The "Complete Lives System"-why so little comment from the medical blogger world?

I missed this when it was published earlier this year in the Lancet and it was called to my attention in the blog "Junkfood Science". Here is the article in which Sandy Szwarc so correctly analyzes the Lancet in this entry of her blog which, by the way, seems to get better all the time.

The title of the Lancet article is Principles for allocation of scarce medical interventions.
I may have missed it but the medical ethics blogs that I regularly read seemed to have missed this or ignored it for some reason and the medical blogs generally have had little to say, with John Goodman (see here) and Sandy Szwarc being notable exceptions.

The basic premise seems to be that since someone or some entity must allocate scare medical resources there should be a "morally" acceptable method for such allocation. The authors, which include Dr. Ezekiel J Emanuel, brother of President Obama's Chief of Staff, and "Special Advisor for Health Policy" to the president presents a detailed proposal of how this allocation should be done. (Using the passive voice here serves the purpose or not having to say that the government will do the allocation.)

The authors begin with a critical review of the currently in existence allocation systems and finding flaws in each proceed to devise their own "hybrid" supposedly salvaging the good and casting out the less desirable elements of the various systems.

Expectedly, this "morally acceptable" allocation process would allocate less to the elderly and those with incurable illnesses. Perhaps unexpectedly, their process would place, for example, a fifteen year person allocation-wise above an infant because they say more social expenditures have been made on the adolescent and society need to get its money's worth.

The underlying theme is that individuals exist for the good of the collective ( state, society, pick one) and in health care decisions the greater good of society, now apparently denominated in "life years", trump the individual every time.

The authors describe their system:

This system incorporates five principles ... youngest-first, prognosis, save the most lives, lottery, and instrumental value. As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.”Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

They explain further in regard to the old folks issue.

Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

The blog Freerepublic.com summarizes the system in this way.

Infants get minimal treatment, because the State has not invested anything yet in their education. Old people get minimal treatment because their working lives are over.

So if you discriminate because someone is old that is ageism and invidious but if you treat differently because they have lived longer ( i.e. have had more life years) it is not. Talk about contrived nonsense.

Here is another quote that I find chilling.

the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them.” (my bolding)

If you like social justice that sentence should really please you. Not only should most things be distributed fairly but now apparently how many "life-years" you get.

If you like distributive justice you will find a lot to like here. If you are old enough for Medicare or economically unfortunate enough to rely on Medicaid, you might be a little worried that the President's Advisor on health matters thinks this way.

It should be noted ,however, that Emanuel seems to believe that a two-tier system is ethically acceptable and he wrote the following about in 1996 :

... The fundamental challenge to theories of distributive justice for health care is to develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially. Such an approach accepts a two-tiered health system-some citizens will receive only basic services while others will receive both basic and some discretionary health services. Within the discretionary tier, some citizens will receive few discretionary services, other richer citizens will receive almost all of available services, creating a multiple-tiered system.

Link for the complete article for the above excerpt is here.

So, even though justice demands a fair distribution of life years, you can opt out of that distribution system by being rich enough.

After reading Dr. Emanuel's writings that seem to give his ethical blessing to a multiple-tiered system, my inner libertarian was somewhat relieved. Yet the chilling nature of the notion that life-years should be distributed fairly frightens the hell out of me.