BOOK REVIEWS
Vol. 324 No. 6
THE NEW TECHNOLOGY ASSESSMENT To the Editor: Fuchs and Garber's illuminating view of the new technology assessment (Sept. 6 issue)* clearly demonstrates the principles involved therein and, although expressing proper concern for the value of life (largely a personal and sometimes a profound judgment), leaves the social concern of pricing life untouched. Since much medical care in the Western industrialized world is free or nearly so at the point of consumption by the individual patient, it is not subject to the usual economic factors. When the difficulty is primarily unaffordable cost, social models of health management will continue to confuse the problem unless the pricing of lives is included. The sensibilities of the public and physicians about this issue would seem misplaced when established methods entrusted to the law, the military, and actuaries weigh daily the risks and costs of life, death, and disability. When approaches to costing are sought, it would seem reasonable to apply a real number to the monetary price of life to complete a mathematical model and arrive at some finite quantities to help us resolve judgments of scale. A framework based on probabilistic considerations with examples in specific medical or surgical scenarios pricing life in dollars (at, say, 104, 105, 106, and so forth) would be interesting to see and would certainly raise conflict within all of us, but since resources are not infinite, we should at least look at the issue honestly.
Dryden, ON P8N 1Z4, Canada
P.W. RYAN, M.B.CH.B., C.C.F.P. Dryden Medical Clinic
*Fuchs VR, Garber AM. The new technology assessment. N Engl J Med 1990; 323:673-7.
Letters to the Editor should be typed double-spaced (including references) with conventional margins. The length of the text is limited to 40 typewritten lines (excluding references). Abbreviations should not be used.
BOOK REVIEWS WHO LIVES? WHO DIES?: ETHICAL CRITERIA
IN
PATIENT SELECTION
By John F. Kilner. 359 pp. New Haven, Yale University Press, 1990. $29.95.
STRONG MEDICINE: THE ETHICAL
RATIONING OF
HEALTH CARE
By Paul T. Menzel. 234 pp. New York, Oxford University Press, 1990. $29.95. Few problems are more perplexing to modern medicine than how care might be rationed. These two books illustratejust how difficult it is to devise a defensible approach to this problem. In the first book, Who Lives? Who Dies?, Kilner takes on the daunting task of gathering all the criteria that have been proposed to select patients for medical treatment when resources are insufficient to provide treatment to all those in need. Kilner groups selection criteria into four categories: social, sociomedical, medical, and personal. He then presents the arguments for and against each criterion and tries to find some acceptable ground. He proposes two sets of criteria for rationing, one socially acceptable and the other ethically acceptable. The social criteria for selecting a patient to receive medical care include the medical benefit (with an established minimum for probable benefit, quality of benefit, and length of benefit), imminence of death (to the extent that imminence of death can be separated from medical benefit, the dying would have priority), likelihood of benefit (beyond the minimal likelihood required in the medical-benefit category), intensity of resource use (treatments requiring large investments of resources would have, generally, lower priority than treatments using fewer resources), special responsibilities (patients with special responsi-
421
bilities that could not be met by others and who needed the treatment in question in order to fulfill those responsibilities effectively would have a greater claim), willingness to be treated (patients who refused treatment could ethically be excluded from treatment), and random selection (generally in a first-come, first-served format). The author judges that the appropriate ethical criteria (in their order of application) are a willingness to be treated and the satisfaction of medical criteria, including minimal standards for quality, duration, and probability of benefit; the imminence of death, the existence of special responsibilities, and a requirement for reasonable levels of resource investment; and random selection, preferably by lottery, if further selection criteria are needed. Kilner believes that this constitutes a socially acceptable scheme for selecting patients, even though he also concludes that it is radically different from what currently goes on in U.S. health care. Kilner has performed a real service by gathering together all this material. On the one hand, anyone who wants a quick primer on the arguments for and against any particular criterion for rationing now has somewhere to turn. On the other hand, the presentation of the material itself reads very much like a long literature review. Most of the text consists of Kilner's heavily annotated summaries and descriptions of the work of others. Only in the last chapter does he propose what to do with all this information. That might be worth reading if one were convinced that his proposal was sufficiently persuasive on both the practical and the theoretical levels. Unfortunately, the practical application of his proposal - which is surely as theoretically sound as many other rationing proposals - seems elusive. In the second book reviewed here, Strong Medicine, Menzel finds such approaches as society-wide fairness inadequate as solutions to the problem of rationing, which, he feels, leaves in place the conflict between the patient and society. Instead, he identifies the solution in the concept of prior patient consent. The idea is that patients should decide how their resources in life are to be allocated. He argues that rationing is acceptable when someone subscribes to a health-insurance policy that limits coverage explicitly - for example, for organ transplants. His prior-consent model also depends on presumed consent in many situations, as in the case of the person who buys a health-insurance policy with specific exclusions. Menzel holds that this approach allows rationing to occur without any moral abandonment of the patient, insists that the patient who is to be denied care has previously agreed that other lives should be saved before his or her own, and states that care can be withheld without any deception of the patient: "Discriminating providers may ration care with a clear conscience. Even a right-minded economist could take their Hippocratic oath." As for the poor, Menzel rejects medical egalitarianism in the absence of redistribution of income. He judges that it would "seem appropriate for a rational poor person to adjust his or her level of medical care downward from what the middle class selects in order to balance out his or her health-care needs with other important goals." Since the "rational poor person" would select "a leaner package of health care," publicly supported programs should provide some care to the poor, but by no means equal care for equal needs. Menzel's medicine surely is strong, but can it be swallowed and should it be prescribed? The presumption that the poor, with fewer resources, would choose to devote some of their health care funds to bread, or to circuses, is rather close to the position of those who oppose Social Security, the minimum wage, Medicare, and fluoridation. Like education, health care is a strategic good, which should be provided equitably. Presumed consent is highly problematic as a doctrine. Very few people have much idea of what their health coverage is until they need care, even if they have copies of their insurance policies. To think that this can be changed is unrealistic. The rich and the poor person might equally be presumed to have consented not to receive the publicly rendered care, but the consequences are very different for the two: one still will be able to buy care, whereas the other will not and will suffer the consequences. The argument that the poor can do with less and would rationally select leaner and meaner policies depends on the asocial concept that it is the poor themselves who must meet their costs, not the society that may well have contributed to their ill health (to take the clearest example). Menzel is unwilling to look at a model in which the resources to be allocated on the basis of rationing decisions are those of society as a whole. This failing reflects the inability of
The New England Journal of Medicine Downloaded from nejm.org on November 13, 2015. For personal use only. No other uses without permission. Copyright © 1991 Massachusetts Medical Society. All rights reserved.
Vol. 324 No. 6
THE NEW TECHNOLOGY ASSESSMENT To the Editor: Fuchs and Garber's illuminating view of the new technology assessment (Sept. 6 issue)* clearly demonstrates the principles involved therein and, although expressing proper concern for the value of life (largely a personal and sometimes a profound judgment), leaves the social concern of pricing life untouched. Since much medical care in the Western industrialized world is free or nearly so at the point of consumption by the individual patient, it is not subject to the usual economic factors. When the difficulty is primarily unaffordable cost, social models of health management will continue to confuse the problem unless the pricing of lives is included. The sensibilities of the public and physicians about this issue would seem misplaced when established methods entrusted to the law, the military, and actuaries weigh daily the risks and costs of life, death, and disability. When approaches to costing are sought, it would seem reasonable to apply a real number to the monetary price of life to complete a mathematical model and arrive at some finite quantities to help us resolve judgments of scale. A framework based on probabilistic considerations with examples in specific medical or surgical scenarios pricing life in dollars (at, say, 104, 105, 106, and so forth) would be interesting to see and would certainly raise conflict within all of us, but since resources are not infinite, we should at least look at the issue honestly.
Dryden, ON P8N 1Z4, Canada
P.W. RYAN, M.B.CH.B., C.C.F.P. Dryden Medical Clinic
*Fuchs VR, Garber AM. The new technology assessment. N Engl J Med 1990; 323:673-7.
Letters to the Editor should be typed double-spaced (including references) with conventional margins. The length of the text is limited to 40 typewritten lines (excluding references). Abbreviations should not be used.
BOOK REVIEWS WHO LIVES? WHO DIES?: ETHICAL CRITERIA
IN
PATIENT SELECTION
By John F. Kilner. 359 pp. New Haven, Yale University Press, 1990. $29.95.
STRONG MEDICINE: THE ETHICAL
RATIONING OF
HEALTH CARE
By Paul T. Menzel. 234 pp. New York, Oxford University Press, 1990. $29.95. Few problems are more perplexing to modern medicine than how care might be rationed. These two books illustratejust how difficult it is to devise a defensible approach to this problem. In the first book, Who Lives? Who Dies?, Kilner takes on the daunting task of gathering all the criteria that have been proposed to select patients for medical treatment when resources are insufficient to provide treatment to all those in need. Kilner groups selection criteria into four categories: social, sociomedical, medical, and personal. He then presents the arguments for and against each criterion and tries to find some acceptable ground. He proposes two sets of criteria for rationing, one socially acceptable and the other ethically acceptable. The social criteria for selecting a patient to receive medical care include the medical benefit (with an established minimum for probable benefit, quality of benefit, and length of benefit), imminence of death (to the extent that imminence of death can be separated from medical benefit, the dying would have priority), likelihood of benefit (beyond the minimal likelihood required in the medical-benefit category), intensity of resource use (treatments requiring large investments of resources would have, generally, lower priority than treatments using fewer resources), special responsibilities (patients with special responsi-
421
bilities that could not be met by others and who needed the treatment in question in order to fulfill those responsibilities effectively would have a greater claim), willingness to be treated (patients who refused treatment could ethically be excluded from treatment), and random selection (generally in a first-come, first-served format). The author judges that the appropriate ethical criteria (in their order of application) are a willingness to be treated and the satisfaction of medical criteria, including minimal standards for quality, duration, and probability of benefit; the imminence of death, the existence of special responsibilities, and a requirement for reasonable levels of resource investment; and random selection, preferably by lottery, if further selection criteria are needed. Kilner believes that this constitutes a socially acceptable scheme for selecting patients, even though he also concludes that it is radically different from what currently goes on in U.S. health care. Kilner has performed a real service by gathering together all this material. On the one hand, anyone who wants a quick primer on the arguments for and against any particular criterion for rationing now has somewhere to turn. On the other hand, the presentation of the material itself reads very much like a long literature review. Most of the text consists of Kilner's heavily annotated summaries and descriptions of the work of others. Only in the last chapter does he propose what to do with all this information. That might be worth reading if one were convinced that his proposal was sufficiently persuasive on both the practical and the theoretical levels. Unfortunately, the practical application of his proposal - which is surely as theoretically sound as many other rationing proposals - seems elusive. In the second book reviewed here, Strong Medicine, Menzel finds such approaches as society-wide fairness inadequate as solutions to the problem of rationing, which, he feels, leaves in place the conflict between the patient and society. Instead, he identifies the solution in the concept of prior patient consent. The idea is that patients should decide how their resources in life are to be allocated. He argues that rationing is acceptable when someone subscribes to a health-insurance policy that limits coverage explicitly - for example, for organ transplants. His prior-consent model also depends on presumed consent in many situations, as in the case of the person who buys a health-insurance policy with specific exclusions. Menzel holds that this approach allows rationing to occur without any moral abandonment of the patient, insists that the patient who is to be denied care has previously agreed that other lives should be saved before his or her own, and states that care can be withheld without any deception of the patient: "Discriminating providers may ration care with a clear conscience. Even a right-minded economist could take their Hippocratic oath." As for the poor, Menzel rejects medical egalitarianism in the absence of redistribution of income. He judges that it would "seem appropriate for a rational poor person to adjust his or her level of medical care downward from what the middle class selects in order to balance out his or her health-care needs with other important goals." Since the "rational poor person" would select "a leaner package of health care," publicly supported programs should provide some care to the poor, but by no means equal care for equal needs. Menzel's medicine surely is strong, but can it be swallowed and should it be prescribed? The presumption that the poor, with fewer resources, would choose to devote some of their health care funds to bread, or to circuses, is rather close to the position of those who oppose Social Security, the minimum wage, Medicare, and fluoridation. Like education, health care is a strategic good, which should be provided equitably. Presumed consent is highly problematic as a doctrine. Very few people have much idea of what their health coverage is until they need care, even if they have copies of their insurance policies. To think that this can be changed is unrealistic. The rich and the poor person might equally be presumed to have consented not to receive the publicly rendered care, but the consequences are very different for the two: one still will be able to buy care, whereas the other will not and will suffer the consequences. The argument that the poor can do with less and would rationally select leaner and meaner policies depends on the asocial concept that it is the poor themselves who must meet their costs, not the society that may well have contributed to their ill health (to take the clearest example). Menzel is unwilling to look at a model in which the resources to be allocated on the basis of rationing decisions are those of society as a whole. This failing reflects the inability of
The New England Journal of Medicine Downloaded from nejm.org on November 13, 2015. For personal use only. No other uses without permission. Copyright © 1991 Massachusetts Medical Society. All rights reserved.
