Rationing Health Care in America: Perceptions and Principles of Justice

by Larry R. Churchill

(University of Notre Dame Press)

180 pp., $19.95

For 45 minutes last December, the body of 11-year-old Alvaro Garza Jr. lay below the ice-hard surface of the Red River dividing Fargo, N.D., and Moorhead, Minn. Firefighters pulled Garza from the freezing waters and, within 15 minutes, trauma center doctors at St. Luke's Hospitals-MeritCare in Fargo had split open his chest, hooked up a heart-lung machine to warm his blood and attached standard and jet ventilators to help him breathe. Three days later, Garza, who initially had no vital signs, asked for a hamburger.

Another life saved by medical technology. But at what cost? At what point can society no longer afford to save or even prolong the life of an individual?

Garza and his family are fortunate in some ways; they're on welfare, and Minnesota's Medicaid program is picking up tens of thousands of dollars of the hospital tab for Garza's 18-day stay at the hospital. The hospital is writing off the rest.

Too often, however, accident victims without health insurance are shuttled by ambulance among hospital emergency rooms in search of needed care.

Americans face a crisis of conscience: In times of limited health care resources, who gets what care, why -- and who decides?

Though health care spending is rocketing to new heights, almost one in six Americans lacks health insurance, many health resources such as transplantable organs are in short supply and costs of advanced medical technologies threaten to outstrip the pace of health dollar outlays.

Clearly, America is a country of "startling contrasts," observes Larry R. Churchill in "Rationing Health Care in America." Churchill is an associate professor of social and administrative medicine and of religious studies at the University of North Carolina, Chapel Hill.

"We must focus on a more elementary fact, that we are in the United States currently rationing health care and have been for some time," Churchill states. To imply rationing is not going on, he says, is false. Price is the primary determinant of who gets care, but Churchill alleges that age, race and even type of disease are also key components in rationing decisions: "The question which finally must be answered is: Are these allocations of health care just?"

In trying to answer that question, Churchill takes readers on a compelling, often provocative journey, examining the nation's ethical stance toward health care allocations in the era of the "me generation."

Unfortunately, Churchill states, most Americans' current views of "What is good?" and "What is right?" are lodged definitively in a powerful image of "the individual as the only meaningful level of moral analysis." This "ethical individualism," as Churchill calls it, cripples the nation's ability to devise methods for equitably rationing health care, he contends. Moreover, even thinking about the idea of rationing is "foreign and slightly repugnant," he says -- "foreign because we do not have a robust tradition of social ethics in America and repugnant because part of the individual ethics we live by has a very high place for both abundance and self-sufficiency."

"Individual freedoms and social bonds are not, when properly conceived, opposing but complementary forms of human well-being . . . Our identities as individuals cannot be secured outside of social ties," writes Churchill.

Though providing readers overly abundant material on which to base health rationing decisions, Churchill's lengthy philosophic discussion often blurs his book's focus on health care allocations. Churchill is at his best when he peppers his text with stories tying the discussion directly to health care. For example, when discussing the concept of "moral distance," Churchill zeroes in on "inconsistencies and contradictions in our health care system" and cites one of President Reagan's Saturday radio broadcasts. "While President Reagan made his emotional appeal for a doomed, single child (in need of a liver transplant) and invoked a variety of flashy resources, including an Air Force jet, he cut basic programs for poor mothers and children whose names and plight he did not know in any concrete way."

In tackling the question of who gets what care in this country, Churchill says people ultimately must consider whether health care is a right -- "and if so, what that means" -- and whether equitable access to needed care is a societal goal. "To the extent we must be committed to access to the health care necessary to achieve their freedom . . . For many people in this country, the choice to seek medical attention is bought at the price of sacrifice of another of life's necessities."

Churchill readily concedes that America's health care system cannot serve all needs, even all legitimate needs, of its population. It's simply too expensive. But the nation is currently mired in a "mishmash of ad hoc rationing that depends on media appeal and personal pleas for marginally effective high-tech procedures," he says. Such a random system should not continue, argues Churchill, noting that physicians, though distancing themselves for the rationing role on moral grounds, are best capable of making those choices and do so today.

While "the physician's primary obligation is still to his or her patient," Churchill writes, "this does not preclude a secondary obligation to use resources wisely and to desist from marginal and very expensive care."

In the book's appendix, Churchill challenges readers to judge the allocation decisions in three case studies. It's an enlightening self-examination of values. And given the burgeoning number of Americans contracting AIDS and the subsequent costs of treating those with the virus, his challenge is well-timed.

"Rationing will inevitably be painful when we realize we are engaged in it, and is already painful for those whose rationed share is inadequate," he says. But, he adds, the goal of health care is to meet needs. "A just health care system, whatever its final shape, requires a recognition of our sociality and mutual vulnerability to disease and death. Individual self-sufficiency, which was a virtue in the American frontier of the past, has become a vice in our late 20th-century thinking about health care. A more mature ethics will not discard self-reliance but temper it with social concerns."

Jeffrey Finn is a medical writer in Washington.