Any talk of rationing health care puts people on edge. In hospitals, we no longer use the word "rationing." Instead, we discuss "allocating scarce resources."
Rationing conjures up images of totalitarian states and greed.
Medical students, when confronted with the notion that physicians ration care, go wild in their opposition. Physicians are ethically obligated to act in the best interest of their patients, they argue, and rationing is contrary to this goal.
When a professor points out that acting in the best interest of one patient may require you act against the interest of another, the classroom plunges into a thoughtful silence.
When the supply is limited for resources such as the physician's time, intensive-care beds or organs for transplant, doctors must choose who gets the treatment. The discussion, which focuses largely on who would benefit more, is subjective.
Take this example: A 52-year-old father of three, the owner of a large business, suffers a serious heart attack and lies in the emergency room of a small rural hospital awaiting a bed in the intensive-care unit.
He needs constant monitoring and the careful administration of medications that cannot occur in a regular hospital ward.
The 12-bed ICU is full. One patient, a 77-year-old man, had open-heart surgery 17 days ago and has not regained consciousness. Another, a 27-year-old woman leukemia patient, is now gravely ill with an infection that will likely kill her.
A 44-year-old alcoholic with profound liver failure occupies another bed. He is being treated for an infection, receiving dialysis, and hoping that a transplant will become available.
Should the fate of the ICU bed be determined by a first-come, first-served philosophy? If so, then the 52-year-old man loses out. He would likely die without the attention of an ICU, attention that would go to one of the other gravely ill patients who might not survive as long as he.
For every system, there are winners and losers. One medical student in class suggests we make decisions based on the person's value to society. Would this value be measured by income? Clearly, such a system would favor men and the well- educated.
Another student suggests we base the decision on the expected benefit of the treatment. Yet none of us has an accurate crystal ball.
The 77-year-old man could wake up, but it is very unlikely. A neurologist who conducts a careful exam and reviews the medical records may put the chance of survival at 3 percent. The cardiac surgeon who did the surgery and knew the patient well may, through wishful thinking, prayer, or a different experience place the chance of recovery at 30 percent. Is there a right answer? Is survival different than recovery?
Another student suggests that doctors are too close to patients to make these decisions. She suggests we leave such difficult choices to administrators or committees.
But decisions by committees tend to follow strict protocols that fail to take into account individual differences that might constitute an important exception to a written rule.
In situations where an ICU is full, it usually falls to the charge nurse to work with doctors to transfer out of the ICU those patients who are well enough to be managed on the regular hospital floor or who are so sick they are unlikely to benefit.
Rationing – or "allocation of scarce resources" – is common in the U.S. health care system and is unlikely to go away anytime soon. Things really get dicey when care is rationed based on a person's finances. Next week, I will look at this issue.
Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at drwilkes@sacbee.com.
