Customer Reviews

Pricing Life: Why It's Time for Health Care Rationing (Basic Bioethics)

5 star:		(0)
4 star:		(1)
3 star:		(1)
2 star:		(0)
1 star:		(0)

 

 

Modern medicine is one of the great successes of industrial civilization. This remarkable progress, however, has come at a very high price. In the USA, for example, we spend close to 15% of our GNP on health care. We are the champion health care spendthrift of developed world but other industrialized countries spend huge amounts on health care. It is not surprising that huge pressures are exerted to hold down costs; HMO management in the USA, waiting lists for complex procedures in many countries; restricted access to specialists in Great Britain. All of these cost containment involve rationing of health care services. It is a surprise, then, that this good book is one of the few to explicitly address rationing of health care. Dr. Ubel makes a series of cogent, indeed, commonsense points. Rationing is common. Rationing is inevitable in any system without infinite resources. Physicians, even those who believe that they are not rationing health care, either practice rationing at the bedside and are enmeshed in systems that make rationing decisions. Ubel decries properly the existence of this type of implicit rationing and argues instead that since rationing is inevitable, physicians should participate in explicit and rational efforts to ration care. This leads Ubel to a series of interesting recommendations. One is that physicians are in the best position to make certain kinds of rationing decisions, "bedside rationing', because they can individualize care and are best able to attempt to reconcile the needs of patients with the existence of limited resources. Ubel is an advocate of a certain type of utilitarian analysis, cost effective analysis (CEA), as a tool for deciding the value of tests and interventions. He exposes the limitations of CEA carefully and suggests ways in which it might be improved in order to become a useful tool. I think this book is primarily aimed at academic physicians with the hope of influencing physician education and approach to this kind of difficult problem. In this respect, this is a successful effort.

There are several problems with the book. As Ubel acknowledges, it is not a rigorous or systematic book, but more polemical in spirit. There is definitely a need for a major systematic work(s) on this topic. Another problem is Ubel's recommendation of CEA. He is very clear about the limitations of this method but he recommends it because he views it as flexible enough to incorporate societal preferences. Even if this were methodologically possible, I doubt this would work in the USA. In relatively homogeneous and consensus oriented countries like Sweden or Japan, this approach would have real value. It has, however, been a long time since Americans reached consensus on many, many fundamental issues related to values, and this situation is unlikely to change. Finally, Ubel does not go far enough. Given resource limitations, methods like CEA,which help make choices among tests and interventions, will not address the really tough issues regarding who should receive care and how much is appropriate. These are horribly difficult problems but must be faced squarely.

Dr. Peter Ubel has written and important and useful book. He describes very clearly how medical care in the U.S. is already being rationed--even though we might not call it 'rationing,' or even realize it. He gives clear examples of how that process is being taken place; the arguments for and against it; and a very coherent argument that medical rationing will continue, and grow, because it is economically inevitable.

This book is important because it tells the reader that rationing will take place--with or without an informed patient role. It is up to those who receive medical care to understand what's at stake to make sure they do play an active part in the decision-making process.

The book is very clearly written, but more examples, particularly in the latter part of the book, would make is more readable.