principles you could rely on to make your choice?

Alex Tabarrok had an interesting post the other day at Marginal Revolution in which he asked readers to imagine standing behind a Rawlsian veil of ignorance. This is a thought experiment in which you are about to be born into a world, but you don't know which person in that world you will be (e.g., you could be born smart, dumb; rich, poor; black, white; etc.). You can decide the rules governing the world you are about to be born into, but you must make your choice "position blind."

What decision rules would you choose?

For his part, Tabarrok focuses on how to allocate kidneys among transplant prospects and his own solution is: allocate scarce organs so as to maximize remaining years of life:

In the current system, a 60-year-old patient can be given a 20-year-old kidney - that's a waste because the life expectancy of the kidney is longer than that of the patient; it's like putting a new clutch in a car that is rusting away.  If we had 20-year-old kidneys to spare, this wouldn't be a big problem.  But we don't have 20-year-old kidneys to spare, so we also give 20-year-old patients 60-year-old kidneys which means the kidney is likely to die early, taking the patient along with it.  If we want to maximize total life expectancy, younger people should get younger kidneys.

There are other good sentences, followed by comments - some of which dispute Tabarrok's understanding of organ survival - and there are previous Marginal Revolution posts on this subject worth checking out.

Consider, however, the broader issue. Is maximizing years of life really the best standard? In general, such a standard implies that we should choose younger patients over older ones. But this conflicts with a long-standing view that everyone should have equal access to care.

Suppose you were an emergency room physician on triage duty and chance forced you to choose between saving one of these two patients:

  • (a)    A 40-year-old college graduate or a 20-year-old high school dropout?
  • (b)   A 50-year-old scientist or a 30-year-old derelict?
  • (c)    A brain-damaged child or a healthy young adult?
  • (d)   A 40-year-old successful entrepreneur or a 30-year-old day laborer?
  • (e)    A 30-year-old concert pianist mother or a 20-year-old welfare mother?

Triage decisions in which life and death hang in the balance must surely be agonizing. I for one am glad I have never been forced to make one. But suppose you had to. Would you choose the patient with the most remaining expected years of life? Or would you make these choices by flipping a coin (thereby giving each patient equal opportunity)? If you could dictate a decision rule to all emergency room doctors, would you insist that others decide by coin flipping? My own criticism of the coin toss approach is here. But if not by age and not by randomization, how should rationing decisions be made?

I believe that most people, most of the time would choose to save the patient who is likely to make the greatest contribution to national well-being. That is, most people will allocate care in order to maximize national output broadly defined. (Broadly means, considering not just GDP, but also things that aren't well measured by GDP, such as contributions to the arts and sciences.)

But before I send this idea out to all the ERs in the country, we will give readers a chance to comment.

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