On Rationing

Whew, this is a big topic. What got me thinking about rationing was Ruth Bader Ginsburg’s recent Whipple procedure for pancreatic cancer. For those of you who don’t know (seeing as only like three doctors read this blog, I’m sure you do know), a Whipple is a complex, 12 hour long surgical procedure where the pancreas is removed with all of it’s surrounding structures, and then everything is reattached back together. There are only a handful of places that can do this sort of thing well, and RBG went to Memorial Sloan-Kettering. Of course, everyone is also aware of Ted Kennedy’s recent brain tumor removal at Duke. As we saw on inauguration day, things aren’t going well for Senator Kennedy, but his physicians already knew that his cancer was going to relapse because the tumor margins were positive (meaning they left some tumor in his brain to preserve as much brain tissue as possible).

Ruth Ginsburg is in a slightly different position in that her cancer is felt to be localized to the head of the pancreas and can therefore be removed with a good chance of cure. Nonetheless, pancreatic cancer has a five percent five year survival rate, and that’s with appropriate therapy including surgery and chemotherapy. What people don’t talk about is the fact that she’s 75, she’s emaciated, and she’s already battled colon cancer. Most surgeons wouldn’t touch her because her perioperative mortality is sky high. But, since she is a Supreme Court Justice and has the ability to pay for the most advanced therapies, she can do whatever she wants. The same, of course, is true for Kennedy, and he had no chance for cure.

Now, I know what you’re thinking – it’s wrong to waste precious resources on old folks who are going to die anyway. I’m not so sure. The US healthcare system, for all its faults, is the best in the world in efficiently matching patient’s demand for healthcare with doctor’s/hospitals’/pharmaceutical’s supply. There is tremendous inequity no doubt, but for those who can pay for it, care is the best in the world. I’m sure old Ruthie would argue that she should get the surgery AND the poor guy down the street should, too. There is no reason, in our affluent society, that we can’t do both.

I can feel the socialists out there welling up with anger at the notion that our healthcare system is efficient and accessible. In some ways I agree, but let’s imagine that Ruth was in Canada. She would have waited months for the CT scan that was rapidly done executive-style at the NIH. OK, so maybe the scan was excessive (she had no symptoms to suggest she had an abdominal cancer), but it would never have happened anywhere else, and with an aggressive disease like pancreatic cancer, that spells a death sentence. I’m not sure what the right answer is. Some would say, not catching early cancers is just tough luck - we should spend money on procedures that have a lasting impact on quality and quantity of life. Others would say, if I’m paying for it, why shouldn’t I have access to the very best medical technologies at my disposal? Ultimately, I think it will come to a head when our entitlement programs like Medicare and Medicaid are asked to continue providing the same level of service as private insurers. Then, the taxpayer is footing the bill for that new, great technology, and America just can’t afford it for much longer.