How to Ration Healthcare

Philosophy Forums Society, Government, and Economics
1

I don’t actually think we need to ration health care (the first world is treating the edge cases that affect people in their 70th year, while people in the third world are dying of vitamin deficiencies; healthcare is poorly distributed, but there’s probably enough to go around). But it is conceivable that there would be situations where there is actually less ability to treat illness and injury than there are illness and injuries to be treated – say, a Mars colony, where supplies are limited and injuries common and relatively new (not many low-gravity related impairments cropping up on Earth).

In such a situation, it would be necessary to prioritize not only diseases, but patients: in a case where doctors are the bottleneck, it would be very important to treat any ill doctor first, and to expend the most resources to ensure a quick recovery. But that is an easy case. What should the policy over the longer term?

Each human life should be considered valuable. A more able life should be more valuable, but with diminishing returns; most of the value of a life should be recouped by increasing wellness from 0% to 10%, while significantly less value comes from increasing wellness from 90% to 100%.

A similar principle should apply between individuals: the most valuable individual is not significantly more valuable than average (especially where a group is small, extreme outliers in terms of social value are unlikely). As such, saving the life of an average person (0-10%) is likely to be much more valuable than solving minor issues (90-100%) for the most valuable individuals.

But there are harder cases. While there are diminishing returns, the shape of the curve is not easy to specify. It might even be that the curve is non-linear; large stems in value seems to occur between alive and dead, comatose and conscious, delirious and coherent, immobile and mobile, etc.

But if value is quantifiable, the value of all such improvements should also be quantifiable. And in such a situation, the values should be used to ration healthcare to maximize social value. Sometimes, valuable people should get preferential treatment, because by definition their improvements are more beneficial to all of society. But that does not justify unlimited preference. In nearly all cases, the severely ill should be treated first, to prevent as many deaths as possible, before treating mere inconveniences such as pain, fatigue, or arthritis.

2

I’m afraid to ask what your non-linear curve actually means.

Your talking about Triage. I don’t see how the medical approach to this, including rationing organs in short supply, doesn’t already answer this. As far as personnel, military triage. Medics treat themselves first, move on. Troops know well in advance, based on the likelihood of survival, who to place in what groups.

Think of a helicopter landing area out in a field… injured troops brought in every minute, piling up. We put the ones needing immediate help, that can be saved, in the 6 o’clock position, 6 being the closest to the helicopter landing. The ones certain to die, or already dead, 12 o Clock.

Those with bad injuries, need medical care, but can survive a few hours would be 3 O’ Clock, while those with minor injuries that still need treated, 9’ O Clock. I might of gotten 3 & 9 switched, but doesn’t matter, the concept is standard, everyone gets it. Just as long as I breathe, don’t fucking lay my at 12, I’m a 6er till I expire dammit.

Colonel Due Picq was essential to France in the war on 1870. Germany was winning, but he was the only one capable of saving France, if not in that war, then in future wars. He took a mortar to the head. He was being checked over, and heard a hound soldier screaming. He told the doctor to look after him instead. Du Pics ended up dying of his wounds. His psychological insights were taken on my incompetents, never expanded outside the military into general psychology… while on the German side, Nietzsche was just beginning to formulate his… as a medic having to listen to soldiers in hysterics over their combat situation.

Had Du Picq lived, we wouldn’t of had a WW1, or at least, not that WW1. Instead, we got National Socialism, Dr. Mengeles, concentration camps, Hitler’s push for the overman.

We live in a culture where the ideas sit off balanced, on the periphery, as successor theories take root. A better system of triage during the 1870 war on both sides would of saved up a lot of hell during the 20th century. Du Picq could of further reformed the French Army, evolved this thought, had they prioritized him by rule, not by choice. He was a essential asset. The Prussians could if had a better trained medical corps, trained in empathy and first aid, and not reliant on volunteer REMFs bewildered, over their heads, taking the situation surreal, and not knowing what to do professionally and mentally. We suffered really, really bad as a global civilization from this flaw. Yes, we are all human, when dying or dead one and the same… but until that day comes, some are more essential… ones who keep others alive for max survival.

Mars is 6-9 months away. Air, heat, Protection from radiation, water, food is important in that order of priority. Those who keep it going, are important in that order. Excess is just that, excess. This being said, Mars isn’t devoid of organic compounds, and humans are labors when not in essential use, as John Smith found at youngstown. You can possibly get more of those priority arwas with innovative thinking, taking chances. If it is a crazy disease, quarantine.

3

Your also gonna need to check your liberal views at the door and look into how drugs actually are made. It isn’t a old age issue alone, we develop unique, hard to produce drugs… the price isn’t always arbitrary, and we can’t just go cross eyed and commie the production. They are rare synthetic compounds, not easily reproduced given the lack of infrastructure. We ration these medicines, via the free market system, because we couldn’t invent them at the speed under a socialist system… after Europe went Socialist, their medical researched dropped dramatically, it is mostly just universities doing it. Prior to that, they had a lot of success as a center for research. The Doctor in India who was forced to return (he was a medical researcher in the US, India enslaves all it’s medical graduates, he wasn’t allowed to keep working, he insists he can’t find similar work in India, and refuses to be a medical practitioner) back to India… he can’t find our level of research anywhere else. Why? We fund the craziest medicines off of their profits… but these medications are rare, and in small quantities at first. It takes years to refine the process, find suppliers of raw materials, and enlarge the operation. By time that is done, the patent is up… and generics (if they can even be made cheaper) pop up on the market.

We ration our exotics. In South Africa, they had a truly cursed universal medical program, everyone had a constitutional right to medications, paid for by the government, no matter how absurdly expensive. Note South Africa isn’t known as a hub of medical research… that is very risky business. Imagine if you found a cure that cost $5 million a treatment, such as for AIDS… you needed Bald Eagle brains (unique protein) and ice from a lake in Antarctica (unique anti-oxidents), and real Truffles. Nobody can synthetize it otherwise… and the whole damn country has AIDS. That company is either going to be nationalized, with no positive results, nobody getting cured, for the sake of lip servicing social justice, or the country will go banckrupt trying to gather enough supplies as supreme course case after supreme court case hits.

We can’t supply everyone with vaccines for Ebola even now, much less during the African outbreak. Brand new medication. We couldn’t make that in mass if we wanted to fast enough, even if you had Lenin and Marx whipping the scientist themselves, running to other labs to coordinate. It is impossible, had it broke out in the US, and it nearly did, we be quaranting people left and right.

No in twenty years, yeah… lots of countries will be able to mass produce it. It will be better understood, more ready to offer generics. It isn’t just old people suffering from mutations and organs failing in aging… everyone gets a freaky disease. My cure for Vitigilo would cost about 18,000 for one year treatment. Why? It is a recent drug, whole new class of medicine, nothing like it. 30 years from now, chump change (as long as bald eagle heads aren’t a ingredient).

Socialism = Less Medical Research
Less Medical Research = More Deaths, often painful.

What causes medical socialism? Desire for these treatments as a fix all.

What us the compromise? Mist medical research centers go just, token university research continues to justify guys like Kropotkin, giving sob stories. That medicine only exists because of our system. You destroy that system, you fuck everyone over after you, who will die of uncureable diseases that never had a laboratory competent, motivated, and equipped well enough to succeed. We will all die of the lack of some medical marvel someday, that could of saved us… just unfortunate when we create a system that enforces it on us. I prefer progress forward, not forcing a step back in the wrongfully attributed name of humanity. It if far better to storm the horizons for cures as rapidly as possible, while preserving quality. Capitalism and free markets will do the rest, patents don’t last forever. You may die, but many others will live. It is scary to follow in South Africa’s cursed path.

4

Honorable mention to Nestle, since wevare talking future mars:

theverge.com/2014/6/23/58353 … replicator

5

…then all we need is the sonic shower, and the transporter, and we’re good to go :slight_smile:

The billions of pounds a week that we give to the EU (to help fund other countries services) should really be going to our own cash-strapped NHS… I’d say our health service is on rations… they won’t book any hospital appointments in unless your as sick as…

Carleas… why would your healthcare service need to be rationed if it’s not publicly funded? or is it about keeping insurance costs down for you guys?

6

:neutral_face:

In my experience (as a fatigue sufferer :stuck_out_tongue: ) not treating minor cases can often lead to a person’s health spiralling out of control, and probably costing the tax-payer much more money in the long run.

7

Spoken like a true elitist and aristocrat. Carleas has finally revealed his hand. :laughing:

Now we can finally take a rare glimpse inside the mind of Carleas revealed to all publicly here.

8

Over here, that is what private healthcare is for… preferential treatment.

9

Isn’t social equality a beautiful thing? :laughing:

10

Nigel, is that you…?

11

It’s interesting how quickly the sub-Nietzschean neo-fascists bring up socialism in a thread where the OP made no mention of it. But then they’d need to engage with the philosophical content otherwise…

That being said, I do think that in order to ration healthcare you will need to rationalise, and thus instrumentalise, its management. This means that certain arbitrary decisions will be made as we see in national health systems like the UK all the time. In effect, these sorts of calculations often take place both at the macro and the micro level within any type of healthcare system. What this would require, in other words, is a comprehensive system of public health education in order to clarify decision-making procedures within the healthcare system to patients and to help them to make informed judgements about their own health. On a small scale like the Mars colony that seems quite achievable, but at the national level where the system is going to be accessed by millions of people that becomes very tricky indeed.

12

Still others would say to ration healthcare for individuals is itself authoritarian or fascist.

Well, neo liberals are a different brand of fascists, are they not? Similar they are to their communist or socialist cousins but not entirely identical.

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They might, yes, and in certain circumstances they’d be right, which is one of the things my analysis was referring to with the potential for instrumentalism.

No, I wouldn’t say so, but then you’re talking about terms in political economy (at least in respect of neoliberalism and socialism) that are either contested or broadly-based, depending on your perspective.

14

Alright, then I take it we’re in agreement with that.

Well, I would argue that neo liberalism and liberalism in general was born out of socialist thought historically.

Liberalism is kinda like moderate socialism whereas communism is socialism taken to the extreme.

15

TF, how did they deal with ranks in the clock system, other than that medics get treated first? Was an infantryman’s 6 an officer’s 3? Who made the call, or was relative value fixed in advance? And was it actually personal, or was it just rank, i.e. could a shitty officer be given lower priority than a top notch infantryman?

The military situation is a useful starting point, since it’s been iterated on for generations, but I’m not sure it maps onto the situation where a society as a whole is unable to satisfy healthcare demand. If only because military injuries are of a certain sort, and aren’t going to include slightly-disabling afflictions like arthritis. That latter type of medical need presents difficult cases, because while in a military setting you might triage between someone who’s shot in the chest vs. shot in the leg, you wouldn’t send the person who’s leg-shot back into battle because he’s not dying. In a society-wide rationing situation, you would very likely tell someone with arthritis that, tough shit, your hands are going to keep hurting.

The non-linear curve I have in mind has value along the y-axis, and health along the x-axis. Think of both axes as percentages, so the curve runs through a square from the lower left (a 0% healthy person is dead, and so provides 0% of their maximum value) to the upper right (a 100% healthy individual provides 100% of their value, or at least of their health-mediated value). So we can ask, what percent of a person’s maximum value will be recouped by making them x percent healthier? And if we knew the shape of the curve (which may differ from individual to individual), and we could measure value differences between individuals, we would be able to determine where medical resources should be allocated by selecting for the greatest expected payout in value.

That’s a lot of outlandish assumptions, but my intuition is that, in a rationing situation, trying to do that math is better than not trying. I’m open to an argument on the other side; perhaps the temptation to game the system or to skew the system for subjective reasons is harmful enough that the expected outcome is better if patients are treated by some simpler rule. But what would such a rule be? How much of value should we ignore to avoid the bad outcomes, and what are the edge cases where we might want to break the rules?

I’m not advocating a socialist seizure of the medical industry, but I think that interventions like a global unconditional basic income would go a long way to solving the problem. Medical researchers spend years and millions developing Viagra, not because that produced the most value for society, but because the people with the money to afford drugs were the wealthy men in the first world. If wealth were redistributed towards the bottom, the market would respond by selling them vaccines and vitamin supplements for health issues that have long been solved in countries whose citizens can afford to pay. Simple redistribution seems to solve (or at least reduce) the problem with health inequality, without the nasty consequences of actually granting all health interventions as a constitutional right (though I don’t think such a policy would be insane down the road, for a slightly constrained definition of ‘illness’ and ‘treatment’).

The market is an implicit form of rationing (and not a particularly good one), so I agree that the case I’m exploring really only comes up when looking at a centrally controlled system, or when trying to model a baseline to see how well the market is functioning. But that latter function is useful; it’s possible to influence markets without destroying them, so knowing how far off the market is can be used to evaluate a set of market-influencing policies.

Matty, shouldn’t there be a way to eliminate arbitrary decisions? Or rather, what would be the conditions where we could do so? I’d argue that being able to quantify value and accurately capture the social value of individuals and their individual value-health curves would eliminate the need for arbitrary decisions. Failing that, progress towards such a system could at least minimize arbitrary decisions. One thing in favor of the market, which, again, I think is a bad way to ration healthcare, is that it is minimally arbitrary. In the space of healthcare, if just happens to select for the wrong outcome (money rather than value).

16

The caveat in that sentence is important, so it depends whether you are talking about what “others” think or what you think, and if what you think whether you’re taking the observation about authoritarianism as an absolute.

You’re going to need to do some unpacking to convince me of that, because most historians would consider liberalism to pre-date socialism, but then it depends whether we’re talking about the traditional categories of political economy.

17

Carleas, I’d suggest that human health is a very difficult thing to rationalise because it isn’t easily amenable to a simple quantification of values. You would have to select a small number of variables to evaluate in order for the assessment to be manageable, but you have very few guarantees that those variables will be constant. Now you could rely on “data” to determine a value to a specific case and it would most likely be defensible at the macro level of averages, but ultimately there is still a requirement to choose a point where the calculation that determined that value had to end, thus excluding other factors. In addition, real-world micro-level illness doesn’t perfectly conform to trends. Alongside that, you would also need a universal system of triage, as TF has pointed out, which relies not only on those carrying out the assessments being able to make all of the necessary value judgements but also on the patients being able to present their state of health accurately. My wife is a General Practitioner and her biggest problem is getting the patients to clarify their problem accurately in the time available for her to assess them. She can, and does, rely on procedures for history-taking, examination and diagnosis to help in this process, alongside her professional skill, but it isn’t perfect, and that is talking about a highly-qualified and experienced doctor - what happens when you bring in administrators and other support staff into the decision-making process, or financial concerns?

18

socialized medicine is the surest way to tax the people into oblivion

but further, medicine and money just do not mix, never will, because financial interests are against finding any serious cures, but will rather keep people sick as long as possible… people who chose to work in the medical fields should be prepared to work for donations only and service people.

Monetary speculation on drugs IS deadly for society as a whole. I read the other day that a Hep C treatment costs 37K in america and 2K in india, SAME PILLS. What medical insurance do we need here when it is all about currency manipulation and big pharma kickbacks obviously. No wonder that india’s medical tourism is skyrocketing… very difficult to rationalize ??? I dont think so.

People should have “economics classes” in elementary schools to start with

19

You believe in social equality?

20

I do believe in social equality when NOT enforced.

Thats a natural law, one cannot coerce benevolence. Interventionism has made this world a lot more dangerous, examples: drug wars and all the gangs it has created. Food stamps programs that so many abuse, etc

when enforced, benevolence becomes entitlement… and that is where things go wrong because everybody wants to milk the cow/gov to get perks.

socialism (for the masses) and globalism (for corporations) are mere collectivism since everybody relies on the money printing press… until the boom ends in tears.

as long as people accept to pay the war-tax, immorality will rule