March-April 2011 HASTINGS CENTER REPORT 23

inclusionofarighttobetreatedwithcompassioninthecode,formanyofthereasonsexplainedinthisessay.Nolawchangeensued.Butiflegislationisnottherightsolution,howshouldwepromotecompassionatecare?

Letmeofferafewsuggestions.Aseducators,wecanteachtrainees about the nature of suffering and the value thatpatients place on empathy, kindness, and understanding.As health professionals, we can model compassionate care.Regulatorscanplayapart,too.ArecentKing’sFundpapernotes that “professional regulators can and should providesignificantleadershipinrelationtocompassionatecare;talk-ingexplicitlyaboutwhatisnotacceptableintermsofcon-duct,attitudes,andbehaviours;andsettingstandards.”13Tothisend,thehealthanddisabilitycommissioner’sofficehaspublishedpatients’storiesofgreatcare.14

Nussbaumbelievesthattodevelopcompassioninpubliclife,wemustgivethehumanitiesandtheartsa largeplaceineducation.15Shesaysthattheimaginationofpoetsisre-quired,andcitesWaltWhitman.ThisbringstomindsomelinesfromLeaves of Grass.Whitmanrecallshisexperienceasawounddresser,tendingtoCivilWarsoldiersinhospital.Hiswords—carvedinstoneattheDupontCircleMetrostationinWashington,D.C.—areasubtlebuteloquentreferencetoanepidemicthatremindedusofthe importanceofcare intheabsenceofcure:

Thus is silence in dreams’ projections, Returning, resuming, I thread my way through the hospitals,The hurt and wounded I pacify with soothing hand,I sit by the restless all dark night, some are so young,Some suffer so much, I recall the experience sweet and sad.

Acknowledgments

ThisessaywasdeliveredastheKirbyOrationattheinaugu-ralconferenceoftheAustralasianBioethicsAssociationandtheAustralianandNewZealandInstituteofHealthLawandEthicsinQueenstownonJuly9,2009.IamgratefultoJimEvansandCharlottePaulforcommentsonearlierdraftsandtoElizabethBrowneforresearchassistance.

1.1John3:17.2.M.Nussbaum,Upheavals of Thought: The Intelligence of Emotions

(Cambridge,U.K.:CambridgeUniversityPress,2001),301,306.3. American Medical Association, Code of Medical Ethics (2001),

principle 1, http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.shtml.

4.NewZealandMedicalAssociation,Code of Ethics(2008),principle4,http://www.nzma.org.nz/about/ethics.html.

5.AustralianMedicalAssociation,Code of Ethics (2006),1.1.1(b),http://ama.com.au/codeofethics.

6.HealthandDisabilityCommissioner,CodeofHealthandDis-abilityServicesConsumers’Rights,Regulations1996,madepursuanttotheHealthandDisabilityCommissionerAct1994,section74(1).

7. Health and Disability Commissioner, Capital and Coast Dis-trict Health Board, A Report by the Health and Disability Commis-sioner, case05HDC11908,March22,2007,http://www.hdc.org.nz/decisions--case-notes/commissioner%27s-decisions/2007/05hdc11908.

8.HealthandDisabilityCommissioner,North Shore Hospital March to October 2007, A Report by the Health and Disability Commissioner,2009, http://www.hdc.org.nz/media/30145/north%20shore%20hos-pital%20inquiry%20report.pdf.

9. United Kingdom Department of Health, The NHS Constitu-tion—the NHS Belongs to Us All (2010), http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf.

10.A.Broyard,Intoxicated by My Illness and Other Writings on Life and Death(NewYork:C.Potter,1992),44-45.

11.Theoriginaldefenseinsection59(1)oftheCrimesAct1961wasrepealedbysection5oftheNewZealandCrimes(SubstitutedSection59)AmendmentAct2007.

12. Health and Disability Commissioner, A Review of the Health and Disability Commissioner Act 1994 and the Code of Health and Disability Services Consumers’ Rights: Report to the Min-ister of Health, June 2009, http://www.hdc.org.nz/the-act--code/review-of-the-act-and-code-2009.

13. J. Firth-Cozens and J. Cornwell, The Point of Care: Enabling Compassionate Care in Acute Hospital Settings (London, U.K.: TheKing’sFund,2009),9.

14. Health and Disability Commissioner, The Art of Great Care(2010), http://www.hdc.org.nz/media/124280/the%20art%20of%20great%20care.pdf.

15.Nussbaum,Upheavals of Thought,426.

Aconfessionisinorder.Asdidalmosteveryoneelseofacertainpersuasion,IrecoiledwhenSarahPalinin-voked thenotionof a “deathpanel” to characterize

reform efforts to improve end-of-life counseling.That waswrongandunfair.ButIwasleftuneasybyherphrase.HadInotbeenoneofahandfulofbioethicistsovertheyearswho

Rationing:Theory, Politics, and Passions

BY DANIEl CAllAHAN

Daniel Callahan, “Rationing:Theory, Politics, and Passions,” Hastings Center Report41,no.2(2011):23-27.

24 HASTINGS CENTER REPORT March-April 2011

hadpushedtobringtheneedforrationingofhealthcaretopublicattentionandproposedwaystocarryitout?Andwasnotacommonthreadrunningthroughthelattereffortsthelikelynecessityof somekindof committeeorotherpublicmechanismtomaketheharddecisions?Werewenotinotherwordstalkingabouta“deathpanel,”evenifnoneofushasbeensoimprudenttousesuchaphrase?Anddidwenotreg-ularlybemoanthefactthatpoliticians,leftandright,wouldnotgoneartheword“rationing”?

My answer to all those questions is yes, but with someimportantdistinctions.Oneofthembearsonthetheoreticalefforts to make a case for rationing and to propose meansto carry itout.Another is thegapbetween that effort andthepoliticalrealitiesofbringingrationingtheorybeforethepubliceye.Stillanotheriswhetheritispossibletoenvisionanethicaltheorythattakespoliticsfullyintoaccount.Butthereisfirstalargerbackgroundstorytobetoldaboutallthat.

Thelargerstoryappropriatelybeginswiththe1960eventthathasoftenbeenthoughtofasthebirthofbioethics.Inthat year, theUniversity ofWashingtonnephrologistBeld-ingScribnerdevisedashuntthatwouldallowthosesufferingfromkidney failure tobehookedup to adialysismachinethat couldkeep themalive formanyyears.But therewerefewof thosemachinesandmanymorecandidates for theirusethancouldbeaccommodated.Rationingdecisionsofthemostwrenchingkindhadtobemade.1

Thesolutionwasaproceduralone:theformationoftwocommittees,oneof them todetermine themedical criteriafor selecting candidates.Theotherwas anAdmissions andPolicy Committee to choose, as the prominent journalistShanaAlexanderwrote,“whoshall liveandwhoshalldie.”For four years that committee—whose membership wasanonymous—made case-by-case decisions, and its generalcriterionwasatroublingconcept,thatofthe“socialworth”ofthepatients.Thecommitteehadadreadfultimemakingsuchchoices, and thevery ideaof suchacommitteewaswidelyassaulted.

Dr. Scribner said later that “we had been naive” not torealize that what seemed to be the “reasonable and simplesolutionof...lettingacommitteeofresponsiblemembersofthecommunitychoosepatients”wouldevoke“averyseriousstormofcriticism.”2AmongthoseinethicswhoenteredthefraywereJamesChildressandPaulRamsey,whocontendedthatarandomlotterysolutionwouldbemorefair,andthephilosopherNicholasRescher,whofavoredautilitariansolu-tionthattacitlyseemedtoacceptthe“socialworth”standard.

Thedialysiscontroversyfinallycametoanendin1972,when Congress passed a bill providing Medicare coverageforit.Money,inshort,wasthewayoutofthemoraldilem-masofcommitteedecisions.Butwhy,manycommentatorsasked,didCongressnotdothesamewithlethalconditionssuchascancerandheartdisease?Thatquestionwasansweredwithsilence.ConsistencyisnotoneofthebehavioraltraitsofCongress.

SofarasIknow,nosimilarefforttohavecommitteesmakelifeanddeathdecisionshaseverbeenmountedinthiscoun-try.Nonetheless,amongthoseinbioethicswhohavewrittenmuchonrationingovertheyears—NormanDaniels,Leon-ardFleck,PaulMenzel,AlanBuchanan,PeterUbel,andmy-self,forinstance—thereisafairdegreeofconsensus.Iwouldsumitupasfollows:ifnotatonce,thensoonerorlater,ra-tioningwillbenecessary(thesteadyriseofcostinflationwillnecessitateit);bedsiderationingwillnotbeacceptable(tooopen tobias and erratic criteria); rationingwill have tobedoneatthepolicylevel(mainlyoutofthehandsofindividualdoctorsandpatients);andatthatleveltherewillhavetobeadecision-makingprocedure(mostlikelycommitteesofsomekindthatwill,withdemocraticdeliberation,maketranspar-entdecisionswith“accountabilityforreasonableness,”touseDaniels’sstandard).Thekeypointisthatrationingdecisionswouldbemadeatthepolicylevel,notcasebycase.

s s s

Ihaveleftoutmostdetailswiththatlist,aswellasvariousdisagreementsamongthosewhohavewrittenonration-ing.Muchofwhatwehavewritten is theoretical inthe

sensethatithasnotbeentestedbymuchAmericanexperi-ence—littlesaveforSeattleisavailable—andmakesidealas-sumptionsaboutidealbehaviorinanideallyrationalsociety.

But there is one European model that has been closelywatchedhere,thatoftheUnitedKingdom’sNationalInsti-tuteforClinicalExcellence(NICE).Technically,NICEwasnotestablishedasa rationingagency—qualityofcare is itsmainemphasis—butithastheoptionofrecommendingtothe British National Health Service that NHS not providecoveragefortreatmentsthoughttobeoflittlemedicalvalueorjudgedtobetoocostlyfortheirbenefits.Mostnotableisitsuseofquality-adjustedlifeyears(QALYs),aneconomicstool,tohelpitmakedecisions.Theaimofthattoolistofindawayaroundthesubjectivityofdecisionsthatwillhavetoencompassindividualquality-of-life judgmentswhileatthesametimenotfallingintothe“socialworth”swamp.Theuseofthistoolisnotmeanttotrumprationaldeliberation,buttosupplyitwithaneconomiccriterion,recognizingthat itwouldinevitablyhavesomevalueconsiderations.Itwas,notsurprisingly,singledoutforparticularcondemnationbyop-ponentsofthereformlegislation,athis-could-happen-to-usmenaceifwearenotvigilant.

Therecentandnodoubtendlesshealthcarereformdebatein the United States was a shock to many of us who havetoiledintheneatlytilledvineyardofrationingtheory.Atfirstalllookedwell.Fullyrecognizedwastherealityofunsustain-ablecostescalationwithitsfalloutofagrowingnumberofuninsured, excessive out-of-pocket expenses, Medicaid cri-sesinmoststates,andaprojectedinsolvencyofMedicareinseventoeightyears.TheDemocraticleadership,withatleastinitialRepublicansupport,madeperfectlyclearthatstrongstepstocontrolcostswouldbenecessary.

March-April 2011 HASTINGS CENTER REPORT 25

Butastimewenton,theexpectedfast-trackdrivetoman-agecostsbecamemoreasoft,slow,decade-longshuffle.Ner-vousnessaboutthesubjectofcostswasperfectlyexemplifiedinPresidentObama’sassurancethattherewouldbenoreduc-tionofMedicarebenefitsforseniors.IhaveseennoseriousanalysisofMedicare’sfuturethatdoesnotincludejustsuchareductiontoremainsustainable.“Bendingthecurve”becametheanodynetermofchoiceinlightofthepoliticalrealitythatrapid,fastoptionswouldnotmakeit.

Perhapsthereformlegislationwillmakealong-termdif-ference,butevenifitdoes,thereissomeconsensusthatitwillnotdowhatisnecessary:bringingannualcostescalationinlinewiththeannualriseofthegrossdomesticproduct,fromthepresent6percentto3per-cent.ThecostsofcareforthebabyboomersabouttoentertheMedicareprogrambythemillions will be staggering.Many astute policy analystshave long noted that, forMedicare to survive, either adoublingof the tax rateora50percentcutinbenefitswillbe necessary. No one talksthatwayinCongress.

Nor does the reform leg-islationdomuchtostemthesteady stream of expensivebiologicdrugsforcancercareandcostlymedicaldevicesforheartdisease,manyofwhichcry out for some rationing.Howmanynewcancerdrugscostingbetweenfiftyandonehundredthousanddollarsforjustafewextramonthsoflifecanbeafforded?Thestipula-tioninthereformlegislationthatcomparativeeffectivenessresearchcouldbeusedneithertofashionpracticeguidelinesnoreventomakerecommendationsfortheuseofitsfindingswasasgoodasignasanythatcostcontrolwouldnotencom-passdirectlysayingnotopatients,doctors,orindustry.Pres-suresfromthedruganddeviceindustriesandsomephysiciangroupswereresponsibleforthatcripplingprovision.

Ifend-of-lifecareaslegislativelyenvisionedwasthewrongplacetoaffixthelabelof“deathpanels,”SarahPalinsurelyhadagoodnoseforthepoliticalunacceptabilityofanyra-tioningtalk.Republicansfastenedunrelentinglyonanywhiffof it (particularlyexploiting slippery slopearguments),andDemocratsshiedawayfromitnolesspersistently.Whatcan-didate for reelection will go home admitting to his elderlyconstituentsthathefavorsacut intheirbenefits?Farfromopeningthedoorforsomeseriousdiscussionofrationing,itwasslammedshutinthereformrun-up.

Most of the assumptions about the value and plausibil-ity of deliberative democracy (bringing the public into di-rectengagement)thathavebeenakeypartofthetheoretical

rationingensemblehavebeenrenderedinoperable.Toomanypeopleseemtowantnodeliberationofanykind.Howcanwehaveasensiblepublicdiscussionofpanelsmakinguseof“accountabilityforreasonableness”ifperhapshalfofourfel-lowcitizensconsideritimmoraleventotalkaboutit?Puttingasidetheoftenhostilehysteriathatmarkedanyeffortstoevenraisethetopic,itisnothardtodiscerntherootsoftheoppo-sition.Thereisthedeeplyembeddedhostilitytogovernmentinterference inthedoctor-patientrelationship—assumedtobeabulwarkagainstrationing—financiallywellsupportedbymanymedicalgroupsandthedruganddeviceindustry.Thenthereisthepopularexpectationthatinprinciplethebenefitsof medical progress and health care should be available to

everyone regardless of costs.That view is held by manyphysicians and encouragedby a research enterprise everreadytotrumpet itsbenefits,thatof thedecisivenostrumsand cures just over the nexthill. That public expectationis not matched by a willing-ness topay for thepromisedbenefits, but it is strongenough to stifle any talk oflimitstocare.

Most important, perhaps,is the belief that, in a richcountrylikeours,themoneyisreallyouttheretopayforallwewantorneed.Liberalscanpointtothebillionsspentonunnecessary wars or agricul-tural subsidies.Conservativesclaim that the problem is a

failuretoletthemarket,withitspotentiallyrichmixofpri-vatechoiceandinsurercompetition,begivenitsunregulatedhead. Again and again, moreover, I have found it possiblewithsomepatiencetopersuadeallbutthefanaticalinsomegeneral fashion that some rationing, in someway, at sometimeorother,willbenecessary,onlytobetold,“Yes,you’reright,butnotifitismyspouse,child,orgrandparent.”Forthem,themoralbottomlineisthatrationinglifeanddeathisintrinsicallywrong,andthetestcaseissomeonetheycherish.

Nor is that just anAmericanproblem. In sketching theearlier cited consensus among the bioethicists who haveworkedonrationing,Ileftouttheagreementthatfairration-ingcouldtakeplaceonly inauniversalhealthcaresystem,onewithequalaccesstocareand(Iwouldadd)afixedan-nualbudget.Thatwouldforcetradeoffsinthefaceofscarcityandallowconsiderationoftheopportunitycostsofdifferentrationingpossibilities.

TheUnitedKingdomhassuchahealthcaresystem,andinNICEithasawayofdoingsomerationing.Butdoesthatcombinationsaveitfromthekindofpoliticsthatstifledebatehere?Possiblyalittle,butnotentirelybyanymeans.While

However much individuals may be hurt by rationing

decisions, they must be made eventually. But a serious debate about what many consider a prima facie evil

has proved nearly impossible.

26 HASTINGS CENTER REPORT March-April 2011

therehavebeencriticsofNICE’smethodology,includingitsuseofQALYs, theyhavebeenmatchedbycomplaints thatitsdeliberationsarenotsufficientlytransparent,particularlyamongthesubcommitteesthatcarryoutmostofthem.Thatmay well be true about the process, but the recommenda-tions,andtheNHSroleinrespondingtothem,maketheirwaytothepublicbymeansofanever-alert,aggressivemedia.TheNHSisobligedtocoverthosetreatmentsandtechnolo-gies that meet the NICE standards (one reason why thesetreatmentsoftenraisecosts),butitsconclusionsaboutcover-ingtreatments that fall shortof thestandardscanbemadeonlyasrecommendations.

Recommendations against coverage (or to limit cover-age)ofsomeexpensivedrugsfor cancer anddementia ongrounds of their high costper QALY have caught theeye of the media—and theBritish media is far moreunbuttoned than its Ameri-can counterpart. Its re-porters typically fan out tointerview those who will bedenied a drug. For cancerpatients, that drug will of-ten extend their lives, evenifnotforlong.Nolesstypi-cally, those denied the drugor their families believe thedrug has desirable benefits(nevermindwhatunseenex-perts say) and that itwouldbe inhumane toput apricetagontheirlives.Whyinflictthatnastinessonthem?Thisequalsaperfecttabloidstory.AsRobertSteinbrooknotedinapaperonNICE,“Afterall,sayingnotakescourage—andinevitablyprovokesoutrage.”3

Ironically,then,transparencycanturnouttomakeration-ing decisions all the more difficult to implement. As a re-sultofpublicoutcries,anumberofNICErecommendationsagainstcoveragehavebeentakentocourt,andtheNHShashadtobackdownonsomethatitinitiallyaccepted.EffortstoincludemorepatientsinNICE’srationingdeliberationsmaywellexacerbatethatresult.Astwoadvocatesforthatshiftputit,theeconomictechniquesusedbyNICE“donotmeasurethequalityofsomeone’slifeinawaythatissensitivetoava-rietyofconditionsorthatallowsindividualstoindicatewhatisimportanttothempersonallyandhowtheirillnessaffectsthat....Althoughthedirectcostsofsometreatmentsmayplace a huge burden on society, rationing such treatmentsplaces evengreater (indirect) costson individuals, their ca-reers,andthewiderpopulation.”4

Thelogicofthatkindofindividualpatientvariationar-gumentisbutashortsteptoaSeattle-typecommittee,with

case-by-casedecisions.Italsohasamorerecentfamiliarring:U.S.opponentsofevidence-basedguidelinesbasedonpopu-lation statistics have saidmuch the same thing.They con-cludethatitwouldbebettertoleaveallfinaldecisionsinthehandsofdoctorsandtheirpatients,notgovernmentpanelspeopledbyfacelessbureaucrats.Asickperson’snotionof“ac-countabilityforreasonableness,”muchlesstheresultsofevenfulldemocraticdeliberation,mayofferlittlesolacetosome-onedeprivedofalonger(evenifnotmuchlonger)orintheireyesbetterlife,howeverawfulitmightseeminours.

Yet however much individual patients may be hurt oraggrievedbyrationingdecisions,theywillhavetobemadeeventually.Theywillhave tobeamain, ifhardly theonly,

ingredient in any long-termsolutiontothecostescalationproblem—aproblem thathasthe potential to wreak eco-nomic and medical havoc ifnottakenmoreseriously.It istheclassicandalwaysdifficultdilemma of individual versuscommongood.Tomakemat-tersworse,wedonotordinar-ily attribute a desire to liverather thandie,or to feel lesspainratherthanmore,togrossselfishness. In the case of justwars,wearepreparedtosacri-ficeourchildrentodefendusfrom societal ruin—but onlywhenthereisnootherchoice.But in thecaseofhealthcarerationing,ithasprovednearlyimpossible to have a seriousdebateaboutsomethingmanyconsideraprimafacieevil.Asin the United Kingdom, the

Americanmediawouldinstantlyseizeuponthepredictablemoraloutrage.

Itisharderstilltocutthroughtheplethoraofupbeatideastoavoidrationing,startingwiththoseoldnostrums:first,theassertionthatweneednorationinguntilwehaveeliminatedallwasteandinefficiencyinourhealthcaresystemorcarriedoutmoreandbetterresearchtoridusofallthoseexpensivediseases;orsecond—allotherideasfailing—theassertionthatit does not matter what we spend on health care, held bysomeeconomiststobethebestpossiblewaytospendmoney(eveninasevererecession,healthcareremainsoneofthefeweconomicdomainsthatregularlyaddsjobs).

Istheresomewaytodevelopatheoryofrationingthattakesfullaccountofthepoliticalturbulenceofheathcarereformandthedeeprepugnancefeltbymany,maybeevenmost,atthepossibilityofrationing?NonethatIhaveheardof.Ifpoli-ticshasmadeithardtomanageintheUnitedKingdom,withitstraditionofmorereadilyacceptinghealthcarelimitsthantheUnitedStateshas,itseemsalmostinsurmountableinour

What candidate will admit to his elderly constituents

that he favors cutting benefits? Far from opening

the door for a serious rationing discussion, it was slammed shut in the reform

run-up.

March-April 2011 HASTINGS CENTER REPORT 27

hyperindividualisticculture,suffusedwithskepticismabout,oroutrighthostilityto,astrongroleforgovernmentandanexcessivelygreatloveofnew,alwaysbetter,technologies.

s s s

Ifinditplausibletothinkofrationinginthreecategories.OneofthemIcall“directandnaked”:anunveileddenialofsomeimportanthealthbenefit, includinglife-extend-

ing treatment,byeitheraprivateorpublic institution thathas thepower todo so.Tobe sure, there is a great differ-encebetweenrationinginthecontextofabsoluteshortages,aswiththeearlydialysismachines,anddenyingthesickaninsuranceorMedicarebenefit,butleavingthemfreetobuyitforthemselves.Thelatterwillbesmallcomfortforanyoneotherthantheveryaffluent;manyfamiliesbankruptthem-selves thesedays tocover treatments theycannototherwiseafford.

By“indirectandveiled”rationing,Ihaveinmindtheuseof copayments and deductibles, particularly when they aresethighenoughtodiscouragebutnottoopenlystoppeoplefromusingexpensiveservices.By“covert”rationing,ImeanthekindthatexistedintheUnitedKingdomfromthe1950sthroughatleasttheearly1980s.Restrainedbytightbudgets,itcametobeunderstoodasanunwrittenrulethatpatientsovertheageoffifty-fivewouldbedenieddialysisandsomeformsofheartsurgery.Theyweretobetoldbytheirphysi-ciansthatnothingcouldbedoneforthem.Thatwasaflatlie,butitofferedcovertophysicianswhoknewtheirlimitedbudgetscouldnotstandit.

TheeminentBritishpolicyanalystRudolfKleinhassug-gestedthatalessvisibleformofthatearlierpracticestillexistsintheUnitedKingdom:“themostpervasiveformofration-ingistheleastexplicitandleastvisible:rationingbydilution. . .not toorderanexpensivediagnostic test,or to reducewardstaffinglevelsinordertobalancethebudgetnormallyattract little attentionunless theyexplode ina scandal . . .suchdecisionsareasmuchaformofrationingastherefusaltoprescribeadrug...however,inthetimesaheadnogen-erallyaccepteddecision-makingmodel is likelytoemerge.”“Thebestthatministerscanhopefor,”Kleinconcludes,“isthatmostrationingwillcontinuetotaketheformofdilutionrather thanexcisionandthatdecisionscanbe taken in thenameofclinicaldiscretionandthusbepoliticallyinvisible.”5

Ifpresentethicaltheories—notdesignedfornastyfights—willnothelporbemuch listenedto, justwhatmightoth-erwisehappen? Iwouldbetonacombinationofgraduallyincreased taxes, an expanded government role despite con-servativehostility,andasteady,evenaccelerating,riseofco-payments,deductibles,andcoinsurance—alreadyapervasivepractice.Will there be complaints? Of course. But a long-losingYale football coachonce said that the trickwith thealumniwasto“keepthemsullen,butnotmutinous.”Copay-mentsanddeductibleshavemanagedtowalkthatfineline.Theywill surely continue to rise and are steadily doing soacrossMedicare,Medicaid,andprivateinsurance.

Whilecovertrationingwillundoubtedlybecondemned,Iwouldnotbesurprised if it startshappening.Forat leastsomephysicians, itwillbeanenticingwayofdealingwithcostpressures, akindofwell-meant falsehood toavoid thepain of brutal candor. Available information in the mediaand on the Internet will make it much harder now to getawaywith that tactic,but sincepatients tend to trust theirdoctors,somedoctorsmaysucceed.RudolfKlein’sdourbutsober judgment of rationing in the United Kingdom may,andprobablywill,beapplicablehereaswell.

Therationingproblemintheendisthatwehaveacul-tureandpoliticsthatinviteevasionofhardethicaldilemmas,outrageandshoutinginsteadofdeliberativedemocracy,andabadcaseofwhathasbeencalled“theCaliforniadisease”—alimit on taxation combined simultaneouslywithunlimiteddemandsforever-morebenefits.Wewantunboundedmedi-cal progress, an all-out war on death, lower taxes, and nomedicalrationing.Itisamixthatcannotlongbesustainedbut,likeadrug-resistantvirus,itcontinuesmutatingtokeepussick.It isachroniceconomicdiseaseastenaciousasthemedicalones.Nolesspathologicalisanunwillingnessonthepartofpoliticianstotalkopenlyabouttheneedforration-ing, not just what’s wrong with it. Euphemisms, evasions,androsyscenariosofbendingthecurve,orofsimultaneouslyimprovingqualitywhileloweringcosts,makeuptherhetoricofchoice.

Thecultureofevasiondirectlyclasheswiththenecessityofcostcontrol.Thesamepoliticalforcesclamoringfordeficitreductionarethosethathavemostvehementlycondemnedanytalkofrationing.Theycannothaveitbothways.Some-thinghastogive.Butthereislittlereasontothinkthatwhatgives will be evasion. I find it hard to imagine that openrationingwill bepossibleother thanwith the low-hangingfruit—whatever is the least threatening and economicallymarginal.Thereallyhardchoiceswillbepushedintotheter-ritoryof indirectandcovertrationing.Thereigningethicaltheory on rationing has it right: only committee decisionswithconsiderablepublic inputought tobeacceptable.Butthatmodelhasnotyetbeentakenseriouslyintheworldofpolitics—a failure that simply increases the likelihood thatethicallyflawed strategieswill be embraced.Thatwill be ashame.

1.A.R.Jonsen,The Birth of Bioethics(NewYork:OxfordUniversityPress,1998),211ff;R.C.FoxandJ.P.Swazey,Courage to Fail: A Social View of Organ Transplants and Dialysis(Chicago,Ill.:UniversityofChi-cagoPress,1974).

2.QuotedinFoxandSwazey,Courage to Fail,76.3.R.Steinbrook,“SayingNoIsn’tNICE—TheTravailsofBritain’s

InstituteforHealthandClinicalExcellence,”New England Journal of Medicine359(2008):1981.

4. J. Speight and M. Reaney, “Wouldn’t It Be NICE to ConsiderPatient’sViewsWhenRationingHealthCare,”British Medical Journal 338(2009):b85.

5. R. Klein, “Rationing in the Fiscal Ice Age,” Health Economics, Policy and Law5,no.4(2010):389-96,at389-90and394.