| Condition Critical: A New Moral Vision for Health Care, Richard D. Lamm and Robert H. Blank, 2007, Fulcrum Publishing, Golden, Colo., 188 pp.,$12.95. |
Lamm and Blank say that their book is meant to alert America to a coming public policy train wreck. They see three seemingly unstoppable trends on a collision course: (1) the inventiveness of the promoters of medical technology; (2) healthcare providers’ allegiance to the Hippocratic oath; and (3) the healthcare expectations of the American public. A new moral vision is required because taxpayers now fund more than half of healthcare, and resources are limited relative to need. Medicare and Medicaid are not sustainable. Medical science has invested, discovered, and ethically self-imposed more medical care than those who pay for it can afford. Two of the basic foundations of healthcare in the United States—hat a patient has a right to expect any and all medicine that is wanted or beneficial to his or her health and that a doctor has the right to prescribe and deliver all the healthcare he or she feels is appropriate—need to be challenged.
Rationing becomes inevitable. Rationing is, of course, already going on in healthcare but the authors do not think that rationing on the basis of insurance coverage or money is an equitable system in our democracy. While other countries have opted to ensure universal coverage but to limit the range of healthcare services, the United States has opted for a system that offers high-technology, comprehensive care that is not guaranteed to all. We should decide on priorities for healthcare spending as compared to education, housing, social welfare, national security, and leisure. The national spending for healthcare has now exceeded $2 trillion per year and is accelerating rapidly. This is not sustainable. Eliminating waste, inefficiency and obscene corporate profits will not alone be sufficient to avoid the need for rationing.
Individual behavior and age must be considered in any system of rationing. A vast majority of Americans are responsible for a very small proportion of healthcare spending. Five percent of the population uses 55 percent of the healthcare dollar. One percent of the population spends slightly less than 30 percent of the healthcare dollar. People who engage in high-risk behaviors contribute inequitably to escalating healthcare costs. The authors feel that although people may have a right to design their own lifestyles, if they choose to engage in practices and behaviors that put them at high risk, they should be prepared to relinquish their claim on societal healthcare resources. Eighteen percent of one’s lifetime healthcare costs are spent during the last year of life and more than 45 percent of healthcare resources go to the approximately 13 percent of the population that is 65 years of age and older. As financial and ethical pressures mount, the right to die with dignity should be transformed into an expectation and eventually into an obligation.
So, how are we going to accomplish rationing? Lamm and Black suggest the following
seven rules:
1. Healthcare must be universal.
2. The rationing must be transparent and explicit.
3. Assign individual responsibility for ill health due to bad behavior.
4. Assess all new technology.
5. Shift from curative, episodic medicine to education, health promotion, and
prevention with emphasis on primary care.
6. Broaden healthcare to include social and economic factors.
7. Dialogue onnational goals and future of the republic.
This is not what you want to hear, but don’t put your head in the sand. Society does need to talk about these things, and neurosurgeons must lead the way. Read this book! NS
Gary VanderArk, MD, is clinical professor of neurosurgery at the University of Colorado Health Sciences Center in Denver. He is the 2001 recipient of the AANS Humanitarian Award. The author reported no conflicts for disclosure.