By Raymond Dennehy

The right (and wrong) way to ration health care

Catholic philosophy professor rebuts claim that disability diminishes human value

Peter Singer's current op-ed piece in The New York Times, "Why We Must Ration Health Care," is timely, all the more so since the Congressional Budget Office now estimates that President Barack Obama's health care plan will cost $1.5 trillion more than the White House estimate. Singer notes that in the debate over health care reform, "rationing" has become a dirty word. His essay doesn't attempt to tidy the word up, but only to persuade readers that health care reform is the only solution to the nation's health care problems and that you can't have successful reform without rationing.

Singer's approach here is not his classic vintage. There's no advocacy, let alone mention, of procedures, such as infant euthanasia, that have made his name a national brand for academically sponsored evil. But just as the "Lite" version of a beverage can be as harmful as the "Classic" version, we would be rash to assume that "Singer Lite" is healthier for America than "Singer Classic."

Singer argues that all scarce resources are "rationed in one way or another," and health care is a scarce resource. If your health care plan is privately financed, which it usually is, we're talking about "rationing by price," since the plan we have depends on what we or our employer can afford to pay. And in the case of Medicare, Medicaid and hospital emergency rooms, "health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals."

In addition, health care premiums have doubled in the past decade and are increasing four times faster than wages. According to Medicare trustees, the program's major fund will be bankrupt in eight years. Even privately insured Americans are finding that they can't afford treatment.

All of which is designed to convince us that explicit rationing is the only way to guarantee that Medicare and Medicaid can keep on providing adequate medical care to its subscribers. Singer is right about the inevitability of rationing when medical and fiscal resources are scarce. It would be imprudent to squander scarce medical resources on patients that are bad bets for successful outcomes. It makes sense that, if bodily organs are in short supply, a 70-year-old patient in need of a liver transplant should be bypassed in favor of the 20-year-old patient.

'Deeply unethical'?

But here's where you have to ask whether "Singer Lite" is any better for our democratic values than "Singer Classic." Since rationing medical care requires pitting the needs of one patient against what is good for the majority of patients, how does Singer meet the objection that it is impossible to weigh the value of a single human life against the value of the whole human race? He responds by saying that taking such "feel-good claims" seriously is "deeply unethical."

All right-thinking folks would agree that one shouldn't do what is unethical, let alone what is "deeply unethical." But what one calls "ethical" depends on which moral theory one embraces. Singer is a utilitarian, and a core principle of the utilitarian ethic is that no act is moral or immoral in itself but only in its consequences; accordingly, the goal of action is to produce a balance of benefits over harms.

Thus in his book, "Practical Ethics," he proposes a "deeply ethical" behavior in his defense of infanticide: "When the death of a disabled infant will lead to the birth of another infant with better prospects of a happy life, the total amount of happiness will be greater if the disabled infant is killed. The loss of happy life for the first infant is outweighed by the gain of a happier life for the second. Therefore, if killing the hemophiliac infant has no adverse effect on others, it would, according to the total view, be right to kill him." Singer offers a similar remedy for infants with spina bifida and Down syndrome. How's that for slashing health costs?

Prudence dictates that the ethical theory of those who would decide who gets treatment and who does not be kept in full view while evaluating Singer's proposed basis for making those decisions: "quality-adjusted life-year, or QALY." This is a unit that allows a comparison between the benefits offered by different forms of health care. It is a tool that economists in the health care field use to compare the cost-effectiveness of different medical procedures.

Assuming, he says, that "a year with quadriplegia is valued at only half as much as a year without it, then treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value [italics added]."

Toxic proposal

Singer believes using cases like this to safeguard the claim that everyone has an equal right to life is a sword that cuts both ways: "If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. ... Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition."

The kind of contrast that Singer draws between lives with disabilities and lives without them collides with the doctrine of natural rights that forms the bedrock of our democracy. The basis of life, liberty and the pursuit of happiness is human nature, and a disabled person has not lost that nature. To borrow from the philosopher, Yves R. Simon, it is just as much an act of murder to kill a sickly man as a healthy one; it is just as much an act of murder to kill a colored man as a white man; it is just as much an act of murder to kill a poor man as a rich man; it is just as much an act of murder to kill a child in its mother's womb as a human adult.

The value of the human person and his right to life do not depend on features that make men different, but rather on the essential features of personhood that are common to all human beings.

But Singer is not only consistent with his utilitarian ethics, he is also consistent with his materialism. He has made no secret of his belief that human beings are not sacrosanct, not pre-eminent in nature. Our belief that they are has, he insists, produced more harm than good. Not surprisingly, he regards it just as immoral to torture a puppy as a human baby.

Ultimately, the proposals of "Singer Lite" for rationing health care may be as toxic as those of "Singer Classic."

Raymond Dennehy is professor of philosophy at the University of San Francisco.