August 19, 2009

by Bill Levinson

Rationing and triage (in which only people to whom immediate medical treatment means a life or death difference receive it) apply in disaster and battlefield situations in which there are simply not enough resources for everybody. We state up front that we do not believe that the American medical system is anywhere near this point, especially because 30 to 60 cents of every health care dollar are squandered on waste and inefficiency. These include administrative costs, inefficiencies such as doctors and nurses having to walk or wait to get or record information, and easily preventable medical mistakes such as medication errors and hospital acquired infections. It is totally irresponsible to even consider rationing and triage while such inefficiencies persist, but Barack Obama, his medical advisor Ezekiel Emanuel, and others in the Obama camp think there is indeed a shortage of medical resources that justifies a rationing and triage mentality. This article will continue under this premise.

Consider a genuine disaster situation in which there is, for example, a shortage of food and water. In such situations, deliberate and willful waste of the scarce resources is dealt with very harshly and perhaps even punished with death–which is normally reserved exclusively for crimes like murder and high treason. In the movie Khartoum, a man is caught selling the fortress’ food; General Gordon, who sent his favorite camel to the butcher to help feed the garrison, promptly has him put up against a wall and shot. In the new Horatio Hornblower series with Ioan Gruffudd, a sailor who merely eats more than his ration of food is flogged while the captain, Sir Edward Pellew, promises to hang the next such transgressor. It is easy to envision somebody who deliberately wastes a lifeboat’s water supply being thrown overboard by the other survivors, with the action qualifying as justifiable homicide. If, as President Obama and Ezekiel Emanuel claim, there is a shortage of medical resources, care should first be denied to those who waste these resources. This is not something we advocate but, if the President and his advisors wish to go down that path, AIDS (unless acquired from a blood transfusion or accidental contact with blood), venereal diseases, and tobacco-related illnesses must be put onto the table for discussion.

Let us first examine what Barack Obama and Ezekiel Emanuel have said about the need for rationing. From Dr. Emanuel’s “Where Civic Republicanism and Deliberative Democracy Meet,”

“This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources. Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity-those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic. Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia. A less obvious example is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason.”

Ezekiel Emanuel and his coauthors say the following in “Principles for allocation of scarce medical interventions” The Lancet, Volume 373, Issue 9661, Pages 423 – 431, 31 January 2009

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated.

Barack Obama said the following in an interview with the New York Times:

[Obama] If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

[Interviewer] And it’s going to be hard for people who don’t have the option of paying for it.

THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

[Interviewer] So how do you — how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

The President is probably quite correct about “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here,” but these are normally “There but for the grace of God go I” situations in which anyone may find himself or herself. Risk factors for dementia, for which Ezekiel Emanuel advocates denial of extensive medical care, are still largely unknown although there are at least some theories as to how to reduce the risk. The same applies to most forms of cancer except those of the lung and skin. On the other hand, the cause of AIDS is well known, the disease is almost entirely avoidable, and the lifetime cost of treatment exceeds a hundred thousand dollars; some estimates exceed half a million dollars. Germany had similar discussions of cost in the context of the Aktion T4 euthanasia program but Barack Obama and his cohorts seem more than comfortable with these kinds of discussions.

If we are indeed in a shortage/rationing situation, then, it is entirely reasonable to enact the following measures prior to rationing or denial of care to senior citizens or people with “There but for the grace of God go I” chronic illnesses.

HIV-AIDS
AIDS is a self-inflicted disease with the following exceptions: blood transfusions (rare now that the Red Cross screens donor blood for the HIV virus), accidental contact with blood as could happen to a health care or emergency service worker, and innocent sex partners (e.g. a wife whose husband sleeps around and then brings the disease home with him). If society cannot afford to care for senior citizens or people with chronic illnesses, it cannot afford $100,000 or more for each case of this self-inflicted disease. Those who waste the lifeboat’s resources have to go overboard.

(1) Any rationing scheme must therefore deny all but palliative care–the pain pill that Obama recommends for senior citizens–to AIDS patients except for the indicated exceptions.
(2) It should be made a serious felony under Federal law for a person with AIDS to have sexual contact with another person without informing him or her of his condition, and anyone who is found guilty of exposing another person to AIDS in this manner should be put on a list similar to the Megan’s Law sexual predator list.
(3) Willful exposure of another person to a less virulent and treatable venereal disease should be treated as reckless endangerment or something similar.

Tobacco
We all know what causes lung cancer, and lifeboats cannot afford to carry those who willfully waste their limited (per Obama and Ezekiel Emanuel) resources. A rationing scheme must therefore allow only palliative and hospice care for lung cancer, with the exception of non-tobacco cases (about 10 percent) and secondhand smoke victims. Alternatively, tobacco could be taxed to whatever extent is necessary to provide treatment for this disease.

We reiterate that the United States’ medical system is far from the point at which lifeboat-type regulations should be applied, but President Obama and Ezekiel Emanuel are both on record as saying otherwise. Keith Ellison (D-MN) also has said something about the need for living wills to reduce health care costs. If there are to be discussions of rationing and denial of care (which we oppose but Obama & Co. apparently support), it is only reasonable to put self-inflicted illnesses like AIDS with six-figure costs on the table for discussion.
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Addendum (August 19 2009): we received a critical E-mail from an Israeli who thinks our purported suggestion to withhold treatment from AIDS patients reflects badly on IsraPundit and Zionism. If we need a Zionist perspective (although a stand-alone category for this blog is “Obama”), our position is that “Never Again” has to apply all the time and not just when it is convenient. Barack Obama and his health care advisors have used language that is not substantially different from that Germany used to justify the Aktion T4 euthanasia program, which in turn served as the precedent for the Holocaust.

We thought we had made it clear that we were talking about the kind of rationing and triage that prevails in a disaster situation, in which there are genuinely not enough resources to treat everybody. Actions that might normally constitute negligence or even criminal misconduct, such as withholding all but palliative care from mortally injured people and giving very low priority to people with serious but not life-threatening injuries become reasonable and necessary in disaster and battlefield situations. Our position, for the record, is that the United States has more than enough health care resources to care for everybody, and that it is unconscionable to discuss rationing when 30 percent or more of the resources are currently wasted through inefficiencies and preventable medical mistakes such as hospital-acquired infections. Barack Obama’s health care agenda does little or nothing to address this waste and inefficiency.

The position of Barack Obama and Ezekiel Emanuel is apparently, however, that we are in a “lifeboat situation” in which there is not enough space in the lifeboats and “tough decisions” need to be made about who gets rescued. Ezekiel Emanuel is on record as saying that very young and very old people should get reduced chances, and Obama has stressed the cost of end-of-life care and the cost of caring for chronic illnesses. If we take THEIR position, with which we disagree emphatically, we must indeed cross lines that decent people normally do not like to cross. Suppose you are a legitimate passenger on an ocean liner that hits an iceberg and starts to sink. Dozens of stowaways (illegal aliens) suddenly appear and demand places in the lifeboats.

If there are more than enough lifeboats, which is our position, it would be murder or manslaughter not to rescue the stowaways The United States can, in our opinion, afford to provide at least emergency care to illegal aliens, although we think they should be transferred to Mexican hospitals once their condition is sufficiently stable. No decent person would allow stowaways to drown if there were enough lifeboats to save them, although the stowaways might then have to face legal consequences ashore. On the other hand, if there are not enough lifeboats (Obama’s and Ezekiel Emanuel’s position), it is impossible to envision giving stowaways places in the lifeboats while legitimate passengers have to make do with scraps of wood or whatever else might float. If we are really going to talk about rationing and “tough decisions,” then illegal immigrants should get that pain pill that Obama discussed long before American senior citizens forgo treatment. The same applies to people with obviously self-inflicted illnesses. That is emphatically not a place where we wish to go but, if Obama insists on taking us in that direction, yes, we need to discuss it.