Who should call the shots?
In the fiery debate over taming the cost of US healthcare, there is a dirty word that no one wants to use: Rationing. When he was interviewed last week on the Daily Show, the president’s chief budget nerd Peter Orszag said that spiraling healthcare costs dwarf the banking crisis as a long-term financial threat. He carefully avoided suggesting that medical treatments or supplies might need to be rationed. But in a world with limited resources, rationing of some kind is inevitable. Consider one of the hardest cases of all: What should we do with limited Tamiflu stocks during an epidemic of bird flu?
The avian influenza virus has not mutated into a form that can spread epidemically, but public health experts warn that this could happen at any time. The only drug available to treat people with bird flu is Tamiflu (oseltamivir phosphate), but supplies are limited. At some point, hospitals could be forced to decide how to allocate what they have left. But who should be saved? And who gets to call the shots?
Harvard bioethicist Jim Sabin wrestled with this question last month during a seminar at the National Undergraduate Bioethics Conference. He painted a chaotic picture of hospitals using different allocation strategies at the same time. Hospital A keeps a stock of Tamiflu for staff who become exposed, to ensure that they will continue to be able to respond to the outbreak. Hospital B uses its remaining resources to try to save its sickest patients. In order to maximize the number of survivors, Hospital C reserves its drugs to treat patients who present within 48 hours of disease onset and are thus most likely to respond to treatment. Hospital D assumes that Tamiflu supplies will soon be depleted regardless of strategy, so it treats all probable and confirmed cases, regardless of severity. Finally, Hospital E is giving priority to younger patients.
Which hospital’s method should be adopted for the entire community? Or should hospitals be forced to unify their actions at all? If we can decide on the right strategy now, perhaps we can gain greater confidence that when the shots do need to be called, they’ll be called right. (Note: One strategy that Sabin left out is giving treatment only to those who can pay for it, which is the essence of US healthcare today.)
—Jennifer Marett
April 8th, 2009 at 9:03 pm
Well, some people are using the word “rationing”. Liberals who support healthcare reforms to bring the US in line with other industrialized nations in offering universal healthcare, for example:
http://www.prospect.org/csnc/blogs/ezraklein_archive?month=04&year=2009&base_name=paul_ryan_embraces_health_care
Meanwhile, Republicans conjure up the Rationing bogeyman to make healthcare reform seem ill-intentioned, for example congressman Wally Herger (R-CA):
http://www.house.gov/herger/eupdate_health_GovtCare_Feb09.shtml
Maybe we should just call it “cost effectiveness” like the Brits do and wink.