Sunday, January 11, 2009


Legal systems have long made use of "fictions" because it facilitates expression of legal principles. Thus, for legal purposes, a corporation is treated as a person, and the government is allowed to confiscate your car if, unbeknown to you, it was part of a drug transaction, on grounds that the car committed a crime.

Our healthcare system is also burdened by the use of fictions, and in fact, the typical large hospital intensive care unit is often a theater in which doctors, nurses, patients and their families play "Let's pretend," so as not to too directly confront the unpleasant and painful. There is however, one fundamental fiction in haelthcare that should be identified and recognized as false, since it inhibits reasoned analysis of the challenges of healthcre delivery. That fiction is this: We only want what is best for the patient. The reality is that everyone wants more or less what is good enough for the patient considering other concerns.

For any given patient, there are a number of parties interested in the healthcare decisions applicable to that patient; and not "interested" in the sense of humanely concerned, but interested in the way the mafia is interested in protection rackets. The hospital is interested in providing care that is economically sustainable in the setting of limited reimbursement, staffing concerns and its role as a community resource. Insurance companies are interested in reimbursing providers for care that is cost effective, and to some degree predictable so that they can perform their actuarial functions and assess risk. Nurses are interested in providing care in a manner that allows them to effectively care for all of the patients in their charge without having thier services monopolized by any one patient. Doctors are interested in providing care according to their ethical obligations, the constraints on their time, the necessary stewrdship of resources, and the competing demands of all of the other parties. This of course has not mentioned the specter of defensive medicine. In sum, what each of the parties wants is to do what is good enough for the patient, while having their interests considered.

To better understand this dynamic, one should think in terms of efficiency, that is, each patient care decision should be thought of a ratio of the benefit to the patient per unit of something valuable that is expended. Each party measures the patient's care (or wants to anyway) according to different ratios. Let's say the numerator for such ratios is the improvements in the objective health measures of the patient. The hospital administrator considers the amount of such change per unit of unreimbursed hosptial services; the nurse may consider such benefit per unit of his or her time, and the doctor needs to consider the benefit with respect to his time, the risk of adverse consequences to the patient, and the knowledge that his decisions could bankrupt some of the players involved. Even the patient has to consider the amount of benefit against the pain, disability, burden of therapy and risk of a poor outcome. In no absolute sense can anyone identify what is "best" for the patient.

In a sense, each of the players has an argument for why their interests should be considered. The insurance company can say, "hey, when you bought your policy, in exchange for lessening the risk that a disease would financially ruin you, you agreed to our efforts to reasonably limit the costs of your care. The physician can say, "when you chose me to care for you, you did so subject to my time constraints, training, and ethical perpective," etc.

When we regard healthcare decisions in terms of efficiency as above, where each decision tries to maximize some benefit with respect to some cost, it is rather straight-forward to see that each such cost is the criteria for sime form of rationing. THis is the fundamental fact of healthcare in the United States, in Canada, Great Britain, wherever; all healthcare is rationed.

The fiction that we "do what is best for the patient" is a child's fable meant to hide the fact that healthcare delivery is a mix of moral, economic, technical, and metaphysical concerns. It creates the paradox that, in reality, healthcare in some form or other is available to everyone, but if they are expected to pay for it, then they are somehow denied access to it (thus requiring a government "system" to intervene on their behalf). This, however is the beauty of a healthcare market. Patients are free, by their choices to seek care that is efficient in terms of financial risk to themselves, if that is their desire, or efficient in terms of their moral values, or in terms of philosophy of life, or really just about anything that is important to them. And in the long run, having this choice may be what is best for the patient.

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