Peter A. Ubel's "Pricing Life"

Peter A. Ubel, Pricing Life: Why It's Time for Health Care Rationing. Cambridge: MIT Press, 2000. Pp. 208, $25.

This book can be summarized in three theses: (1) rationing of health care is ubiquitous and morally necessary; (2) the "most useful rationing tool (at the bedside and at policy levels ) is cost-effectiveness analysis (CEA)" (p. xix); and (3) the physician at the bedside must be part of that rationing process. On the first claim, Ubel is powerful and persuasive. On the second, he offers much helpful insight. On the third, I found him utterly unconvincing. Two out of three is not bad.

On the Moral Necessity of Rationing

On the claim that rationing is ubiquitous and morally necessary, this is quite simply the best thing ever written. It is not that Ubel offers startlingly new analysis. At least for one who is familiar with his provocative and original journal articles, some of which are incorporated into this volume, parts of this story will be familiar--but, especially for the clinician or layperson not already persuaded of the compelling case in favor of rationing--he sets out that case in dramatic, easy-to-grasp, powerful prose. Ubel shows how the old Hippocratic moral dictum that the physician should always to do what is best for the patient leads to impossible and immoral requirements.

As a onetime bedside physician, he recalls having to treat a colleague's patient who was hospitalized for a reaction to a standard contrast dye. The colleague had previously challenged Ubel's thesis that physicians should ration potentially beneficial health care on grounds of cost. But when Ubel pointed out to him that a much more expensive, newer contrast medium was available, the physician claimed (correctly) that, for a patient without a previous history of a reaction, the standard treatment was the morally correct choice, because the newer alternative would squander resources that could do much more good elsewhere. Ubel shows that the extra benefit is not worth the cost and that every physician--even those who rail against rationing--will, if put in a position to choose, forgo the small marginal benefit in order to reduce costs.

In the first four chapters Ubel clarifies the definition of rationing, reveals how many physicians routinely make rationing decisions while denying that they are doing so, demonstrates the necessity for rationing (including, he claims, at the bedside), and reveals the difficulties of measuring community values upon which rationing decisions ought to be based.

Cost-Effectiveness as the Basis for Rationing

Ubel shows that cost-effectiveness analysis (CEA) can be very useful in comparing the relative benefits per unit cost for widely disparate interventions, which would otherwise be very hard to compare. For example, he notes that studies have shown that using intravenous immune globulin to prevent infections in leukemia patients costs over $7 million per year of life saved, while screening for stomach cancers with fiber-optic scopes costs $420,000 per year of life saved. A health plan that is trying to choose which treatments to cover should find these numbers relevant, especially if it does not have millions of extra dollars that its subscribers would like to invest in very marginal benefits.

That cost-effectiveness analysis is a useful and morally relevant tool in health planning seems indisputable. That it is, as Ubel puts it, the "most useful rationing tool (at the bedside and at policy levels)," seems, however, to be morally controversial--indeed, morally wrong.

Ubel himself sets the stage for someone to critique his view. In Chapter 5, on "How Do People Want to Ration Health Care? Balancing Cost-Effectiveness and Fairness," Ubel summarizes his own and other empirical studies that show that the public prefers giving preferences to severely ill patients, even when their care is less cost effective. In the words of philosophers, justice in the pattern of the distribution of health care benefits is a morally right...