Everywhere in politics, but in discussions of healthcare in particular, there is a powerful bipartisan impulse to insist that tradeoffs are illusory—infinite ponies can now be yours! Progressives are too eager to believe that national health care will make it possible to expand coverage while reducing costs—reducing deficits, even!—apparently because all those costs are in pernicious “overhead,” which seems to be joining that political holy trinity “waste, fraud, and abuse.” Conservatives, on the other hand, just seem to be in a weird state of denial about how our existing system actually works when they talk about “rationing.” Here’s Mickey Kaus:
r enough. But I want to make the decision to cut off treatment, not have it made by a cost-watching health board. Choice! The resonance with the abortion debate seems obvious. … Both are life/death decisions. Are they both best handled by individuals and their families in consultation with their doctors? You’d think the case for “choice” at the end of life might be stronger, since the life at stake is likely to be able to participate in making that choice. …
It’s one thing to deny the choice to die, quite another to deny the choice to live. The individual may not have a right to get killed, because the state’s interest in protecting people from coercion and abuse is a good one. But Kaus is concerned about a government that wants you dead — perhaps not by actively offing you, but by maintaining full control over the medical treatments you need in order to fend off death.
In a world where we all wrote personal checks for our health care, I’d be entirely on board with this. If someone with a terminal illness thinks the best possible use of their accumulated wealth is to blow it on a longshot chance of eking out a few more painful days or weeks in an ICU—and the evidence suggests that aggressive end-of-life intervention often doesn’t even get you that—then that’s their choice. I hope that’s not my own reaction when the time comes. A lot of what passes for indomitable where-there’s-life-there’s-hope optimism in American culture is a not-terribly-convincing attempt to camouflage our failure to come to terms with our own mortality. I hope I’ve made my peace well enough not to insist on every desperate gesture of denial science has to offer. Even if it’s a question of genuinely adding a few extra weeks or months to a long life well-lived, I hope I have enough other worthy uses for whatever money I’ve saved that I don’t empty the accounts buying every last available minute. But hey, death is scary. Maybe I’ll feel differently when the time comes; I certainly won’t second-guess anyone who wants to make a different choice.
Except, that’s not actually how our existing healthcare system works. In the real world, the decision to do throw the kitchen sink at every ailment is either funded by the government, or by private insurance. A fair amount of the time, it will be made not by the actual patient, but by family members for whom “do whatever it takes” is a low-cost salve for the guilt of never actually visiting grandma at the home. The insurers are substantially constrained in the range of treatments they need to cover, which gives doctors little enough incentive to control costs or limit tests or treatments themselves. (My impression is that this is partly a function of an increase in the increasingly cozy relationships between referring doctors and testing facilities.) These “choices” are not free. They are not a noble reflection of the infinite preciousness of life. These socialized costs—and they’re effectively “socialized” whether it’s the government or private insurers picking up the tab—raise premium costs, make it more expensive to employ people, push some people out of coverage entirely, and otherwise divert scarce resources from things that might actually help somebody. The notion that this perverse result is somehow required by “medical ethics” is simply grotesque.
This is pretty clearly unsustainable. The more medical technology advances, the greater the number of expensive longshots, the more hours and minutes we can lease back from oblivion at ever greater cost. Over the long term, we can decide that any probability of any added increment of lifespan for people in medical care trumps evey other possible private and public good, or we can ration. That rationing can be by individuals weighing the costs and benefits relative to their resources, or it can be by governments—whether directly or by regulation of insurers and providers. Between those options, I’ll leave it to the wonks. But please, if you’re going to claim an unlimited right to make other people subsidize the understandable impulse for denial and wishful thinking, at least let’s not pretend that it’s somehow a matter of protecting “individual choice.”