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Peter Singer

A NYTimes magazine article by Peter Singer advocating for the rationing of health care

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Rationing health care as both the most ethical and the most pragmatic choice

  • Jul 28, 2009
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+5
Peter Singer, a professor of bioethics at Princeton University, makes the case for rationing health care, arguing that rationing is both the most ethical and the most pragmatic choice.  He claims that rationing is the most effective way to bring the greatest good to the greatest numbers, and the only way to make the hard ethical decisions that need to be made as part of the health care debate.

Singer starts by laying out the case for rationing, demonstrating how we must make decisions, either explicitly or implicitly, over how to allocate our resources to saving lives.   He points out that we have a relatively easy time making those decisions when we aren't faced with a decision to save a specific person -- for example, in deciding whether a particular safety measure is worth the expense.  Say that you know a particular safety measure will save one person a year, and cost $40 million dollars (in this case, adding seat belts to school busses) -- generally, people have an easy time agreeing that we should implement all other safety measures that save more lives more efficiently first.  So, we might implement changes that make mattresses less likely to catch fire, saving an estimated 270 lives a year at a cost of $343 million, well before we take other more expensive actions that save fewer lives.

The difficulty we have is when we are faced with a $40 million decision to save a single life, where we have a real person in front of us, rather than an abstract statistic suggesting that we could save an unknown life through a safety measure.  But Singer argues we must make the same decision in both cases if we want to help as many people as possible -- effectively, we must be willing to let someone die rather than treat them.  Because we aren't willing to do this, we spend millions of dollars to save a single year of life, but don't allow for certain obvious treatments that would save far more people.

Since I had already bought into the idea that we must ration health care, Singer's initial arguments were interesting to me, but not compelling.  The part I found completely novel and fascinating was Singer's explanation of the best way to go about this rationing.  First, how do you decide how much to spend to save a single life?   It turns out you don't -- you instead measure treatments by how many quality-adjusted life-years they save (QALY).   If you can give someone 80 more years of perfect health through a treatment, that should be worth considerably more to you than a treatment that just extends your life by a single year, and has you in the hospital for that entire time.  QALY is a way to measure the impact of a treatment.

Singer also discusses the best way to let people opt out of this system, going into detail on how health care works in Australia as an example of how to combine personal choice with a government health system.

I found Singer's arguments well reasoned and his explanation of other systems and their benefits very informative.    That said, I would like to hear a critique of his rationale from other ethicists.  I disagree with a variety of Singer's other positions, and I feel like I might be missing some of the potential downsides of his approach.

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August 08, 2010
Singer is an "Act Utilitarian," as such he would be compelled to harvest 3 organs of a person who had alzheimers to save the lives of 3 25 year old people who could go on to live a "happy" life. Act Utilitarians are willing to play god way too often. I think we need to find a better way.
 
August 10, 2009
Health care is rationed in the US already. The criteria is who can pay for it. Why not provide universal care with decisions made on who gets what by putting the emphasis on what is effective, that is, by emphasizing evidence-based medicine. There is an awful lot of information out there about what works and what doesn't, and the expensive stuff isn't always the best. Check out Atul Gawande's excellent story in The New Yorker, "The Cost Conundrum." http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
August 11, 2009
Thanks for the link, that was a brilliant article which had a totally different perspective. I reviewed it based on your recommendation: http://www.lunch.com/data/McAllen_Texas_and_...ng_the_costs-12029.html
 
July 28, 2009
Good review. I am a physician and NY Times subscriber and I did not read the article because we already ration care and ethical/pragmatic considerations don't fly in our society. Try telling the Medicare population (I am one) that you want to ration care and shift some dollars to the pediatric population where it will do some good. Try telling physicians billing for end-of-life care (I am one) that it is money down the drain. Try telling obese, smoking, sedentary people to shape up and make better choices. Try telling tennis players (you are one) that your knee and shoulder surgery is on you. Lets not even talk about abortion, euthanasia, assisted suicide.
July 29, 2009
Wait, the tennis and knee surgery could be on me?  That would be horrible ;).  My claim is that if you are basing governmental support for surgery on QALY, I enjoy tennis so much that any possible surgery should be publicly supported, since it increases my quality of life so much :)
July 29, 2009
ok, just the knee surgery since my quality of life would improve with less general whining
 
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About the reviewer
Ari Miller ()
Ranked #107
I mostly write about my main obsession, tennis. When I'm not experimenting with new tennis racquets, I love to watch a good movie or read a great book. I'm a fan of both non-fiction (especially books … more
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