Electing God

Ezekiel Emmanuel MD, Rahm Emmanuel's brother, who is Barack Obama's "Special Advisor for Health Policy", is described by the Huffington Post article as engaged in a very important mission: redesigning the US health care system.

Emanuel and the White House are attempting to reorganize the delivery and reimbursement systems of health care, changing what the types of procedures doctors rely on, making people more aware of disease prevention, encouraging insurance companies to expand coverage, and so on. It is a process rife with sensitivities, trickeries and, of course, the potential for failure. It is not, he insists, impossible.

"It is a complicated process and we have to try and make the choices clear and give people good reasons for making them," Emanuel explains. "I don't think that's an impossible task and thankfully we have one of the great communicators, Barack Obama, at the helm of this ship of state."

Emmanuel recently authored an article in the Lancet describing the various models of non-market health care rationing. Titled "Principles for allocation of scarce medical interventions", its is co-authored with Govind Persad and Alan Wertheimer. In it the authors simply review the pros and cons of the various ways of deciding who gets treated and who doesn't. The allocation mechanisms they discuss are divided into strategies and substrategies. The pros and cons of each are laid out.

Treating People Equally

  1. Lottery
  2. First-come, first served


  1. Sickest first
  2. Youngest first


  1. Saving the most lives
  2. Saving the most life-years
  3. Saving the most socially useful
  4. Reciprocity (paying back people who have 'contributed', such as organ donors)

The authors are not very satisfied with the current metrics used for making medical decisions based on saving the most life-years. Both the "Quality-adjusted life-years" model and the "Disability-adjusted life-years" have shortcomings which they believe can be addressed by another model of their own: "The complete lives system", which takes all the factors into account. They write:

Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles: youngest-first, prognosis, save the most lives, lottery, and instrumental value. ... When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated ... the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents. Prognosis allocation encourages physicians to improve patients' health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates.

Under this system, patients would receive scarce care according to the graph shown below.

Complete Life

The paper concludes: "the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic situations, it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely affirmed values: priority to the worst-off, maximising benefits, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo."

What's not mentioned anywhere in the discussion, except by implication is the identity of the narrator. Who is the "we" in "Principles for allocation of scarce medical interventions" that decides who gets scarce medical care? The answer is tangentially provided in the paper itself, which writes that "the complete lives system is least vulnerable to corruption".The "we" isĀ  a system; a system that can possibly be corrupted; hence Dr. Emmanuel's efforts to design one in which such distortions will be held to a minimum.

Ultimately health care reform is as much about politics as it is about medicine. The discussion in Dr. Emmanuel's paper is incomplete if limited to pure public health considerations. Politics is central to the whole issue. Whatever "guidelines" are chosen, however rational, however humane, can never implement themselves. Human beings in positions of power are required to do that. And while it is important to note that even under the current system these decisions are being made by someone or by some consensus, it is also vital to realize that in any "health care reform" effort, one of the principal outcomes is to shift the power to make those decisions to someone else. That may not be a fit subject for the Lancet, but it is the elephant in the operating room in the national health care debate.

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