Tuesday, January 24, 2006

Distributive Justice

An upcoming article describes the difficulties - some might say horrors - of allocating ventilators in a flu pandemic:

Drs. Hick and O'Laughlin developed their proposal after a recent drill showing that an epidemic affecting ten percent of the Minneapolis area would lead to a "rapid and critical shortfall" in the supply of mechanical ventilators. "Despite a surge capacity of between 2,500 and 3,500 beds in the area, there were 16 ventilators available in our regional system," says Dr. Hick....

"The goal would be to promote consistency between hospitals and regions," says Dr Hick. "Across the board, resource allocation would be as equal as possible. The concept is distributive justice—doing the greatest good for the greatest number of patients."
This begs all sorts of questions. There are several possible forms of distributive justice in healthcare; one common form, for instance, argues that everyone has a right to basic healthcare, but that the wealthy can elect to purchase a better quality of care.

But in a situation where you have only 16 ventilators to treat 250 patients, a wealthy person's ability to buy access to a ventilator might cost one or more other people's lives; I think most people can agree that it wouldn't be ethical to auction off ventilators to the highest bidder. But then, how should one allocate ventilators to medical personnel, as opposed to other essential workers, or to private citizens? A strictly egalitarian model of distributive justice, in which the professional or financial status of a person isn't prejudicial, is a noble ideal, but it's not necessarily realistic even at the best of times.

And God knows, these aren't the best of times. If BushCo can be said to have any philosophy of distributive justice - the phrase implies a desire for a fair outcome, after all - it's certainly not egalitarian or utilitarian. Instead, it's based on the sociopathic self-regard endemic among American plutocrats. In BushCo's world, a rich person doesn't just have a superior capacity to get healthcare; he or she has a superior right to it, and that right trumps the more pressing medical need of someone who's less well off.

Obviously, Bush's planning decisions will affect the quality and timeliness of emergency response to a pandemic; that's reason enough for fear and trembling. As Robert Putsch and Linda Pololi note in their paper Distributive Justice in American Healthcare:
The primary source of rationing and inequities in American healthcare is the political system.
As far as rationing and inequities go, the steps taken - and not taken - before and after Hurricane Katrina provide a fairly clear picture of how "distributive justice" works under BushCo. Beyond that, I think the administration's elitist, callous philosophy is likely to intensify the dangers emergency workers and doctors face from citizens in a pandemic.

Certain forms of radical individualism are dangerous in an emergency, as are suspicion, paranoia, and pseudo-religious notions that the poor and sick get what they deserve. Unfortunately, Bush and his creatures are modeling and promoting exactly this sort of immoral, irrational, antisocial behavior to a significant chunk of the country. I don't know whether this'll aggravate a pandemic or not, of course. But it does seem to me that any serious plan for egalitarian or utilitarian distribution of healthcare ought to take into account the Bush administration's absolute contempt for egalitarianism and utilitarianism.


Cervantes said...

You have waded into some very complex issues, here, obviously. Trying to put the problem of a sudden surge in need for limited technical health care resources into the context of ongoing maldistribution of resources strikes me as tricky, and maybe it's actually easier and more productive to think about these problems separately.

Health care fails all of the tests for the hypothetical "free market" (which doesn't and cannot actually exist under any circumstances, but is particularly inapplicable to health care), and one of the most obvious reasons is that people's need for health care varies by orders of magnitude for largely stochastic reasons. People are called "victims" of disease or traumatic injury for a good reason, and there is no invisible hand providing any sort of rational or ethical distribution of disease and injury. That's one basic reason why we think there ought to be health insurance, so that everybody's risk gets shared and health care is there when we need it.

But in the case of a pandemic, it won't make any difference whether you have insurance, or a million bucks, or nothing. It will be impossible to take care of even the people who can pay. I think it will inevitably be pretty much a case of first come, first served. And then, once a ventilator opens up (due to death or recovery), which of the dozens of people lying in the hallway gets it is going to be decided by whoever the MD is in charge at that particular place and moment. How should she choose? I would say, by lottery. I don't have a better idea.

Phila said...

But in the case of a pandemic, it won't make any difference whether you have insurance, or a million bucks, or nothing. It will be impossible to take care of even the people who can pay.

I'm sure you're right. And I partially I wrote this post in order to get your expert opinion, so thanks for responding.

The specific scenario I'm thinking about is one where ERs need to have some sort of armed guard to enforce triage decisions. The issue of police powers and enforcement authority is particularly troubling given the nature of Bush's governance - and his remarks on using the military to enforce quarantines - but I think the political mood he's created in this country presents an additional danger.

So I'm not thinking so much in terms of actual inequities in ventilator access, or in disease outcome, as I am about enforcement policies based on corrupt philosophies or political expedience, and the response of a public that's perhaps not emotionally prepared to make sacrifices, cooperate, or accept its own powerlessness.

Sheer speculation. If I'm mistaken, that's great; I'd love to be.

Cervantes said...

Well Phil, you aren't paranoid. We all recall that when the prospect of pandemic flu first came to Chimpoleon's attention, he immediately started talking about calling up the national guard and declaring martial law. I'm sure they have plans to ensconce The Elect in a secure, undisclosed location to wait out the plague days. And of course, if there are a few doses of vaccine available, we can pretty much figure out who will get them.