Unlimited needs and limited resources—we are not new to negotiating how to allocate in situations of scarcity. In a family where there are hours of homework to review, meals to be cooked and baseboards to be cleaned, a parent must determine where his or her limited energy can be best spent. In a city where it would be nice to have all the streets plowed immediately after a snowstorm, we prioritize those roads that are most important to get our towns going. And in a country where we have unlimited health needs, we must decide who gets life-saving care and who goes without it.
Yes. That last one is true. Although we in the United States like to talk about how “other countries” ration health care, we have, we do, and we always will. We treat rationing as if it is a virus, able to infect our health care system and bring it down from inside. But rationing is more aptly described as a vital part of our immune system, central to us staying upright. Without rationing, the percentage of our economy spent on health care (which is already 18 percent) would balloon and crowd out other important social goods.
The New York Times recently ran a story about the ad hoc decisions being made in hospitals across the country. And these aren’t decisions about ancillary items. The drugs, physician time or equipment that get allocated to one patient or another can literally mean the difference between life and death. And the question is not whether we have to ration these items or not. We do. The question is whether we will do it wisely or not. Right now, we aren’t.
Active and Passive Rationing
This isn’t an easy web to untangle. But we’ve done it in other situations of scarcity in health care. We have a well-accepted allocation method for organ donations. And while there are legitimate disagreements whether the method can be improved, we have a broad understanding that some patients will receive a life-saving organ and others will not. It’s public. There isn’t any confusion as to what degree age or chance of success matters. We’ve been able to discuss how we want to make truly tragic decisions in a way that reflects our shared values.
This isn’t the case for much of the rationing going on in hospitals across the country. Many hospitals have ethics committees that take on these tasks, but many do not. And even among those that do, patients rarely know these decisions are being made and there is no public vetting of the values driving the process. The least we can do, as the Times rightly highlights, is to bring this process out of the hidden corners of individual hospitals out into the light of the public square. While it is true that the myriad situations will be exceedingly more complicated than organ allocation (which is complicated enough), we have to start somewhere. This problem won’t be going away.
Rationing is one of the worst kept secrets among medical professionals. But we’re more likely to discuss the active decisions that must get made. The thing that even practitioners rarely talk about is the passive rationing that comes with being poor. The poor are more likely to be denied access to providers because Medicaid payments are considered too low. The poor are more likely to miss follow-up appointments because of limited office hours and lack of hospitals in their neighborhoods. The poor are less likely to get the best care because they have less of the social capital necessary to negotiate a complicated health care system. And on and on. In part, we are under the illusion that we don’t ration because we so often do it in a passive way, permitting the structures we’ve built to do it for us.
When we move forward and take the rationing of health care more seriously, we’re likely to hear more about the active process of rationing—who gets what and why. That would be a great leap forward. But I hope we don’t miss the opportunity to also discuss the passive rationing that underlies the entire system, a rationing that puts the poor and marginalized at the peripheries rather than the center. Dealing with both active and passive rationing requires us to name and debate the values that we hold most dear. There will be disagreements. But when life and death are on the line, I’d rather disagree with you than avoid the conversation until its too late.
Michael Rozier, S.J., is a doctoral student in the department of Health Management and Policy at the University of Michigan School of Public Health, Ann Arbor, Mich.