Health care as described by many of the proposed plans from Congress is costly and the only way to pay for it is to ration, namely allocate limited resources. The allocation procedure must be based upon some set of accepted principles, not necessarily a moral set, but some logical set to some group of people. Enter the Harvard philosopher Rawls and his Theory of Justice. Rawls seems to invent what he call justice out of whole cloth to justify what he feels is the correct way to allocate resources, whatever they may be. They could be tags to the town swimming pool, or life saving surgery for an ill person.
The Rawlsian approach has then been applied by physicians at NIH particularly the current White House Chief of Staff's brother, also an advisor to the current President. An analysis of this paper is worthy of doing at this time to see what will most likely be incorporated into the interpretation of many of the proposed Congressional laws.
Rawls has proposed a theory of justice that is a statement of what many proponents of antitrust theory ion the mid-fifties and sixties promulgated. The essence of Rawls’ theory is composed of three elements;
Original Proposition: There exists a means and method for a society to establish a Contract amongst and between themselves. This Contract thus created in this society of the just is one that maximizes the return on every transaction to the least of the individuals in the society. This approach to Contractarianism is one related to individuals in a non-bargaining environment establishing between and amongst themselves a “contract” to govern their society.
There are two elements contained herein. The first is the essence of a contract, and in fact a form of social contract between the members of society and amongst them as a whole. The second element is that of a view towards man as a constrained and unconstrained view of human nature. The unconstrained view states that man, individually and in concert, has the capabilities of feeling other people’s needs as more important than his own, and therefore we all act impartially, even when the individuals own interest are at stake. The constrained view is to make the best of the possibilities which exist within the constraint.
For example, the constrained view of health care is one which would state that if it costs a certain amount to provide the service, an there is a portion of the society not able to purchase the service, then there is no overriding need to provide it if such a provision is uneconomical and places a significant burden on the other member of society. The unconstrained view, as a form of socialism, states that if there is the least of us in want for whatever the telecommunications revolution has in store, then they should have access to it at whatever cost. One can see that the current trend in Health care is such an unconstrained view.
Rawls approach to this contract is one wherein the individuals in the society collect themselves as individuals, and agree to a plan for the operations of that society.
First Principle of Justice: each person shall have equal rights and access to the greatest set of equal fundamental personal liberties.
Second Principle of Justice: social and economic inequalities are to be arranged so that they both, (i) provide the greatest benefit to the least advantaged., and (ii) attached to positions available to each individual under conditions of fair equality of opportunity.
Now let us see how this may be and is being applied to health care.
In the recent paper entitled Principles for allocation of scarce medical interventions, by Govind Persad, Alan Wertheimer, and Ezekiel J Emanuel (Rham Emanuel's brother and health care advisor to the current President) the authors, all apparently Government employees develop a suggested plan to ration health care. They state:
"Principles must be ordered lexically: less important principles should come into play only when more important ones are fulfilled. Rawls himself agreed that lexical priority was inappropriate when distributing specific resources in society, though appropriate for ordering the principles of basic social justice that shape the distribution of basic rights, opportunities, and income. As an alternative, balancing priority to the worst-off against maximizing benefits has won wide support in discussions of allocative local justice. As Amartya Sen argues, justice “does not specify how much more is to be given to the deprived person, but merely that he should receive more”.
This is a clear statement of not just giving health care but of rationing health care. They continue:
"Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending. , The complete lives system explicitly rejects waste and corruption, such as multiple listing for transplantation. Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions. , Hearts for transplant and influenza vaccines, unlike money, cannot be replaced or diverted to non-health goals; denying a heart to one person makes it available to another. Ultimately, the complete lives system does not create “classes of Untermenschen whose lives and well being are deemed not worth spending money on”, but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible."
The begin the paper by stating their basic premise of rationing in health care. Specifically they state:
"In health care, as elsewhere, scarcity is the mother of allocation. Although the extent is debated, the scarcity of many specific interventions—including beds in intensive care units, organs, and vaccines during pandemic influenza —is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary …"
Now although they suggest that this be applied in times of crisis for such things as vaccines, they have set the stage for expanding this to overall health care as is currently envisioned. Thus it is critical to bring Rawls and Emanuel into resonance. The seek a "justice" based argument rather than a moral based argument. They try to seek a solution based on humanistic elements rather than what one would call a moral or natural law argument. In fact we would argue that they reject any moral argument and any economic based argument and seek a politically correct extreme left wing argument as stated by Rawls.
Now the propose several systems which we summarize I their own words as follows:
"…Lottery Allocation:.. lottery has been used, sometimes with explicit judicial and legislative endorsement, in military conscription, immigration, education, and distribution of vaccines…
First-come, first-served: Within health care, many people endorse a first-come, first-served distribution of beds in intensive care units or organs for transplant. The American Thoracic Society defends this principle as “a natural lottery—an egalitarian approach for fair [intensive care unit] resource allocation.” Others believe it promotes fair equality of opportunity, and allows physicians to avoid discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals,,,
Favoring the worst-off : prioritarianism Franklin Roosevelt argued that “the test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little”. Philosophers call this preference for the worst-off prioritarianism…
Sickest first: Treating the sickest people first prioritizes those with the worst future prospects if left untreated. The so-called rule of rescue, which claims that “our moral response to the imminence of death demands that we rescue the doomed”, exemplifies this principle. Transplantable livers and hearts, as well as emergency-room care, are allocated to the sickest individuals first…
Youngest first: Although not always recognized as such, youngest-first allocation directs resources to those who have had less of something supremely valuable—life-years. Dialysis machines and scarce organs have been allocated to younger recipients first, and proposals for allocation in pandemic influenza prioritize infants and children…
Save the most lives: One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccine and responses to bioterrorism. Since each life is valuable, this principle seems to need no special justification. It also avoids comparing individual lives…
Prognosis or life-years: Rather than saving the most lives, prognosis allocation aims to save the most life-years. This strategy has been used in disaster triage and penicillin allocation, and motivates the exclusion of people with poor prognoses from organ transplantation waiting lists. Maximizing life-years has intuitive appeal. Living more years is valuable, so saving more years also seems valuable…
Instrumental value: Instrumental value allocation prioritizes specific individuals to enable or encourage future usefulness. Guidelines that prioritize workers producing influenza vaccine exemplify instrumental value allocation to save the most lives. Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation...
Reciprocity: Reciprocity allocation is backward-looking, rewarding past usefulness or sacrifice. As such, many describe this allocative principle as desert or rectificatory justice, rather than reciprocity…
The complete lives system: 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…: (i) youngest-first, (ii) prognosis, (iii) save the most lives, (iv) lottery, and (v) instrumental value. As such, it prioritizes younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate…."
Emanuel et al then state:
"As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; this argument is supported by empirical surveys. , Importantly, the prioritization of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo. Consequently, poor adolescents should be treated the same as wealthy ones, even though they may have received less investment owing to social injustice. "
The complete lives system in my opinion reduces to a simple formula. Save anyone say between 15 and 55, and let the rest die. The very young have nothing immediate to contribute and the old have already contributed. The morality of the approach is not the least it considered, it appears to be pure Rawlsian with a flavor of keeping costs down.
Thus it seems that with the Emanuel et al system we would let say a Nobel Prize winner who is 66 die and treat a 23 year old crack addict with three counts of murder. The system allows those in teens thru early middle age be treated and then withdraw treatment from the others. This approach seems to take abortion a few more steps beyond the womb.
They then conclude:
"The complete lives system discriminates against older people. Age-based allocation is ageism. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. , Even if 15 year olds receive priority over 65 year-olds, everyone who is years now was previously years. Treating 65 year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."
The Rawlsian approach has then been applied by physicians at NIH particularly the current White House Chief of Staff's brother, also an advisor to the current President. An analysis of this paper is worthy of doing at this time to see what will most likely be incorporated into the interpretation of many of the proposed Congressional laws.
Rawls has proposed a theory of justice that is a statement of what many proponents of antitrust theory ion the mid-fifties and sixties promulgated. The essence of Rawls’ theory is composed of three elements;
Original Proposition: There exists a means and method for a society to establish a Contract amongst and between themselves. This Contract thus created in this society of the just is one that maximizes the return on every transaction to the least of the individuals in the society. This approach to Contractarianism is one related to individuals in a non-bargaining environment establishing between and amongst themselves a “contract” to govern their society.
There are two elements contained herein. The first is the essence of a contract, and in fact a form of social contract between the members of society and amongst them as a whole. The second element is that of a view towards man as a constrained and unconstrained view of human nature. The unconstrained view states that man, individually and in concert, has the capabilities of feeling other people’s needs as more important than his own, and therefore we all act impartially, even when the individuals own interest are at stake. The constrained view is to make the best of the possibilities which exist within the constraint.
For example, the constrained view of health care is one which would state that if it costs a certain amount to provide the service, an there is a portion of the society not able to purchase the service, then there is no overriding need to provide it if such a provision is uneconomical and places a significant burden on the other member of society. The unconstrained view, as a form of socialism, states that if there is the least of us in want for whatever the telecommunications revolution has in store, then they should have access to it at whatever cost. One can see that the current trend in Health care is such an unconstrained view.
Rawls approach to this contract is one wherein the individuals in the society collect themselves as individuals, and agree to a plan for the operations of that society.
First Principle of Justice: each person shall have equal rights and access to the greatest set of equal fundamental personal liberties.
Second Principle of Justice: social and economic inequalities are to be arranged so that they both, (i) provide the greatest benefit to the least advantaged., and (ii) attached to positions available to each individual under conditions of fair equality of opportunity.
Now let us see how this may be and is being applied to health care.
In the recent paper entitled Principles for allocation of scarce medical interventions, by Govind Persad, Alan Wertheimer, and Ezekiel J Emanuel (Rham Emanuel's brother and health care advisor to the current President) the authors, all apparently Government employees develop a suggested plan to ration health care. They state:
"Principles must be ordered lexically: less important principles should come into play only when more important ones are fulfilled. Rawls himself agreed that lexical priority was inappropriate when distributing specific resources in society, though appropriate for ordering the principles of basic social justice that shape the distribution of basic rights, opportunities, and income. As an alternative, balancing priority to the worst-off against maximizing benefits has won wide support in discussions of allocative local justice. As Amartya Sen argues, justice “does not specify how much more is to be given to the deprived person, but merely that he should receive more”.
This is a clear statement of not just giving health care but of rationing health care. They continue:
"Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending. , The complete lives system explicitly rejects waste and corruption, such as multiple listing for transplantation. Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions. , Hearts for transplant and influenza vaccines, unlike money, cannot be replaced or diverted to non-health goals; denying a heart to one person makes it available to another. Ultimately, the complete lives system does not create “classes of Untermenschen whose lives and well being are deemed not worth spending money on”, but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible."
The begin the paper by stating their basic premise of rationing in health care. Specifically they state:
"In health care, as elsewhere, scarcity is the mother of allocation. Although the extent is debated, the scarcity of many specific interventions—including beds in intensive care units, organs, and vaccines during pandemic influenza —is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary …"
Now although they suggest that this be applied in times of crisis for such things as vaccines, they have set the stage for expanding this to overall health care as is currently envisioned. Thus it is critical to bring Rawls and Emanuel into resonance. The seek a "justice" based argument rather than a moral based argument. They try to seek a solution based on humanistic elements rather than what one would call a moral or natural law argument. In fact we would argue that they reject any moral argument and any economic based argument and seek a politically correct extreme left wing argument as stated by Rawls.
Now the propose several systems which we summarize I their own words as follows:
"…Lottery Allocation:.. lottery has been used, sometimes with explicit judicial and legislative endorsement, in military conscription, immigration, education, and distribution of vaccines…
First-come, first-served: Within health care, many people endorse a first-come, first-served distribution of beds in intensive care units or organs for transplant. The American Thoracic Society defends this principle as “a natural lottery—an egalitarian approach for fair [intensive care unit] resource allocation.” Others believe it promotes fair equality of opportunity, and allows physicians to avoid discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals,,,
Favoring the worst-off : prioritarianism Franklin Roosevelt argued that “the test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little”. Philosophers call this preference for the worst-off prioritarianism…
Sickest first: Treating the sickest people first prioritizes those with the worst future prospects if left untreated. The so-called rule of rescue, which claims that “our moral response to the imminence of death demands that we rescue the doomed”, exemplifies this principle. Transplantable livers and hearts, as well as emergency-room care, are allocated to the sickest individuals first…
Youngest first: Although not always recognized as such, youngest-first allocation directs resources to those who have had less of something supremely valuable—life-years. Dialysis machines and scarce organs have been allocated to younger recipients first, and proposals for allocation in pandemic influenza prioritize infants and children…
Save the most lives: One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccine and responses to bioterrorism. Since each life is valuable, this principle seems to need no special justification. It also avoids comparing individual lives…
Prognosis or life-years: Rather than saving the most lives, prognosis allocation aims to save the most life-years. This strategy has been used in disaster triage and penicillin allocation, and motivates the exclusion of people with poor prognoses from organ transplantation waiting lists. Maximizing life-years has intuitive appeal. Living more years is valuable, so saving more years also seems valuable…
Instrumental value: Instrumental value allocation prioritizes specific individuals to enable or encourage future usefulness. Guidelines that prioritize workers producing influenza vaccine exemplify instrumental value allocation to save the most lives. Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation...
Reciprocity: Reciprocity allocation is backward-looking, rewarding past usefulness or sacrifice. As such, many describe this allocative principle as desert or rectificatory justice, rather than reciprocity…
The complete lives system: 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…: (i) youngest-first, (ii) prognosis, (iii) save the most lives, (iv) lottery, and (v) instrumental value. As such, it prioritizes younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate…."
Emanuel et al then state:
"As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; this argument is supported by empirical surveys. , Importantly, the prioritization of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo. Consequently, poor adolescents should be treated the same as wealthy ones, even though they may have received less investment owing to social injustice. "
The complete lives system in my opinion reduces to a simple formula. Save anyone say between 15 and 55, and let the rest die. The very young have nothing immediate to contribute and the old have already contributed. The morality of the approach is not the least it considered, it appears to be pure Rawlsian with a flavor of keeping costs down.
Thus it seems that with the Emanuel et al system we would let say a Nobel Prize winner who is 66 die and treat a 23 year old crack addict with three counts of murder. The system allows those in teens thru early middle age be treated and then withdraw treatment from the others. This approach seems to take abortion a few more steps beyond the womb.
They then conclude:
"The complete lives system discriminates against older people. Age-based allocation is ageism. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. , Even if 15 year olds receive priority over 65 year-olds, everyone who is years now was previously years. Treating 65 year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."
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