Thought du Jour

A federal advisory panel [in the USA] recently set off a controversy by recommending that most women without special risk factors delay breast cancer screening until they turn 50, not 40 — and that mammograms then take place only every other year.

These guidelines, which differ from those of some other professional or advocacy organizations, have been called a rash misjudgment and an example of ostrich-like thinking. But this criticism is unfair, both to the scientists who prepared the report and to ostriches (who don’t actually bury their heads in the sand in an attempt to hide).

Richard H. Thaler, “Economic View: Gauging the Odds (and the Costs) in Health Screening”, New York Times, 20 December 2009.

Behavioural economist Richard Thayler continues with a concise “discussion of the underlying numbers and a bit of probability theory”. He complains “anyone who even suggests that some test be done less often is accused of condoning ‘rationing’, an all-purpose slur against any change that might reduce costs”.

Thaler teaches economics in the University of Chicago Graduate School of Business. He is co-author, with legal scholar Cass Sunstein, of Nudge: Improving Decisions About Health, Wealth, and Happiness (Yale University Press, 2008; updated edition, Penguin, 2009).

MR. GREGORY:  Senator Hutchison, you said this [task force recommendation against routine mammography for women aged 40 to 49] is the beginning of rationing.

SEN. HUTCHISON:  I think it is.

MR. GREGORY:  Why did you say that?

SEN. HUTCHISON:  It’s because it’s whether the insurance and the public option [in the health reform bill] are going to pay for a woman who decides that she wants to have the mammogram before the age of 50 or more than every other year after 50. If the public option doesn’t pay for that–and the task force recommendations are what the public option is going to rely on. So this task force says all of a sudden we’re going to change the guidelines that we have had for all these years.  And now the public option may not pay for those, and that means the insurance companies are going to follow. The key is that these are covered by insurance so women will not have to decide if they’re going to spend $250 to get a mammogram because they and their doctors believe it is right to do so.

That is TV journalist David Gregory interviewing Senator Kay Bailey Hutchison, a Texas Republican, on “Meet the Press” last Sunday (22 November 2009).  Ms Hutchison is a vocal opponent of the Democrats’ health reform bill. Yet she also believes that public or private insurance should cover the full cost of a mammogram. If a woman of any age, on advice of her doctor, wants a mammogram, she should not be forced to pay $250 out-of-pocket in order to obtain it.

Princeton economist Uwe Reinhardt was listening and, only partly tongue-in-cheek, writes

I cannot recall a clearer statement of unreserved support for universal and comprehensive health insurance for America and a more straightforward definition of rationing health care.

Uwe E. Reinhardt, “Health Care Rationing, American-Style”, Economix, 27 November 2009.

Professor Reinhardt is absolutely correct. Senator Hutchinson has been active in promotion of screening for breast cancer, but her logic would apply equally to screening for other cancers, indeed to medical attention for the prevention and treatment of other illnesses, such as hypertension and diabetes. In sum, though she may not be aware of it, Senator Hutchinson’s reasoning supports universal health insurance.

Allocation of scarce medical interventions [-including beds in intensive care units, organs, and vaccines during pandemic influenza-] is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria. During the 1960s, committees in Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependants as criteria. How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested. Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multiprinciple allocation systems. We evaluate three existing systems and then recommend a new one: the complete lives system.

Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. We do not regard ability to pay as a plausible option for the scarce life-saving interventions we discuss. ….

The complete lives system [that we recommend] discriminates against older people. …. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Govind Persad, Alan Wertheimer, Ezekiel J Emanuel, “Principles for allocation of scarce medical interventions”, Lancet, Vol 373 (31 January 2009), pp. 423-431. (Free download, registration required.)

The authors claim BS, PhD and MD degrees, respectively, and work in the Department of Bioethics of the National Institutes of Health (NIS) in Bethesda, Maryland, USA. Dr Emanuel (1957-), who, as Director of the Department, is the superior of his co-authors, is currently Special Advisor for Health Policy to Peter Orszag, the Director of President Obama’s Office of Management and Budget.

Dr Emanuel has become a figure of controversy in the US healthcare debate. Note that he and his co-authors rule out a market solution – increasing price to the point that demand equals supply – in the case of medical interventions. Most – though not all – Canadians would agree. The same is true, I believe, of Europeans. But in the United States, many favour treating health care like any product or service, to be distributed by ability to pay, perhaps with some minimimal distribution of free services to the poor. This, after all, is the way that food, which is essential for life, is distributed: food stamps for the poor, market prices for everyone else.

Dr Emanuel and his colleagues raise very serious and very difficult ethical issues. As Princeton philosopher Peter Singer recently explained, rationing of health care is inevitable. A public debate over how we ration is necessary. Should the wealthy be allowed to spend their own money to jump to the head of the queue? Countries such as Canada and the United Kingdom, with single-payer systems of health care, explicitly prohibit this. The United Kingdom does allow any citizen who has the desire – and the means – to do so to leave the public system and access private health care. Canada so far has not granted its citizens this freedom, but the US border, and a system where health care is rationed only by price, for most Canadians is only a short drive away.