restricted access Rationing and Reality
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Rationing and Reality

To the Editor:Daniel Callahan is correct when, in “Rationing: Theory, Politics, and Passions” (March–April 2011), he tells us that the combination of ever-rising medical costs and ever-increasing demand for expensive resources by physicians and their patients (sometimes with little to be gained in length of life, increased comfort, security, happiness, or improvements in well-being) will—in the absence of any workable, generally acceptable mode of official rationing—lead to covert rationing. Or, more precisely, it will encourage us to extend the covert rationing that already exists (and has since the world began), where those with more get more. As things stand now, this is unavoidable.

However, there are two conditions in medicine and one condition in our society that can change, and changes in them would alter the debate about rationing. The first condition is that the contemporary goals of medicine remain disease-oriented, not focused on sick persons. Success in the world of cancer—which tends to provide the script for other bad diseases—is marked by survival. Early diagnosis is good, the literature in the doctor’s office says, because it increases survival. We hope a new treatment will increase survival. We say, “I’m a cancer survivor,” and so forth.

Yet aside from soldiers in combat, most people do not awaken bent on survival. They want to live functional lives and enjoy well-being sufficient to achieve their goals and purposes. If that was the dominant goal of patients and physicians, costs would be lower, if only because the high costs of the last six months of merely (or aggressively) surviving would be gone. Could that happen? It is difficult to remember that “survival” in this sense is a socialgoal—the term has become part of the language of contemporary society. But society changes, and so do its goals.

Which brings me to the second condition: such a change in goals cannot be achieved absent a special rapport between patient and physician. The details of that new goal are personal to the patient. They must be translated into technical medicine, and this can only happen when the patient and clinician respect each other’s special standing and knowledge and work together. That rapport, called the doctor-patient relationship, cannot be restored as a general phenomenon until it is widely recognized that no one, especially sick persons, can be autonomous without others. And those others are the third condition: a sense of community whose members feel a responsibility to and obligations within their shared history, as well as at least some common social, political, and economic interests.

No conscious being believes that such a sense of shared community exists in the United States at this time. The rise of individualism in this country, which has been gaining strength at least since the 1960s, has persons casting aside connections to groups of all sorts in favor of themselves and their needs, desires, and concerns, to say nothing of their rights. It is true that we in the bioethics world have been a complicit and even a moving force in this—how could it be otherwise, when we live in the same world? Seen in this light, Daniel Callahan’s unhappy conclusions could not be different. Optimistic Hegelian that I am, however, I already see the beginning of change in the rapidly growing hospice and palliative care movement. What the outcome will be of the dialectic between the contemporary thrust and what is coming is impossible to predict. Perhaps we will recognize, at least in part, that the current individualism we prize requires a stable nation that we are unlikely to achieve without shared responsibility and reigned-in greed. ON THE WEB <h1 class="sec-headA">Bioethics Forum</h1>

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