Wednesday, January 21, 2009

When Morality Meets Scarcity in Medicine

The only thing universal about individual morality is that it is in fact individual. Regardless of whether you believe in absolute truth, a religious code, the golden rule, etc, the fact of the matter remains that everyone interprets these things differently. What is or is not truth is secondary in the scheme of what actually happens. This becomes even more complex when considering that certain codes diametrically oppose each other, and some codes clearly sacrifice other people who do not subscribe to the code. There's an interesting conversation about abortion for example over at http://studentdoctor.net in the topics in healthcare forum debating this very topic. One side essentially claims that failure to perform abortion or refer for it is in some way a direct violation of medical ethics. The other side claims that doing these exact same things is a violation of the will of God. Often, neither side believes in an allowance for a differing opinion.

There is one thing however, that holds universally true, and no amount of denying it changes it. Resources are scarce and limited. They may be used ever more efficiently and/or prudently, but there is only so much matter in the universe. This example can be applied to medicine. In its current state, medicine in its attempt to be all things to all people is rapidly becoming nothing to anybody. It's becoming a sort of service black hole and an expensive black hole at that. Rising from ~5-6% of GDP in the days before Medicare, healthcare costs are now estimated at about 16% of GDP. Sure there have been some technological advances, but there are clearly some changes in our approach to healthcare distribution that perpetuate these deficits. Let's consider some of the paradox into which we are plunging ourselves:

Many people advocate doing everything that people need. This is all well and good, except that defining "need," is not all that easy, and there are many times that the "needs," of two individuals conflict. Let's look at the following example:

Two middle aged men walk into a community emergency room. One has terrible crushing chest pain, radiating to the left arm. He has specific V2-V5 ST-segment EKG changes consistent with an anterior wall MI (heart attack) and his cardiac enzymes are through the roof. The other man has a non-compound humeral fracture (a broken arm) and is in considerable pain. The ER is currently full of other patients. What to do? In this case, the usual response is that we have to triage. Even with the full ER, we will make room for the man having the heart attack. We'll start treatment. The man with the broken arm will have to wait. In fact, some of the patients who were already brought back will have to wait.

In this example, it is clear that the man with the heart attack is receiving a benefit at the expense of the man with a broken arm. In this particular example, we've sort of attempted to minimize "badness." The long term outcome for a delay in treatment for the fracture of a few hours is probably nothing, while a similar delay in the treatment of the heart attack is potentially fatal.

Triage is sort of the original approach to the collision of scarcity and morality. If we can't do right by everyone, we'll attempt to get the most right out of the situation. The original concept was that we would go after the sickest who could be saved first and then in order of decreasing severity so as to maximize the chances of the most good outcomes.

In modern day medicine, we have no real triage outside of the emergency room. We attempt to just give everyone everything, the cost be damned. It's the equivalent of building another room onto the ER and hiring another doc every time another broken arm comes in the door. It's incredibly expensive, and it doesn't necessarily improve anyone's long term outcome. We also tend to ignore the most important rule of triage, in which we do not waste scarce resources on individuals beyond repair. Every severely demented nursing home resident who takes a two week vacation in the ICU costs the system tens of thousands of dollars in order to "save" a person who is beyond repair. This is partly why healthcare is 16% of GDP.

Another question is how far do we go to ensure 100% accuracy. In other words, how much money are we spending over progressively smaller benefits in diagnosis and treatment? This is the question that comes about in the current predatory legal environment. The added cost of testing in an environment in which every individual miss imposes a nearly insurmountable burden on the system creates a system in which every low yield test in the system is ordered in order to avoid error. Is it right to tax a large segment of the population solely to fund CT scans of the brain for low risk falls in alcoholics? We surely pay for them now.

It's very simple. In any type of collectivist system, the "morality' of what is being provided will eventually bump into scarcity. There has to be some sort of rationing. There has to be some sort of triage. Someone's rights will have to take a back seat to the more critical or those with better long term potential. Period. If not, any system goes bankrupt and no one benefits.

The alternative is a non-collectivist system. In this system, individual choices determine what happens. Individual morality may factor in, but there is no "morality of the system." This is where competition comes into play. In our above example, the man with the broken arm may go to a different hospital. He may have to pay more. Perhaps the number of people waiting for treatment with broken arms leads a group of entrepaneurial orthopods to open a special orthopedic ER that caters to broken arms and doesn't treat heart attacks. Then there's no conflict at all. If someone felt morally compelled to treat heart attacks, they could go around treating all heart attacks, regardless of ability to pay. This is rationing in a way, but the rationing is done by individual preference and morality. In this particular approach, no one individual can impose a specific morality on everyone else within the system.

Regardless of how you approach it, no code or philosophy on whom is entitled to treatment can overturn the laws of nature. Matter can neither be created or destroyed. Resources have to be rationed. The only question is whether that rationing occurs by an imposed centralized system or the individual codes of the individuals involved.

11 Comments:

Blogger McBrandon said...

If people only knew what their big health care dollars are buying. Like the 9 patients who made 2700 ER visits http://tinyurl.com/dm85kt. Its the people who will never pay anything to the system who get the most value. I know for sure that in Europe where people are actually paying via taxes are not getting tests just to placate the medicolegal sensibility of doctors.

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