A couple of years ago I was invited to speak at the annual meeting of the American Medical Association in Chicago, to discuss the morality of whether physicians should ration care from their patients. I had written extensively on the topic of “bedside rationing” before, arguing as far back as 1995 that it was sometimes okay for doctors to do less than everything for their patients in order to control health care costs.
“Although bedside rationing raises serious moral problems,” I wrote at that time, “these are outweighed by the important social goal of containing healthcare costs while providing adequate healthcare for those who need it. At least for the short and medium terms, bedside rationing will be a necessary component of any successful cost-containment strategy.”
Sharing the stage with me that day was my “opponent,” a physician who vehemently disagreed with me about the appropriateness of bedside rationing. The audience was poised for fireworks. And then I went up to the podium and made one simple change in my talk that diffused the situation.
I refused to use the word rationing.
I opened up by discussing the antibiotic resistance problem I discussed in one of my previous posts. (See “Gorillacillin and the tragedy of the commons.”) The audience of physicians nodded their heads knowingly, recognizing the importance of balancing the interests of society with those of the individual patient.
Then I laid out a few more facts that force us physicians into a balancing act. For starters, I talked about the fact that the high costs of hospital care are killing patients. Literally. You see, because hospital care is so expensive, hospital administrators have been put under pressure to control expenses. They do what they can to get physicians to, say, stop ordering so many unnecessary MRIs. But physicians aren’t easy to push around. So the hospital administrators look for other places to curb costs. Some have accomplished this by cutting back on nursing expenses, by hiring fewer RNs and employing less expensive nursing assistants in their place. The result of these cost cutting measures is a deterioration of hospital care, leading to suffering and death. Morbidity and mortality (that means harm and death) are increased at hospitals that have fewer nurses caring for their patients. So if you receive heart surgery at a hospital that has cut back on its staff of RNs, you are more likely to die after your surgery.
I told them about another fact: that health care inflation prices people out of the health insurance market which can lead them to experience unnecessary illness and death.
Before Obama signed the Affordable Care Act into law, the United States was looking at more than 50 million of its citizens living without health insurance. The reasons for this lack of insurance are complex, but chief among them are the high costs of getting health insurance. Insurance premiums are simply too expensive for some people.
Consequently, people decide to go without insurance, or are forced to go without it, which leads many people to delay receiving medical care until its too late to help them.
In other words, when doctors ignore the costs of medical care, they drive up insurance premiums that then come back and hurt the health of patients who have been priced out of the market. In this way, then, overly aggressive ordering of unnecessary tests and procedures harms public health, just like overly aggressive use of antibiotics creates antibiotic resistance, thereby harming public health.
I closed my talk at the AMA by reminding physicians that people in our profession have long paid attention to this balancing act. The audience nodded along, despite the majority of them entering the debate expecting to disagree with my argument. Then I sat down and my opponent stepped up to the podium.
“I’m not sure what to say,” he told the audience. “I came here prepared to argue with Dr. Ubel, but now I see that his ideas have evolved.”
My ideas, however, hadn’t evolved nearly as much as the language I had used to describe my ideas. I simply endorsed bedside rationing without using the term “rationing”.
A major challenge of our health care system is figuring out how to work together to control health care costs. Experience has taught me that we won’t be able to work together if we frame our conversation in terms of how to ration healthcare.
In 2000, I published my first book titled Pricing Life: Why It’s Time for Health Care Rationing. I included the word rationing in the title because it was a provocative word. I wanted to force people to acknowledge the seriousness of the challenge we face.
But my use of that word was a mistake. It meant that anybody who held a negative idea of health care rationing was able to ignore my argument. I wanted to proselytize. But anyone skeptical about rationing remained skeptical even after reading my book, in large part because that word created such strong negative connotations.
The fiscal future of our country depends on controlling health care costs. It also depends on proponents of cost control realizing that they need to find better ways to discuss their ideas, so as not to alienate people who would otherwise be ready to join them in solving this problem.
