Health is not Rational

Posted by ChrisPMcCoy on Sunday, January 6, 2008 at 3:18 am

There is a significant ongoing blogger discussion about health care reform, particularly the battle between those physicians who want patients to take responsibility more of their health care (and the costs) and physicians who want universal health care system to cover everyone. Over at the Happy Hospitalist, he pounds home the message that Free=More. PandaBearMD lays out the Free Loader worries. Meanwhile, Grahamazon responds about Social Justice.

It strikes me that “patient responsibility” has a similar flaw to the “get tough on crime” line: the vast majority of people don’t make rational decisions about their health care or their criminal tendencies. We’re trying to apply rational-thought theory to a realm where people aren’t rational. It’s as crazy as trying to encourage people to make rational decisions about who they are going to marry. Even though society places value in marriage, and gives it tax and legal benefits, we leave it up to the individuals to decide with whom to get hitched. Even though it is clear to practically everyone that some people are not marriage material, we still confer the same legal benefits of marriage. And as for who makes a good parent, we’ve decided to let just about anyone reproduce (see above) and we’ll work with the consequences as best as we can.

People don’t think rationally about their health. And I don’t think we could make them. We could try to estimate the value that patients place on their own lives, and provide that level of care. Obviously, we couldn’t ask patients to put a dollar sign on their lives (“Priceless, you jerk!”), but we can make assumptions based on their actions.

Seat belt are estimated to be cost less than $100 per Quality Adjusted Life Year (QALY). Airbags cost $44,000 per QALY. Mammograms? About $175,000 per QALY.
So, if you have a patient who buys a car with airbags, but refuses mammograms, then they must value their life at somewhere between $44,000 and $175,000 per year.

But what if the patient doesn’t use a seat belt, but gets her mammogram? Or what about two similar patients who present with breast lumps, one who gets annual mammograms and one who doesn’t? Does the first value her life more, so she should get more treatment than the second for the same cancer?

Yes as a physician, I’m frustrated when I have patients who smoke, and yet are worried about the possibility of bisphenol-A in their Nalgene bottles. It isn’t rational, but people don’t make rational decisions based on cost/benefit analyses about their health care. Instead of trying to parse how much each patient values their own life, and provide a level of care corresponding to that, social justice demands that we place the same value on all lives.

And, that, I suspect, is what annoys commentators like Panda Bear — why should society place the same value on Panda’s life as that of a drug addict?

Well, it seems to me that the whole 3/5ths thing went out of style in the 1800s.

Human rights dictate that all humans are equal. Yes, some people make poor decisions because of lack of education, bad environments and, well, generally being bad people. But as a physician, I don’t take a moral inventory when I assess my patients. I treat all patients who need my skills based on their medical needs, not their social or financial “value”.

If you are concerned about patients who are draining the system with their poor decisions, then maybe you should help them to make better decisions — provide education, change their environment, discourage bad decisions. This extends beyond the exam room — funding schools, creating jobs in underprivileged areas, limiting corporations from profiteering from people’s bad decisions (excessive eating, gambling, drinking, gun-fighting), etc.

And you should support providing a basic level of health care to everyone, regardless of ability to pay.
Arguing that patients should have more responsibility for their basic health, and that health insurance should be limited only to catastrophic events seems backwards to me, especially from the conservative point of view. Conservatives should be arguing that everyone is given the same opportunity for basic health care and information (especially as children), but then they are responsible for what they do with that information. If they choose to smoke, then no catastrophic coverage for COPD. If they do drugs, no coverage for endocarditis.

Heck, no one (except infants) should be covered for AIDS since that is the ultimate disease of personal irresponsibility.

Limiting care to only those who have done the “right” things (including obtaining their own insurance) seems like a grand idea, but I dare any physician to determine which patient, without a doubt, developed pancreatitis because of alcoholism and which one has familial pancreatitis. Or what percentage of diabetes is due to obesity versus a genetic tendency.

Physicians are not God (despite what some may think). We cannot make those determinations, nor should we decide who is “worthy” of health care. We have two options: 1) deny care to the “unworthy”, but also include those who lack the education, money or skills to make good decisions. Or 2) provide care to everyone, knowing that some free loaders will be included.

I believe in an America that does not punish the innocent, even if it means letting a few of the “guilty” slip through. That is why America should have universal health care.

(Cross-posted at medipol.livejournal.com)

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Category: high quality health care for all

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