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Singer's Deadly Tune: The Right (and Wrong) Way To Ration Health Care | Raymond Dennehy
Peter Singer's recent op-ed piece in The New York Times, "Why We Must Ration Health Care," (August
2, 2009) 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.
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
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."
(This article was originally published as "The right (and
wrong) way to ration health care" in the August 8, 2009, edition of Our
Sunday Visitor newspaper.)
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Dennehy is Professor
of Philosophy at the University of San Francisco.
After serving from 1954-58 as a radarman in the U.S. Navy aboard the heavy
cruiser, USS Rochester in the Pacific Theater of Operations, he attended
the University of San Fransisco, obtaining a B.A. in philosophy. He studied
philosophy in the graduate school of the University of California, Berkeley,
finally getting his Ph.D. in philosophy from the University of Toronto.
He is the author of Anti-Abortionist
at Large: How to Argue Intelligently about Abortion and Live to Tell About It and, most recently, a novel,
Soldier Boy: The War Between
Michael & Lucifer (2007). His previous books are Reason and Dignity
and an anthology he edited, Christian Married Love. He is frequently
invited on radio and television programs, as well as university campuses,
to speak and debate on topics such as abortion, physician-assisted suicide,
He is married to Maryann Dennehy, has four children and eleven grandchildren.
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