UHC Ethical Dilemma: Where do you draw the line?

Loosely based on this thread in the Pit: http://boards.straightdope.com/sdmb/showthread.php?t=545309. As it is the Pit, it turned into a pitting against a poster, and left the “real” issue behind, which Sateryn76 and I tried to revive on page 5.

First of all: please do not confuse the issue with comments about what is or is not in the current health care bill. This debate is not (intended) to be about that subject.

Second: lets all try and keep our panties from being bunched up about “death panels”. This is about rationing health care, because many people (myself included) do not think it is likely or reasonable to assume that everyone will get all the care they want or need for free (paid by the gov’t) all the time. Its a wonderful fantasy, but that’s all it is.

So here’s the hypothetical situation:

From PrettyVacant:

Reply back from me:

that’s the question I now dump in GD: should the child in this hypothetical case get the care?

I will go out on a limb and say, no, in this case, I’m sorry, the child does not get the care, just due to high cost and low probabilities. That is this debate, what is your take on it? If yes, the child gets the care, then where do we draw the line?

If politicians in the US could say No to this kind of spending, there would be no need for health care reform. But they can’t.

The very first time anything like this came up, imagine Terry Schiavo[sup]10[/sup].


wow - excellent post and point Shodan. Short and to the point and I think dead-on. I had not thought of it from that perspective.

Now, how about how you would do things if you were in charge?

I don’t see how this is a specifically UHC dilemma? Don’t American insurance companies face this problem every day?

(By the way, a good solution would involve something like NICE.)

No. The vast majority of Group Healthcare policies work on a “up to a max payout” plan, but typically don’t make the types of treatment calls described above prior to that.

Before I consider whether this is a “dilemma” or not, I need to know what percentage of our Health Care dollars are actually spent on these “million dollar babies.” I imagine these cases are quite rare, and pointing them out as an argument against UHC seems to me to be missing the big picture.

A million bucks sounds like a lot, but compared to $14,300,000,000,000 annual gross domestic product, it’s a tiny drop in the bucket.

There are countless ways that the wealth of this nation is, in my opinion, wasted. It’s all a matter of what our priorities are. Our military spending, which is 50% of the world’s overall military expenditures even though we make up only 5% of the world’s population, should be on the chopping block before we consider whether saving a child is “worth it” or not.

the details of the GDP (for this hypothetical example) are spelled out in the OP. We are starting with a $10billion GDP, 10% of that goes to UHC. And this is not to say why we shouldn’t do UHC. As I said in the Pit I am a waffler, I was initially against it, but the proponents have some really good arguments that are (or have) swayed my opinion. I see good points on both sides, which is why I have a hard time deciding anything.

I agree that there are a lot of costs that should go on the chopping block before lives go on the line (children’s or adults), but the point is, at some point in time, there will have to be a line drawn and if you fall on the wrong side of the line - too bad so sad.

Its a little easier to set this line with adults and the elderly, so that’s why we are talking about a child. This is where people get the “oh noes - think of the childrens”, which does nothing to actually answer the question.

I agree something similar to NICE would be the decider, but where is the decision line?

I’m curious as to why you think government health insurance runs this way.

a) the state of funds in the UHC bucket is unknown when the medical provider makes the decision to do the work or not.
b) budgets are meted out based on projected expenditures, but (especially the federal) government will pay its liabilities even if they “break” the budget.

so to answer your question, the doctor will perform the surgery and seek reimbursement from the government medical provider. you’re massaging a fictitious budget crises to provide a comparable scenario to a public policy decision where it is known, a priori, that a certain, non-emergency wasteful procedure won’t be paid for. not the same thing.

No, I was trying to craft a question that people couldn’t weasle out of answering, by following the suggestion given by PrettyVacant as to how rationing would work. PV was the only poster to give me an example of how you would ration care, and I was trying to create a situation that would force someone to answer the question.

So your suggestion is that everyone gets whatever care they need regardless of cost? How is that even reasonable for budgetary and deficit concerns? I guess ultimately my question is: how do you ration care? Who gets screwed and who doesn’t? Do you spend whatever it takes to give someone a 50/50 chance?

Something roughly similar to the DRG system. Patients are assigned a code based on factors like disease, comorbidity, age, etc. If you fall into certain codes - birth weight less than 2.2 kilos, Alzheimer’s, pancreatic cancer, lung cancer, etc. - you get palliative care. That’s it.

And we need to make up our minds that yes, this means that a certain number of people are going to die, who would otherwise live.

A relative of mine runs the NICU at a hospital. A clear majority of her patients die, and most of the rest go home compromised in some way. But a few do not. A few go home to normal childhoods. There is, unfortunately, no good way to predict which is which.

My recommended changes mean that most of those who go home OK will die. And that we will allow this, in order to save money.

I do not wish to sugar-coat or deny this. Some will die, who will otherwise live. Because we, as a society, prefer to spend money on something else.

It is also necessary to institute tort reform to allow this kind of change to operate, but that is another thread.


Yes, everyone gets whatever they need. That works fine in Israel. There isn’t going to be any rationing. Don’t believe everything you hear from Sarah Palin.

Well Goddammit. I’m quarterback, I’m popular. My mom says I’m a catch, I’m popular. And then I find this out.

Either way, if you need to ration care the best way to do it is via comparative effectiveness research designed to get the most quality and quantity of life per $ spent. That is what programs like the NICE program in the UK do, and what the $1.1 billion in comparative effectiveness research in the stimulus was designed to do.

There is a simple way around this situation though, outsource major surgery. If it costs $1,000,000 in labor intensive surgeries, have those surgeries done in Singapore, Thailand or India instead for $200,000.

Also, everyone who goes through primary, secondary and tertiary public education ends up consuming roughly $100,000 in taxpayer funded public education investments. That is roughly what K-12 & 4 years of college costs, assuming all are public.

I think the average household gets about $20,000 a year in direct and indirect government services. So these questions aren’t as cut/dried as they seem. Should 20 people be allowed to go to college (and collect $30,000+ each in public subsidies, for a total of $600,000) if they are not going to use their majors in their careers? I think so.

Giving an 85-year old a 50/50 chance at another 2 years of life is an entirely different question than giving a newborn a 50/50 chance at a life, period. Anyone except rank simpletons and those with agendas to push can recognize this. Edit: I would also point out that this in no way limits the ability of the 85-year old to get the procedure - we’re talking about who pays for it. I mean triage is entirely based around the concept of who is more “deserving” of certain medical procedures than others - it’s not an inflammatory or difficult subject at all.

I am of the opinion that an 85-year old is less deserving of that 50/50 than an infant. But that’s merely my opinion, I am one voice of many. Others may feel differently, others may feel the same.

I do feel, however, that one of the large reasons that people are willing to spend the money now with absolutely no further analysis is because it comes at absolutely no direct, or even first-degree indirect cost to them. In fact, the burden of their decision falls onto a nameless, faceless corporation - there’s no incentive to think about this rationally or as a member of society. They bought the policy, they will use it for its maximal benefit. Maybe that won’t change with making it all government-paid?

What forum would you like me to start this thread in? I would really like to disabuse you of your incorrect and inane notions.

Yes, and in 50 years (after you & I are dead) they’ll be facing the same problems Medicare, and Medicaid will be facing in what 10 years? Here is a PDF from the CBO. Newsflash, if Medicare and Medicaid are going to have financial problems, then no everyone cannot have everything. Hence the discussion.

SP is a complete moron, which I why I didn’t want this thread derailed by people freaking out about “death panels”. I was hoping (irrationally) for a debate in which people would say, “yes clearly there is a point where we have to make tough decisions, here’s what I think”.

I am very happy for Israel, but they had the political will to do it a long time ago, and just waving our hands about and saying “but look at Israel - why can’t we do that same thing” does not mean that our gov’t will get it done the right way.

Outsourcing is an interesting idea. I am not sure I understand your point about education though.

Rumor Watkins I agree: infants get a 50/50 shot before an 85 yr old. And your question regarding choices and visibility of costs to the end user is an important one. But really, if my taxes are going to pay towards it, why shouldn’t I get all the care I want?

Next question: do we start to ration care based on poor health choices? If someone is obese and always eats at McD’s (as in their health problems are directly related to poor choices in food and lack of exercise) do we limit the care they get for not taking care of their body?

No. Because we have an unacceptable degree of non-certainty that your free choices caused your medical affliction. Further, we don’t ration other government services based on poor choices (other than in the penal/criminal system); we do not live in a society where we prescribe and proscribe behaviors on an individualized level. That’s the entire point of living in a free society - society bears the externality costs of your shitty decision making.

But do the “shitty decision makers” bear an ethical obligation to think of the other pool members? And by extension, do the parents of that premie have an obligation to think of the pool when making their healthcare decisions about their premie?

we do not live in a society where a certain type or amount of ethical thought is mandated - you’re assuming that all ethical thought requires one to think of others.

some people would choose to spare no expense, some people would think about the overall implications for everyone in making those choices. society’s role is to enable, within the limits that the society itself defines, people to make that choice for themselves.

Sure we do - there are all kinds of means tests for government services like Medicaid and educational scholarships.

Actually we do that too, in things like the civil court system. Or even in things like smoking bans in privately-owned restaurants and bars.

Actually, in a free society we do as little of that as we can manage. I may make a shitty decision to spend the rent money on gambling, but that doesn’t mean that society has to bear the cost of making the mortgage payment.

Having the government tell you how to spend your money is about as far from being free as might be imagined. We have to have a certain amount of that, but it certainly is not the “entire point” of being free.