It's Not Whether We Ration Health Care, But How

Read Peter Singer's article, "Why We Must Ration Health Care"

Biothecist Peter Singer makes the case for health care rationing based on philosophical, economic and ethical issues. In his piece for the New York Times, he argues health care rationing is necessary, and done right, provides the best value for the money.

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NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington.

One of the chief criticisms many Republicans levy at Democratic-designed health care bill is that the result would be, they say, rationed health care. Last week, that view was reinforced in their eyes not once but twice. Two separate medical panels proposed new guidelines to limit screenings for younger women, the first for mammograms for breast cancer, the second for Pap smears and cervical cancer.

Conservatives seized the opportunity to say their worst-case scenario was coming true. The government indeed plans to ration health care. As the demands on the country's finite health care resources increase, how should we decide which treatment patients get and who pays for them?

Our phone number, 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our Web site. That's at npr.org. Click on TALK OF THE NATION.

We're going to hear the argument in favor of rationing today from bioethicist Peter Singer. In a New York Times article, he argued the case for "Why We Must Ration Health Care." Tomorrow, we will hear from the other side. Peter Singer is a professor of bioethics at the Center for Human Values at Princeton, and he joins us from the studios on the campus at Princeton in New Jersey. Nice to have you on the program with us today.

Professor PETER SINGER (Professor of Bioethics, Center for Human Values, Princeton University; Author, "Why We Must Ration Health Care"): It's good to be with you.

CONAN: And you make the argument, essentially, that there is no alternative but to put a price on human life.

Prof. SINGER: Yes, that's the sad reality when you have limited resources and medical care, medical technology, that could be virtually unlimited in costs. But it's not a new proposal to say that we must ration health care because we already do ration health care. We already deny health care to tens of millions of people, and in fact, even those who have insurance can't get everything possible. So the question is really not should we ration health care, but how shall we do it best and most sensibly so that we get the best value for the money we spend.

CONAN: Well, give us some examples of how you would argue we already ration health care.

Prof. SINGER: Well, I suppose the most obvious one is that the 45 million people who don't have health care insurance don't get health care unless it's an emergency and they go to an emergency room, then they'll get some. But of course, that's a very inefficient way of giving them health care because very often they're only in an emergency because they didn't go to their doctors earlier and they could have got very simple and effective treatment that would have prevented them getting at the situation. Where now, when they present themselves at an emergency room, they may need tens or even hundreds of thousands of dollars worth of care.

CONAN: You also cited a really interesting study that looked at people who were in traffic accidents and had no choice about going to the emergency room or not and found that, indeed, those who had health insurance got much better coverage - got much better health care, than those without it.

Prof. SINGER: That's right. And those without health insurance died more frequently as a result of their accidents, even when controlling for all the other variables. And what the study showed was that that would have been a very efficient way of saving extra life. It would have been much cheaper to save extra life there than some of the things that we already do in other cases, where we're spending a lot on drugs, for example, for people in the last year of life who might get a lot of drugs at a vast cost that does very little to extend their life. So that's just another example of how we're rationing now, but we're doing it in an inefficient way that means that many people die unnecessarily because we're not sort of open and honest enough with ourselves about the rationing.

CONAN: And to put it in the context, in the same kind of context in which we heard the debate over the mammogram argument in the past week or so, you cite a drug for advanced kidney cancer, a very expensive drug, and a decision made by the British board - they of course have universal health coverage in Britain. And there's a board that sits and decides, well, are we going to pay for - how much does this drug cost, and is it worth it for us to pay it? And it doesn't particularly help that this board goes by the sort of Orwellian acronym of NICE.

Prof. SINGER: Yes, that's true. NICE here stands for the National Institute for Clinical Excellence, but maybe it's an unfortunate acronym. But I think, you know, you could still say, well, what the board does is necessary. And it's actually - it is a nice thing to do because it means that more lives are being saved because, given that we have limited health care resources, and the British government has set aside a certain sum, a very large sum, but a certain sum to give free health care to the entire population, you have to sometimes decide that if a pharmaceutical company brings out a drug that costs a very large amount - in this case the drug was called Sutent, and although it had some uses where it was highly effective, when it was being used for advanced kidney cancer, it wasn't very effective. It did extend life by some months but at a very high cost. And the National Institute for Clinical Excellence said that's not good value. There are better things we can do with the money. So they recommended that the drug not be prescribed on the National Health Insurance for that particular condition.

CONAN: And easy to say, as you point out in the article, easy to say, well, this is - generically, this is an easy - not an easy decision to make, but it's one thing to say generically, well, you can save more life by not spending on this drug. It's another thing when it's your life that's at stake.

Prof. SINGER: Yes, of course, and then you get somebody with the condition who says, well, I could live longer. I'd like to have this drug. They go to the media. The media make a big story about it, and sometimes, of course, the political pressure does get too much. And the drug in this case was re-evaluated. Some more evidence was found, suggesting it was more effective than had previously been thought, and it was then allowed to be prescribed for advanced kidney cancer. I'm not sure, you know, how genuine that evidence was. Maybe it really was, but I do think it's unfortunate when the media gets hold of a particular case like this and basically says: How can you not save this person's life? Because what the media�

CONAN: Well, how can a soulless bunch of government bureaucrats decide not to save this person's life? That's the point.

Prof. SINGER: Exactly. That's the way it will be put, of course, yes.

CONAN: Yeah.

Prof. SINGER: But what they don't see is this bunch of government bureaucrats, with souls or without, as you may see fit to decide, is actually saying we can save more lives. It's just that the other lives you can't identify so easily who are the people who are being saved because we don't spend so much money on this one drug. There are other people who are going to be living longer because they get more treatment or better kind of treatment that's more cost-effective, but we don't know who they are. So we can't go to the news media and say here's somebody who is alive who would have died if the government had used the money that was used to help them less effectively to save a smaller number of other people.

CONAN: Yet you argue the case that, essentially, and I think this is - part of it is inarguable - health care resources are finite. You can argue about where the levels go, but I think everybody has to accept that they are finite. Not everybody will get every bit of care that is possible. That's just not in the cards. So therefore, there is a system of saying we will decide not to make the decision. We will not call it rationing. We will just do what the system is that we have now. And nobody argued that this was rationing in any sense of the word, but that's the way it works out, or we will have to sit and make some very difficult decisions.

Prof. SINGER: Yes, that's right. I think it's - what - the system that we have in the United States is an attempt to avoid difficult decisions or at least avoid them publicly. I say that because, of course, the health insurance companies and the HMOs do make decisions about what they'll cover and what not, and they do refuse treatments for patients all the time. Most people, a lot of people, know that and have some experience with it, but they won't call it rationing. They'll deny that the treatment is effective, or they'll say that somebody has a pre-existing condition. They'll find various reasons, and then they will deny them. But they're making decisions, certainly.

I mean, the other example, of course, is in terms of the cost of prescription drugs in this country. A survey showed that in the United Kingdom, in Britain, where, you know, there is rationing, when they asked people, have you ever refused to fulfill a prescription for a drug that was medically indicated because of the cost of the prescription? In Britain, only 13 percent of people said that that had ever been the case. In the United States, the comparable figure is 54 percent. So there are far more people who go without medically-indicated drugs here because they can't afford it because, you know, there's various kinds of prescription coverage, but it's not complete. You have some very high co-payments of a sort that are completely unknown in Britain.

So you know, that's another form of rationing, that people don't get the drugs because they can't afford them even though the doctor has prescribed them.

CONAN: Let's get some listeners in on the conversation, and we would like you to contribute. Well, let's say you were in charge. How would you decide who gets which kind of care? How much the cost of a human life is? Give us a call, 800-989-8255. Email us, talk@npr.org.

Let's start off with Leslie(ph), Leslie calling us from Cary, North Carolina.

LESLIE (Caller): Hi, thank you for taking my call.

CONAN: Sure.

LESLIE: Yes, I'm being a practical-type person. I believe that you have to - or health care is rationed based on our incomes, based on our situations, based on how we can get to the public. And you have to start looking at that scientific evidence to say what has given us the most returns for our dollars, increasing the quality of life of someone.

CONAN: A lot of people can - scientists argue with each other all the time, don't they, Leslie?

LESLIE: Yes, they do, on that all the time. And I've even rethought the quality of life myself, being 63 and with a little fast heart rate sometimes that needs to be kept under control, so�

CONAN: And what point do you decide, Leslie, that, well, this is worth it, and this isn't? Do you make that on a societal basis? Because inevitably, it goes down to the individual.

LESLIE: It has to be made on a family basis. My father was 87 and had aortic valve problems. And we had an agonizing decision. My brothers and I, and with him, decided rather than him going through an aortic valve replacement and all the trauma with that and the potential bad outcomes, that we decided not to do that. And he lived another two years, and fortunately, he was able to pass away at home in a very humane way. And we sorely missed him, but I don't know if we regretted not having him going through that six months of recovery for a valve, where he may have died anyway. So we've kind of made some of those decisions on our own.

CONAN: Yeah. Would you prefer to make them on your own or have someone else make them for you?

LESLIE: I think you have to have both because the cardiologist, who had a mother of the same age who had the same procedure done 10 years younger, and he said, you know, if she'd have been 10 years older, her conditions, you know, he probably wouldn't have done it. And so, you know, we took a while to think about it, but�

CONAN: Well, Leslie, curiously you've come up with something that, in fact, resembles in a lot of ways what Peter Singer is talking about in his article for the New York Times. He calls it quality of life years. We'll explore that with him when we come back after a short break. Thank you very much for the call, Leslie, appreciate it.

LESLIE: Thank you.

CONAN: Bye-bye. We'll talk more with Peter Singer, who makes the case for rationing health care and has come up with a system in order to do it, a judgment that we might make about how to do it. How would you decide? 800-989-8255. Email us, talk@npr.org. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. Rationing is a dirty word in the health care debate. President Obama even reportedly asked a handful of governors to avoid using that term. The fact remains, though, with limited money and rising health costs, many see some form of rationing as inevitable. Indeed, many argue we ration already.

CONAN: Today, Peter Singer is with us. He's a professor of bioethics at Princeton and wrote the New York Times article "Why We Must Ration Health Care." How should we decide which treatments patients get and who pays for them? Our number here in Washington, 800-989-8255. Email us, talk@npr.org. You can join the conversation at our Web site, as well. That's at npr.org. Click on TALK OF THE NATION.

And Peter Singer, our caller just a moment ago, Leslie, used a phrase that you use a lot: quality of life.

Prof. SINGER: Absolutely. I think that's really important, and I think what Leslie did for his father was no doubt the right thing. He wasn't just concerned about extending his life as far as possible - his father, I think he said, was 87 - but was concerned to give him good quality of life at that time, and I think we need to take that into account. I think we should be thinking about quality of life. And when we think about what we can do with our health care resources, as well as trying to help people to live longer, if their quality of life is good, we should also be trying to improve the quality of life of those whose quality is not so good.

So extending life for a year for somebody who is 87, let's say, if the extension will mean they have a major operation - and I think Leslie said it would take about six months to recover fully from it - that's not necessarily going to be the best thing to do. I mean, it may be, but I think that's the sort of choice that doctors and patients have to come together and think about. But we also have to think about the amount that we are spending to prolong people's lives when the quality is no longer good.

CONAN: And if I'm an 87-year-old person, I say whoa, wait a minute. Aren't you just putting me on the ice floe and letting me die?

Prof. SINGER: No, definitely not. We're trying to find out how beneficial to you it is going to be to have your life extended. I've - you know, after I wrote that New York Times article, I had many letters from physicians, many of them saying that they feel trapped in a situation where they sometimes have no choice but to resuscitate people who are brought into hospital even though their quality of life is very poor. But if they haven't filled out a living will, if they haven't specified a do-not-resuscitation order, then they feel they have no legal choice. And we're spending a lot of money now on extending people's lives pointlessly.

You know, one physician told me an elderly, demented lady who was brought into the hospital - seriously ill, clearly wasn't going to live very much longer - she was on 17 different medications. I don't know what that was costing, but in his view, it was just completely pointless.

CONAN: Here's an email from Josh(ph) in Middletown, Connecticut: Insurance companies are currently rationing health care by denying coverage for certain prescriptions and medical treatments. Why don't we have a system where doctors make these decisions, which I guess you were just referring to?

Prof. SINGER: Yes, I think in some cases, definitely doctors, after consulting with the patients, are in the best position to make the decisions, but not always. I mean, if we go back to that drug that we were talking about in Britain, Sutent, for patients with advanced kidney cancer, the doctor has an ethic of doing the best for their patient.

Now, sometimes doing the best for your patient may be saying look, perhaps enough is enough, and your quality of life has fallen to the point where it's better not to have more treatment. But sometimes, the doctor isn't the right person to say: although this treatment would benefit you to a modest degree, it's very expensive. And that amount of health care, that amount of resources would benefit others more. That decision, I think, does need to be made at a higher level.

This is where the so-called soulless bureaucrats come into it. I mean, they are going to have to be saying: We will not reimburse the patients for this treatment even if it has a small benefit, simply because of the extremely high cost.

CONAN: Here's an email that we have, this from Richard(ph) in Ann Arbor, Michigan. Two questions: Why shouldn't medical care be rationed by ability to pay when so many other things, for example prime rib and Cadillacs, are? Is it really better, he goes on, to have medical care rationed by government panels, saying this drug or procedure is illegal or saying Congressman Smith's life is more important than Tom Doe's, so Smith gets the treatment, Doe doesn't, than that the treatment is available to both or neither based on their ability to pay? Note: It's also been along a civil-engineering equation that a million dollars in safety equipment is needed to prevent one death on a project, a skyscraper, for example.

Prof. SINGER: Well, just on the last point, of course, U.S. government agencies, like the Department of Transportation, have to put a figure, a dollar figure, on the value of a life because they have to decide how much to spend to, let's say, rebuild a road where there's been an accident black spot, and they can predict that over the next 10 years, let's say, three people will be killed unless they change it. And currently, the Department of Transportation's figure is much higher than that one million that your caller mentioned. It's actually about $5 million to spend to save a life, and often I think we could save many more lives if we covered the uninsured.

But your caller was also making a philosophical point, I suppose, when he said, well, why shouldn't we use ability to pay in this area, as we do with many of the other things that we buy. I do think that health care is different, partly because it's a matter of life and death. And I think a humane, compassionate society, especially one that's as wealthy as this society, may feel that whether someone lives or dies should not depend on things like how much money they've been able to earn during their life or where they are now.

The other thing is that we perhaps, you know, health care is special in that you don't buy it regularly and then say oh, this wasn't worth it, I think I won't buy that again, which might happen with many of the things that we spend money on. You only get the one chance to make your decision. And I don't think we want to really hold it against people to the extent of saying that they've got to die if they've made the wrong decision just once on that occasion.

CONAN: Yet you also, in your proposal, say yes, there should be a public system, a universal system that covers everybody, that's called - that makes decisions on the basis of these quality-of-life years and those sorts of calculations, but you also say it has to be in addition to a private system, so those people who want to opt out of it and can afford to opt out of it can do so.

Prof. SINGER: Well, that's true. I would not stop anybody from buying more insurance than the public option would provide. I would provide the public option, or I call it Medicare for all, I would provide that, but that would provide a, if you like, a decent basic minimum of health care for everyone. And if you want something with all the bells and whistles that will not have the inevitable limits that a public scheme will, then you should be free to pay for that, and there will be insurance companies that offer that at a market price. That's a system that I'm quite familiar with because I am from Australia, and Australia has exactly this kind of system. It has universal health coverage, but it does allow you to privately insure on top of that coverage. And many people do, but also, you know, many people are quite content with the public coverage.

CONAN: Let's get another caller on the conversation. This is Matt(ph), Matt with us from Fort Wayne, Indiana.

MATT (Caller): Yes, hello.

CONAN: Hi.

MATT: No, my comment was: I would assume that the boards that the government would use would be similar to the panels that insurance companies use already in making the decisions, in making, you know, rational decisions about what medicines and what procedures to cover. So I don't see that there would be much of a difference, and I certainly don't think the comparison to - I think they call it a death panel - is fair. So anyway, that's what my thoughts are, that it would be using similar processes to what's already in place with the insurance companies, so - and obviously, they do make rather sharp decisions about what is and isn't covered and what's, you know, what's viable.

CONAN: It's interesting, Matt, you say - I take your point about the death panel, but nevertheless, if you're - let's say that board in Britain had made the other decision - as Peter Singer said, they went back and re-evaluated and decided to authorize the drug - but nevertheless, if they make a decision saying all right, we're not going to pay for this. We're not saying you can't pay for it on your own, but we're not going to pay for this. And the person is a normal person who doesn't have the $5,000 per treatment or something to pay for it, isn't that the same as saying, okay, I'm going to die very quickly?

MATT: Well, yeah, it would be, but I mean, again, this is nothing different than what the insurance companies are already doing and the way that they're already operating because there are certain things they won't cover. There are certain procedures they won't cover. And in essence, they're not public. They're not visible. They're making these decisions without any of the public input. And I think the government option would be actually a better option.

Prof. SINGER: Yes, I totally agree because it would be a public, more transparent process, and other people could come in and discuss and criticize the basis for it. So I think you're right about that.

CONAN: All right, Matt, thanks very much for the call.

MATT: Well, thank you.

CONAN: Bye-bye. Let's go next to Justin(ph). Justin's calling us from Orlando. We're just on the air in Orlando for the first day. Welcome, Justin.

JUSTIN (Caller): Excellent.

CONAN: Go ahead, please.

JUSTIN: I'm curious if anyone's had the occasion to run the numbers to see what happens to the cost of health care based on people's lifestyle decisions, things of that nature, you know, rather than have to look at rationing health care for people who are otherwise, you know, whose conditions are either genetic or environmental, say, what happens if you no longer provide, say, lung cancer treatment to lifetime smokers and things of that nature.

CONAN: Ah, so based on how much they may have contributed to their own perspective demise?

JUSTIN: Correct.

CONAN: All right. Peter?

Prof. SINGER: Right. Look, I haven't seen figures, although I do know that on the smoking one, curiously enough, some economists have done figures. And they have said that smokers don't really cost us - it may sound strange, but the reason is that they get lung cancer and they die reasonably quickly from that, often about the time of life when they're about to retire. So they might die when they're around 60, 65. And they've been paying their insurance, paying their Social Security as well. And then they die at 65 so we don't have to pay them Social Security. We don't have to pay them the Medicare that they would be on after 65 maybe for another 20 years if they hadn't smoked. So, I mean, it's rather cruel to put it that way.

CONAN: Or the extended health care coverage that they might need if they - 20 years later got Alzheimer's.

Prof. SINGER: Yes. Exactly. That's right.

CONAN: Yeah. Yeah.

Prof. SINGER: So, you know, it's rather cruel to think of it that way. But some people think that smoking in particular doesn't cost us money. Now, some of the other conditions certainly may. Perhaps, heavy drinking if it pickles your liver and you need a liver transplant, if you can get that, which, of course, there's a great scarcity of organs for that. It could cost. Obesity, which happens much younger, may cost us quite a lot.

It becomes difficult though to figure out exactly what are we going to blame people for here. For instance, there have been some interesting studies showing that red meat consumption correlates with cancer of the digestive system - of the bowel and the colon. Are we going to say if people eat red meat - I think more than twice a week was the figure given - that then they're responsible and they going to have pay for their own surgery? Where exactly you draw the line between something that obviously is very negative to your health, like smoking, and other things that are less obvious, like not exercising enough? It's going to be pretty hard to tell.

CONAN: Hmm. Justin, I'm glad I'm not the person who has to decide. I think Justin has left us. But anyway, thank you very much for the phone call. We appreciate it. And welcome to our listeners in Orlando.

We're talking with Peter Singer in the first of a series of conversations about the rationing of health care. He is the author of an article in the New York Times, �Why We Must Ration Health Care,� that was published back in July. There's a link to it on our Web site. You can go to npr.org. We'll hear the opposing argument tomorrow. You're listening to TALK OF THE NATION from NPR News.

CONAN: And our last caller was referring to people who may have contributed. There is a more difficult decision that you write about in the piece, and that involves people with disabilities.

Prof. SINGER: Yes. That's right. And this certainly was perhaps the most controversial thing that I said in the piece because we were talking earlier about quality of life. And one of the reasons why, I think, we should spend money on helping people with disabilities to get over their disabilities, to get through it, to cure them or for that matter to try to prevent people having disabilities is because it's an improvement in the quality of life. If somebody is in a wheelchair and then they can walk again, most people would think that's an improvement in the quality of life. But the flipside of that is that if people have an incurable disability and it's a question of saving their life or saving the life of someone who has no disability, we would have to say that you're saving more life of good quality if you save the life of the person with no disability, assuming they have, let's say, the same life expectancy, 20 years each, for instance. So that would suggest that when it comes to saving life, we get better value for our resources by saving the lives of people without disability. And that's a disturbing implication I readily admit because we don't like to think that we're going to give second-class treatment to people with disabilities. They're already worse off, and we sometimes feel, well, we should even do more for them to improve their condition.

But, on the other hand that, you know, when you get to an extreme probably people would agree, if somebody is not conscious, even if they're in a persistent vegetative state, most people would agree it's not worth spending money to prolong their life. So there is this question: So where do you draw the line? How serious does a disability have to be for us to say that somebody�

CONAN: How do you define the quality, yeah?

Prof. SINGER: Yes. How do you define quality? Exactly. Yeah.

CONAN: Let's see. We have time for one more caller. This is Greg(ph). Greg with us from Idaho Falls.

GREG (Caller): Yeah. Hey, there. Certainly, I'm pretty adamant about the patient being the one responsible for paying for it. I guess we're all talking about all these different options and programs and nobody has put a true cost figure to this thing. And if I'm happy with my insurance that I pay for and the company somewhat subsidizes, and they talk about options that the states can opt out at the public option, I still want to know who's paying for all of this and are my taxes going to go up. So that's my biggest concern.

CONAN: Well, we haven't seen the bill that would emerge from the Senate much less a bill that would emerge from a House/Senate conference committee. So it's a little difficult to put an accurate number on that, Greg. But, indeed, I think that's a question that a lot of people are asking.

GREG: Yeah. I guess, the concern is, is we're already talking about options and the money's got to come from somewhere. And if I'm already paying for some, I think the responsibility ought to be on the patient for paying for it as much as they can. And I hope that - I hope we all don't see our tax rates going up because of all these options that people are talking about. Like you say, we don't even know the dollar figure yet.

Prof. SINGER: True.

CONAN: All right, Greg. Thanks very much for the phone call. Appreciate it. And, indeed, well, he's talking about the immediate context of this health care debate. But in a lot of respects, Peter Singer - and I'm afraid we just have a few seconds left - this health care debate is just about this issue: Rationing. What's the value of a human life? Who decides?

Prof. SINGER: Well, that's true. But I have to say, you know, I am prepared to pay taxes so that nobody in this society has to die simply because they can't get health care. That seems to me to be a worthwhile thing for my taxes to go on.

CONAN: Peter Singer, thank you very much for your time today. Peter Singer is a professor of bioethics at the Center for Human Values at Princeton University. He wrote the article in the New York Times, �Why We Must Ration Health Care,� published July 15th, 2009. And he joined us from a studio on the campus at Princeton. There's a link to his story at our Web site. Go to npr.org then click on TALK OF THE NATION.

We hope to hear from the other side tomorrow on why we should not have health care rationing. I hope you'll join us then. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News. Coming up, it's the Opinion Page.

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