Ration End-Of-Life Care: A Debate at Chicago Ideas Week

• Volume 65, Presented On: October 10, 2012
• Visit Full Debate Page

From the Panel

• For: ARTHUR KELLERMANN

• Will Reform Lead to Rationing?
  Arthur Kellermann, Michael Cannon and Sean Tunis, Midmorning, MPR, July 30, 2009Kellermann and others look at why rationing has become such a dirty word in the politics of health care reform on Minnesota Public Radio’s Midmorning.
• What Will Change Most About Our Routine Physicals Over the Next Decade?
  Arthur L. Kellermann, Zocalo Public Square, August 31, 2012In a nation long fearful of healthcare rationing, we are just beginning to come to grips with the opposite problem—the enormous costs and grievous harm that come from excessive testing and needless treatments.
• Time to Focus on Health Care Costs
  Arthur L. Kellermann, U.S. News & World Report, June 29, 2012The bottom line is this: With or without the Affordable Care Act, the nation can no longer kick the can down the road on costs.
• Withholding Resuscitation in Prehospital Care
  Arthur L. Kellermann, Annals of Internal Medicine, May 2, 2006Resuscitating people who will otherwise die defines a major mission for emergency medical services. Having the technical capacity to resuscitate some patients, however, does not mandate attempting it nor ensure its success.
• Publications by Arthur Kellermann
  Arthur Kellermann, RANDAccess publications by Kellerman on the RAND website.

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• For: PETER SINGER

• Why We Must Ration Health Care
  Peter Singer, New York Times, July 15, 2009Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse.
• Eight Questions for Peter Singer
  Peter Singer, Economist, July 25, 2012The Economist's interview with Singer.
• Issue Clash
  Peter Singer and Michael Tanner, NOW on PBSSinger and Tanner debate the question, ‘Will the proposed health care reforms that include a government insurance option lead to rationing of medical services?’

• Against: KEN CONNOR

• Boomsday: Coming to a Theater Near You
  Ken Connor, Center for a Just Society, June 27, 2012In his 2007 book Boomsday, Christopher Buckley writes of a fictional future where an overwhelming number of elderly baby boomers are given tax incentives to end their lives early. With recent developments out of Switzerland, Buckley's tongue-in-cheek novel may prove all-too-prescient.
• Diminishing the Disabled
  Ken Connor, Center for a Just Society, July 31, 2012Increasingly, members of the medical community have embraced a "quality of life" ethic rather than a ‘sanctity of life’ ethic.
• Medicine in the Nanny State
  Ken Connor, Center for a Just Society, May 23, 2012There's no doubt that the concept of universal health care has its appeal, but at the end of the day what individuals must consider is who they want making decisions for them in the event of a serious or life-threatening medical situation.
• Racing Down the Slippery Slope
  Ken Connor, Center for a Just Society, March 7, 2012If an unborn child’s right to life can be denied based on criteria like age, size, location, cognitive capacity or simply the wishes of the mother, then what’s to stop similar criteria from nullifying the life rights of the elderly, the disabled, or even the very young?
• Elder Abuse: America’s Dirty Secret
  Ken Connor, Center for a Just Society, October 15, 2010What kind of care and treatment does our society consider appropriate for its most vulnerable members?

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• Against: SALLY PIPES

• What Now for Health Care Reform?
  Sally Pipes, Orange County Register, June 29, 2012The taxing power of Congress, which the Supreme Court cited in validating Obamacare, could create better reforms if the law is repealed.
• Health Care Expert Sally Pipes on What Could Replace Obamacare
  Will Rahn, Daily Caller, January 30, 2012Sally Pipes, the renowned health care expert and president of the Pacific Research Institute. Pipes has a way to replace Obamacare’s expensive government health care bureaucracies with a market-driven system.
• Obama Will Ration Your Health Care
  Sally Pipes, Wall Street Journal, December 30, 2008Think of his health plan as a federal HMO.
• President Obama’s Medical Board: A Backdoor Path to Health Rationing
  Sally Pipes, Forbes, March 5, 2012Last week, a House of Representatives subpanel overwhelmingly approved a measure to repeal a key component of President Obama’s 2010 health reform bill. The full House and Senate must ratify the subcommittee’s vote and scrap the Board from the books. If they don’t, America’s seniors could face the prospect of government-rationed health care.
• Even Obamacare’s Supporters Don’t Support the Rationing Board
  Sally Pipes, Forbes, June 13, 2011The Independent Payment Advisory Board (IPAB). IPAB may not directly ration care — but seniors will sure feel like it did.
• The Era of Rationing Begins
  Sally Pipes, NJToday.net, September 29, 2010The Food and Drug Administration plan to revoke approval of the drug Avastin for the treatment of advanced breast cancer is ‘the beginning of a slippery slope leading to more and more rationing under the government takeover of health care.’
• Under Obama Health Care Scheme, Big Government Rations Care for Sick Patients
  Sally Pipes, U.S. News & World Report, May 13, 2009American healthcare may not be perfect. But it's not on the verge of collapse either—unless President Obama succeeds with his various healthcare reform efforts.

ARTICLES FOR & AGAINST

• AGAINST

• Should Government Determine the Value of Human Life?
  Randy Pate, The Foundry, July 21, 2009In the name of expanding health care insurance to all, the administration and liberals in Congress are quickly leading the country down the road to government-rationed health care—where government holds the power of life and death over every American. In such a system, boards of “experts” will evaluate the relative values of human lives and make coverage decisions accordingly.
• Spare the Old, Save the Young
  Amitai Etzioni, Nation, June 11, 1988Once the precept that one should do ‘all one can’ to avert death is given up, why stop there?
• Obama's Health Rationer-in-Chief
  Betsy McCaughey, Wall Street Journal, August 27, 2009White House health-care adviser Ezekiel Emanuel blames the Hippocratic Oath for the 'overuse' of medical care.
• With Health Care Put in Federal Hands, Is Rationing in Our Future?
  Margaret A. Bengs, Sacramento Bee, August 25, 2012With Obamacare handing over the reins of the health care system into federal hands, is rationing really far from our shores?
• Rationing Life Itself
  Patrick Buchanan, American Conservative August 20, 2009If Congress enacts universal health care coverage, we are undeniably headed for a medical system of rationed care that must inevitably deny care to some terminally ill and elderly, which will shorten their lives, perhaps by years.
• Opposing View on Health Care: On the Road to Rationing
  Grace-Marie Turner, USA Today, January 6, 2011A pattern is emerging that at least gives the appearance that payment can be denied if therapies are seen as too costly.

• FOR

• Must We Ration Health Care for the Elderly?
  Daniel Callahan, Journal of Law, Medicine & Ethics, March 27, 2012Rationing should be done by policy, not by individual doctors and patients at the bedside, policy must be set by democratic process, policy must be carried out in a transparent way, and there should always be a provision for appeal.
• ‘Rationing’ Health Care: What Does It Mean?
  Uwe Reinhardt, New York Times, July 3, 2009In short, free markets are not an alternative to rationing. They are just one particular form of rationing.
• End-of-Life Care: Where Ethics Meet Economics
  Uwe E. Reinhardt, New York Times, August 14, 2009As health spending grows, year after year, roughly twice as fast as the payroll that supports private health spending in this country, Americans sooner or later will have to confront the hard questions about access to expensive treatments, perhaps after a rational national conversation, if such can still be had in America.
• Beyond Obamacare
  Steven Rattner, New York Times, September 16, 2012Unless we start allocating health care resources more prudently—rationing, by its proper name—the exploding cost of Medicare will swamp the federal budget.
• Rights, Respect for Dignity and End-of-Life Care
  J.M. Freeman, Journal of Medical Ethics, 2010We cannot continue to have all our demands met; thus rationing of care will become a necessity.
• Principles for Allocation of Scarce Medical Interventions
  Govind Persad, Alan Wertheimer and Ezekial Emanuel, Lancet, January 31, 2009The authors recommend an alternative system—the complete lives system—which prioritizes younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.
• Our View on Health Care: Nonsense About ‘Death Panels’ Springs Back to Life
  USA Today, January 6, 2011Here we go again. A clumsy bit of rulemaking by the Obama administration has revived nutty talk about "death panels" — the inflammatory but thoroughly debunked notion purveyed last year by opponents of the new health reform law.

RELATED ARTICLES & LINKS

• OVERVIEW

• End-of-Life Care
  Miller Center of Public Affairs and MacNeil/Lehrer Productions, March 24, 2010Panelists in a Miller Center program debate the motion, ‘The United States must ration costly end-of-life care.’
• Rationing Health Care at the End of Life
  Lois Shepherd, Miller Center of Public AffairsA summary of some of the arguments for and against rationing end-of-life care.
• Ethics and Health Care: Rethinking End-of-Life Care
  Daniel Callahan and Peter Lawler, Center for Policy Innovation, Heritage Foundation, July 24, 2012America is undergoing a demographic revolution, with a rapidly aging population blessed with greater longevity. While this is a triumph of modern medicine, it also presents an unprecedented ethical and fiscal challenge for individuals, families, medical professionals, and policymakers. The Center for Policy Innovation asked two leading scholars of ethics and health policy to engage in an exchange on these issues.
• Age-Based Health Care Rationing
  Claire Andre and Manuel Velasquez, Markkula Center for Applied EthicsAs the ranks of the elderly swell, and demands on the nation's scarce health care resources increase, the once whispered suggestions that health care should be rationed by age are now growing audible.

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• RATIONING INEVITABLE?

• There’s Rationing in Health Care Now, and There Still Would Be Under Reform Bill
  PolitiFact.com, Tampa Bay Times, August 2009We realize some may read our ruling and conclude that we believe the Obama plan will mean more drastic rationing. But we think it's more accurate to say the bill seeks a more rational way to ration. Whether it can succeed is a topic for legitimate debate.
• Rationing Health Care? We’re Already Doing It
  Sarah Burd-Sharps and Kristen Lewis, Carnegie Council, December 4, 2009Rationing happens every day at every level of our healthcare system.
• The Market Does Not Ration Health Care
  Sheldon Richman, Reason, July 15, 2012People’s choices of what and what not to buy and sell at which prices create an arrangement of goods and resources that tends to be intelligible in terms of consumers’ subjective priorities. But that does not warrant calling the process rationing or allocation.
• No Matter Who Wins, Health Care Rationing Is Coming
  Merrill Goozner, Fiscal Times, August 14, 2012Voters subjected to the sound bites of campaign ads will never learn that the dirty little secret of both approaches is that they embody a form of rationing.
• New Health Law Will Not Ration Medical Care
  Arthur Garson Jr. and Carolyn Long Engelhard, Chronicle, February 10, 2012One-third of Americans recently surveyed said the new health law would allow a government "death panel" to make decisions about end-of-life care. They are dead wrong.

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• INDEPENDENT PAYMENT ADVISORY BOARD (IPAB)

• The IPAB: The Center of a Political Clash Over How to Change Medicare
  Bara Vaida, Kaiser Health News, March 22, 2012IPAB is a controversial board that is at the heart of House Republicans' efforts to upend the 2010 federal health law.
• The Return of the Death Panels
  Washington Times, August 20, 2012Death panels also are back. At an appearance in Florida over the weekend, Mr. Ryan criticized the Independent Payment Advisory Board (IPAB) established under Obamcare to “contain” Medicare costs.
• IPAB: The Part of Obamacare That Can’t Be Repealed
  Wesley J. Smith, Daily Caller, July 6, 2012There is much talk in the wake of the recent Supreme Court “it’s a tax” indigestion that the Senate can now repeal the individual mandate without fear of filibuster. Perhaps. But repealing the mandate/tax wouldn’t rid us of one of Obamacare’s most dangerous big-government intrusions: the Independent Payment Advisory Board (IPAB).

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• U.S. HEALTH CARE COSTS

• U.S. Health Care System From an International Perspective
  OECD, June 28, 2012U.S. health care spending and quality compared to other OECD countries.
• CBO Releases Two Analyses Related to the Affordable Care Act
  Congressional Budget Office, July 24, 2012One report presents updated projections of the budgetary effects of the coverage provisions of the ACA to reflect the Supreme Court's recent decision. The other report presents a cost estimate for the repeal of the ACA that passed the House of Representatives on July 11th.
• The Concentration and Persistence in the Level of Health Expenditures Over Time
  Steven B. Cohen and William Yu, Medical Expenditure Panel Survey, January 2012In 2008, 1 percent of the population accounted for 20.2 percent of total health care expenditures and 20.0 percent of the population in the top 1 percent retained this ranking in 2009. The bottom half of the expenditure distribution accounted for 3.1 percent of spending in 2008; about three out of four individuals in the bottom 50 percent retained this ranking in 2009.
• The Cancer ‘Breakthroughs’ That Cost Too Much and Do Too Little
  Laura Beil, Newsweek, August 27, 2012‘Death panels’ are a bad idea, but asking hard questions about health care is not.
• Democrats, Republicans Offer Rival Views to Control Health Costs
  David Morgan, Reuters, August 1, 2012Democrats and Republicans agree that the next U.S. president will have to contend with rising healthcare costs that pose a growing, destabilizing burden for families, employers and government budgets. But two articles published in the New England Journal of Medicine on Wednesday show how far apart each side stands on the question of what to do, ahead of a November election showdown between President Barack Obama and presumptive Republican nominee Mitt Romney.
• The Cost Conundrum
  Atul Gawande, New Yorker, June 1, 2009What a Texas town can teach us about health care.

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• END-OF-LIFE COSTS

• Medical Expenditures During the Last Year of Life
  Donald R. Hoover, et al, Health Services Research, December 2002Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures.
• The Concentration of Health Care Spending
  NIHCM Foundation Data Brief, July 2012Spending for health care services is highly concentrated among a small proportion of people with very high use. Conversely, a significant portion of the population has very low health care spending.
• Trends and Variation in End-of-Life Care for Medicare Beneficiaries With Severe Chronic Illness
  D.C. Goodman, A.R Esty, E.S. Fisher and C.H. Change, Dartmouth Institute for Health Policy and Clinical Practice, April 12, 2011‘In addition to its effects on patients’ quality of life, unnecessarily aggressive care carries a high financial cost. About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease,’ said David C. Goodman, M.D., M.S., lead author and co-principal investigator for the Dartmouth Atlas Project.
• Weighing Medical Costs of End-of-Life Care
  Reed Abelson, New York Times, December 22, 2009The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life.

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• RATIONING IN U.K.

• Rationing Health: Who Lives? Who Decides?
  The World, PRISome experts say to control medical costs, America must ration health care. Others argue that care is already rationed in the U.S., often in hidden ways. It’s a highly charged issue. Even the term "rationing" is subject to dispute.PRI's The World takes a global look at the topic with four perspectives from four countries.
• Health Care Rationing? Not NICE
  Jonathan Wolff, OECD Insights, April 26, 2012What we have in England and Wales is the National Institute of Health and Clinical Excellence (NICE) with the job of deciding whether or not a new treatment or intervention is cost-effective.
• Who Gets Expensive Cancer Drugs? A Tale of Two Nations
  ScienceDaily, December 26, 2009The well-worn notion that patients in the United States have unfettered access to the most expensive cancer drugs while the United Kingdom's nationalized health care system regularly denies access to some high-cost treatments needs rethinking, a team of bioethicists and health policy experts says in a new report.
• Hospital Closures Inevitable and NHS Operation Rationing Will Continue, Warns Think Tank
  Stephen Adams, Telegraph, June 29, 2012NHS patients should expect continued rationing of common operations for years to come, while hospital closures are ‘inevitable,’ according to an influential think tank.
• Nine Out of 10 NHS Trusts Are ‘Rationing Operations’
  Claire Bates, Daily Mail, June 19, 2012NHS hospitals are rationing the number of operations they perform to balance their budgets.
• NHS Rationing: The More Things Change…
  Rudolf Klein, Health Care Cost Monitor, April 27, 2011The U.K. is shifting responsibility for cost control from faceless bureaucrats to general practitioners. Will this change lead to the kind of implicit health care rationing long seen in the U.S.?

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• PALLIATIVE CARE & COUNSELING

• Palliative Care Extends Life, Study Finds
  Donald McNeil Jr, New York Times, August 18, 2010In a study that sheds new light on the effects of end-of-life care, doctors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile and in less pain as the end neared — but they also lived nearly three months longer.
• The Impact of Advance Care Planning on End-of-Life Care in Elderly Patients
  Karen M. Detering, et al, BMJ Advance care planning improves end-of-life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.
• Doctors Providing End-of-Life Counseling See Benefit in Current Controversy
  Jessica Marcy, Kaiser Health News, August 14, 2009The paragraphs, buried deep in the 1,000-page House health reform bill, appear innocuous, but they have ignited a firestorm among critics predicting government-sponsored euthanasia. Yet physicians who work with patients on end-of-life planning say that while they are surprised and upset about criticism of the proposal, it has brought needed attention to what they view as a long under-funded and overlooked service.
• Bunny’s Last Days: When Living Will Isn’t Enough
  Susan Brink, Kaiser Health News, March 5, 2010Studies show the frank discussions that palliative care engenders can ease pain, forestall guilt and increase the chances of a peaceful death. And, significantly, they can save money.

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• ADDITIONAL ARTICLES

• U.S. Lags in Reducing Preventable Deaths
  UPI, August 29, 2012The United States lags France, Britain and Germany in reducing the number of preventable deaths, researchers found.
• A Giant Hospital Chain Is Blazing a Profit Trail
  Julie Creswell and Reed Abelson, New York Times, August 14, 2012During the Great Recession, when many hospitals across the country were nearly brought to their knees by growing numbers of uninsured patients, one hospital system not only survived — it thrived.

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