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Wednesday, July 29, 2009

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.


Anonymous said...

Dear Dr. Gaulte,
I visit your blog daily -- it has been my touchstone of sanity. Thank you. I hope to have the honor to meet you someday.

Hal Dall, MD said...

I'm stunned but not really surprised. Stunned they had the balls to publish this openly.

I had not seen this. Thanks for the illumination.

And of course, the politicians, "thinkers", medicrats (and other paper-shufflers in gov't), etc. will have high "instrumental value".

Are you sure the author's name is not Dr. Strangelove?

Stalwart Hospitalist said...

Let's see if Robert Byrd would vote for a program based on such principles.

james gaulte said...

Thanks for your kind comments.Your blog keeps me supplied with things to think and write and worry about.

MedicalSoundProofingSolutions said...

Is any of this reality-based? I'm seeing a lot of speculation here. I'm scared now. Glad you're out to pasture already.

Anonymous said...

Dr. Gaulte:

As a new senior citizen, it is scary that more people are not aware of this article, and Dr. Emmanual's lean towards Complete Lives System. According to the 2004 census, there are 36.3 million seniors. With the Complete Lives System, younger people are cared for first, because Seniors have already lived their lives. It is evident in the Obama Health Care Plan, and it is interesting that missing in the plan is any detail of what is covered and what is not covered. As an appendix, a list of covered and not covered medical treatments and services should be in the bill.

eagleclanlady said...

Of course Robert Byrd would be one of the high "instrumental value" people along with all the rest of the elite in Washington. Unlike us expendable people. Susan

Anonymous said...

Dr. Gaulte, thanks for writing about our "progressive" eugenic overlords. I have been studying them for years and can not believe our medical profession peritted them to rise to the top of leadership.

I can't believe we are in America anymore. I feel like a foreigner living in a oppressively dangerous society ruled by an oligarchy that borders on a Nazi nightmare. Why has this happened to us?

Bill Baar said...

Thanks much...very important comments. Thanks for posting.

Van W. Cottom said...

What if the cutoff was 65 years old? After which you are just left to die, hopefully comfortably.

A man whom has passed on since came into my life at the age of 65. We became friends even though he was many years my senior. For him, at age 65, he lost his business when the US Government built an Interstate that bypassed his town, already a widower most would have just gave up. He didn't!
At age 65 he started another business, which has since become Kentucky Fried Chicken. His name, Harlan Sanders.

I would support the age based system if it used the same parameters as the Holy Bible. You will find that God specified the age. See: Genesis chapter 6 verse 3.

loriann12 said...

As we're nearing re-election, with the long ago passed health care bill, this subject is being rediscovered. I have to wonder something: If they allocate care based on one's usefullness to society, where does that leave those on Medicaid, foodstamps, SSI and other forms of government assistance who sit at home and wait for that government check?