Saturday, April 19, 2008

The Rationing of Healthcare in America

I recently worked a clinical shift in the emergency department that left me with serious questions about the use of our medical resources and the decisions made about the allocation of those resources. The department where I work is crowded, as are many emergency departments in America. At any moment in time, about a third of our beds are occupied by patients who have been admitted to the hospital, but are waiting for a bed to become available. Of course, the shortage of beds extends to critical care units as well.

On this particular shift, I had three critical patients present within an hour of each other. One had been beaten with a baseball bat and was vomiting blood. One had a large clot in the right lung that had occluded the bronchi, the large passage ways for air. One had a rare blood disorder that had so far required 82 transfusions, and he, too, was vomiting blood. I had one available ICU bed.

Who gets the ICU bed?

Who stays in the emergency department for their critical care?

Some might answer that the most critical patient should get the ICU bed. All three conditions are life threatening. All three will die without immediate care.

Let me add some other factors to the decision:

One of these patients is a federal inmate.

One of these patients is a hospital employee.

One of these patients has terminal lung cancer.

One of these patients has a blood alcohol level that is five times the legal limit.

Should any of these factors change the decision about who gets the ICU bed?

All of these patients are male.

All of these patients are in their mid-30s.

All of these patients have the same insurance status.

Should any of these factors change the decision about who gets the ICU bed?

As the demand for healthcare resources increases, so will the difficulty of decisions regarding allocation of those resources. Unless we as a society are willing to allow life and death decisions to depend on the value system of a single person, we must begin to think about how to best apportion what we have.


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