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Daniel Callahan replies:
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The hoary tradition of letters-to-the-editor is that of taking the author of an article to task for his mistakes, blindness, and wrongheadedness. These letters are different. Their shared response is: if we find rationing distasteful, what can we do about our present situation?

Let me clarify one issue at the outset. Dr. Wells seems to think that those who talk the language of justice and health care ignore the fact that, in the real world, people are unequal in many ways, and notably in their health. “Nature,” he says, “is unfair.” I simply don’t know to whom he might be referring. No health care system can promise that everyone will have good and equal health. A just health care system can only help everyone live as healthy a life as possible within the limits of their biological makeup.

But how do we go about doing that? It is probably no accident that my long-time friend and colleague Eric Cassell and I see eye-to-eye on a basic point: that medicine should focus on patients, not disease. Living a “functional life,” not survival, is the right goal. Our present unwinnable war against death, a fruit of our belief in endless progress and technological innovation, must go. (See my article, “Our Medical Quagmire,” written with Sherwin Nuland, in The New Republic, June 9, 2011.)

Yet I am uncertain whether Dr. Cassell’s solution, leaving the matter in the hands of the doctor-patient relationship, is workable. Much will depend on two critical variables. One is the kind of health care system in which that relationship will be situated. The other is whether doctors and patients—most doctors and most patients—will together embrace a medical goal that is person- not disease-centered.

John Freeman presents one possibility, explicitly focused more on maintaining patient autonomy than the doctor-patient relationship, but assuming (I suppose) that physicians are prepared to go along with patient and family choices, though helping them think through their options. Freeman’s approach sounds much like that of Representative Paul Ryan, and also bears resemblance to the Federal Employee’s Benefit Program. That might work well enough if the fixed amount matched annual insurer premium increases and if the out-of-pocket costs were tolerable. But Ryan’s plan does not do that, and Freeman does not provide enough detail to allow a judgment about how his “fixed amount” is to be calculated—the details really count here.

Cassell’s focus on the doctor-patient relationship as he understands it depends on both accepting the goal of patient-centered care, not survival. But as the successful lobbying activities of some physician groups and medical industry advocates showed in the reform debate, their aim was to use that relationship to hamper meaningful treatment outcome research and to forestall price controls. Far from supporting a community-oriented health care system, or shared responsibility for resource allocation, it accepts the present goals of medicine and the reigning individualism of the doctor-patient relationship.

The hospice and palliative care movements open the door to Cassell’s model of goals. That model might also be seen as a movement back to the ancient goal of patient care, not cure. There are signs we may be moving in that direction. There is a growing consternation about the rising costs of a health care system that, failing to find cures for the major killer diseases, has found expensive ways of keeping very sick people alive longer. The task is to persuade both the public and physicians that a change in our thinking about the goals of medicine need to be changed. Get the goals right, and reform health care accordingly.

Copyright © 2011 The Hastings Center
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Eric J. Cassell. "Rationing and Reality." Hastings Center Report 41.6 (2011): 4-4. Project MUSE. Web. 9 Jul. 2014. <http://muse.jhu.edu/>.
Cassell, E. J.(2011). Rationing and Reality. Hastings Center Report 41(6), 4. The Hastings Center. Retrieved July 9, 2014, from Project MUSE database.
Eric J. Cassell. "Rationing and Reality." Hastings Center Report 41, no. 6 (2011): 4-4. http://muse.jhu.edu/ (accessed...

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