Health Care Rationing and Kidney Rationing

Even if you don’t find them convincing, it’s hard to avoid the arguments of Peter Singer.  This week, he published an essay in defense of health care rationing.  I am inclined to share Singer’s view that health care rationing is both a reasonable and justified (perhaps the only reasonable and justified) method of dividing up scarce health care resources, and so it was unsurprising to me that many of the things he said sounded quite sensible.   But, as I began to examine Singer’s thesis about value, it occurred to me that his argument justified much more than a modestly budgeted single-payer health care system.   If Utilitarians are right that political and economic policies are justified on the grounds that they maximize utility, a system of compulsory national organ donation is justified for exactly the same reason.   I don’t find this conclusion terribly problematic philosophically, but it makes it hard to sell the idea that Utilitarianism broadly encapsulates our moral intuitions.

In my last post, I argued that Utilitarians have a difficult time defending moral rights as they are normally understood because, for the Utilitarian, the moral act is always that which maximizes utility (happiness, pleasure, etc.) across the board.  Utilitarian justifications for breaking conventional moral rules are commonplace and often quite intuitive.  If you have ever told a white lie to spare someone’s feelings, shrugged off a mistake with the qualification that "nobody got hurt," or argued that military action that kills a few to save a million is justified, you have used a Utilitarian justification.   Most people agree that it is justifiable to sacrifice one, nameless, person who just happens to be in the wrong place at the wrong time if such a sacrifice is necessary to save the lives of a million people.  (Imagine one ignorant carrier of a highly contagious virus who is about to enter a crowded thoroughfare and begin a catastrophic epidemic.) As the number of lives saved goes down, or as the identity of the sacrificed person becomes less hypothetical, however, our intuitions about the morality of Utilitarian calculation become less clear.

The standard example used to demonstrate the counter-intuitive implications of Utilitarian ethics is the case of a doctor faced with the opportunity to save five innocent people by killing a sixth innocent person and harvesting his organs.  Most people do not think it is morally justifiable to kill a healthy  human being even if, in death, his organs could be used to save the lives of many other people who will die without a transplant.  Utilitarians have tried to defend* their view from this objectionable implication by arguing that laws that would allow a doctor to divvy up one healthy patient would not maximize happiness because they would keep people from going to the doctor. Unfortunately, these strategies, though politically appealing, do little to alter the moral directives of the theory.  While a law that prevents patient sacrifice may promote more utility than a law which allows the practice, a Utilitarian doctor would reason correctly that the loss of utility from legalizing the practice of patient sacrifice comes as a consequence of public opinion, not at the sacrifice of the patient.  The Utilitarian can make no argument that it is morally obligatory to break the law in such circumstances when utility is maximized by doing so, and so the doctor is left to the conclusion that the morally obligatory choice is to divvy up the patient and then cover up the sacrifice, leading to the maximally optimum outcome of more patients being saved and the public being happily comfortable in their ignorance.

In this week’s New York Times Magazine, Peter Singer makes the reasonable assertion that health care, as a costly and limited resource, is always rationed.  He then makes the case that rationing on the basis of cost-versus-out-come, with the end goal of providing life-saving, and life-improving medical care for the greatest number of people, is a more ethical approach than our current system which doles out the best health care to to those who can pay for hefty private insurance premiums.  According to Singer, a single-payer system of public health care is justified because it is likely to improve overall happiness as measured in QALY’s or quality-adjusted-life-years.

More people will live better lives for longer if we adopt a single-payer health-care system.  But if the only reason to adopt this system is that it maximizes this outcome (utility as measured in QALY’s), then we should also adopt a system of compulsory live-organ donation.  In the United States today, approximately 80,000 people are waiting for a kidney donation, surviving with a very low quality of life on dialysis machines and waiting for the possibility of a live donor match.  Virtually no person donates a kidney altruistically, meaning that almost everyone who will receive a live donation will do so because a loved one has agreed to donate a kidney on their behalf.  This reality is made all the more tragic because live kidney donation is a relatively low-risk procedure.  Because the kidneys function as a single unit, they usually function or fail together meaning that, for almost everyone, one kidney will do the job about as well as two.  An organ donor who lives with one kidney faces very little additional risk once he recovers from surgery because his remaining kidney will expand to do the work of the pair.

In Utilitarian terms, it is not only reasonable but morally obligatory to ration out healthy kidneys to those who need them, perhaps by a compulsory national lottery (like a military draft).  Kidneys, like health care, are a scarce resource which, if better distributed, would maximize utility as measured in QALY’s.  The distribution of functioning or failing kidneys among separate individuals is at least as morally arbitrary as the distribution of quality health care among people of varying incomes.

So, why don’t just governments require all citizens to enter a national kidney registry?  If you believe that they should, and that it is not only morally defensible but morally obligatory to redistribute a scarce resource in a manner that will save lives and cause little overall harm, then, congratulations, you are a consistent Utilitarian.  If, however, it seems wrong to compel others to have an invasive surgery and give up a bodily organ, you need to rethink Utilitarian justifications.  There are other ways to justify single-payer health-care systems, and not all of them require the proverbial pound of flesh.

*There  is some debate in contemporary ethics about modified versions of Utilitarianism can overcome these objections.  The most popular of these modified versions of Utilitarianism is "Rule Utilitarianism."