Sunday, July 13, 2014

Way back in 2008, I summarized a talk given by Brent James and included a comment he made:

Much of the US system is based on the rapid response aspects of health care. In contrast to other countries, where the emphasis is on primary care, we spend a lot on treating those problems. We provide better access to specialists and to technology, and we do not ration these services as they do elsewhere. Accordingly, the US mortality rate for heart attack and trauma, for example, is well below Europe. But the impact on overall mortality of our progress in these secondary care arenas is overwhelmed by the impact of a strong primary care emphasis in other countries.

James cites "the rule of rescue" as a reason for this. This is defined as "the imperative people feel to rescue identifiable individuals facing suffering or death." Our health care delivery system is skewed in this direction.

Ironically, other countries are now finding an increased demand for rescue care and so are seeing large financial pressures emerge in that segment of their own systems.

I thought this was a great insight by Brent, but I could never find the source document. Now, thanks to reader Mark Braunstein, we have it, a journal called Law, Medicine & Health Care, Volume 14, Number 3-4 (1986).  Here's the link from someone's class materials at McGill.

The author, Albert Jonsen, is Emeritus Professor of Ethics in Medicine at the University of Washington, School of Medicine, and the article is called, "Bentham in a Box: Technology Assessment and Health Care Allocation." Describing how funds and other resources are allocated, with reference to Jeremy Bentham, the founding father of utilitarianism, he notes:

We reach a conclusion contrary to the utilitarian principle: We benefit a few at cost to many.

This occurs only when technology assessment becomes specific and explicit. The barrier will not rise up if we let these life-and-death decisions slip by, politely unnoticed, in a general rationing or allocation policy.  But if we work at explicit evaluations of single technologies, the barrier is bound to appear.

I call this barrier the rule of rescue.  Our moral response to the imminence of death demands that we rescue the doomed. We throw a rope to the drowning, rush into burning buildings to snatch the entrapped, dispatch teams to search for the snowbound.  This rescue morality spills over into medical care, where our ropes are our artificial hearts, our rush is the mobile critical care unit, our teams the transplant services.  The imperative to rescue is, undoubtedly, of great moral significance; but the imperative seems to grow into a compulsion, more instinctive than rational.

[When involved in a group that was assessing a life-saving technology,] the evidence appeared to be leading to the logical and reasonable conclusion that the technology was not cost-effective. Before that conclusion could be drawn, however, the rule of rescue threw up an impassable barrier.  The logical conclusion of the assessment faltered and fell, and the technology . . . won the day.

This then is Bentham in a box: the rational effort to evaluate the efficacy and costs, the burdens and benefits, of the panoply of medical technologies--an effort essential to just and fair allocation--encounters the straitened confines set by the rule of rescue. Even the soundest consequentialist argument against that rule seem unable to break out of the box.

Appeals to the quality of life or to the impact of a technology on society or culture carry little weight. As we find ourselves becoming more and more skilled at sorting out the efficacious from the useless and the cost-efficient from the wasteful, we find ourselves, at the same, time, unable to extend our felicific calculus to the very expensive technologies that will rescue the few.


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