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Debate on Whether to Ration Care Looms : Health: President says ending waste will provide funds for everything. But many experts believe that limits are inevitable.


WASHINGTON — Medical ethicist Leonard Fleck likes to draw his audiences into making painful medical decisions:

Should doctors prolong the life of an 87-year-old woman left in a persistent vegetative state after a severe heart attack and with no chance of recovery at a cost of hundreds of thousands of dollars? Should they treat uninsured teen-age parents' new son, who, even with the most expensive therapy, is doomed to an almost certain death within two years because he was born with necrotic bowel syndrome?

Extreme though these cases may be, they lie at the heart of one of the most difficult issues President Clinton and other policy-makers must confront as they seek to reform the nation's health care system: With costs soaring and financial resources clearly limited, when and how should medical treatment be rationed?

The Clinton Administration has rejected the idea of rationing entirely, arguing that cleaning up the waste and profligacy of the current system will allow the country to curb health costs without sacrificing quality or eroding humane ideals.

But many outside health policy experts warn that, although Clinton's reform proposal can buy time, rationing is inevitable. With the population aging, medical science and technology expanding and the economy's slow growth imposing limits on resources, wrenching choices will soon be forced upon the nation.

They say unfair and discriminatory rationing occurs already on the basis of wealth, race, education, geography and insurance coverage limits. If the nation's health care system is to be overhauled, why not make rationing explicit and equitable?

"In the minds of most Americans, rationing is a dirty word, a threatening word," said Fleck, a health policy analyst at Michigan State University. "It's a word which suggests that human life is not priceless. So people are uncomfortable endorsing those kinds of choices. And that's why we ought to be talking about it now."

Typically, more than 90% of Fleck's audiences vote to end treatment of the elderly woman.

The case of the baby boy is tougher because "everyone hopes for a medical miracle" for children, Fleck says. A smaller majority--usually between 60% and 70%--sanctions an early death.

In real life, however, the answers do not seem so simple. In the case of the elderly woman, for example, her family defied all medical advice and fought in the courts to keep her alive. She died after 14 months and the expenditure of $800,000.

The baby boy was sustained for six months at a cost of $250,000 before he was allowed to die.

In these kinds of tragic cases, health policy experts do not claim to have all the answers. But many say it is time the public began to confront the questions.

"We have to do it now--to force people to stop and think about it," said Kristine M. Gebbie, who served as Oregon's chief health officer when that state was designing its controversial rationing plan. The Oregon system explicitly makes treatment decisions on the basis of costs and benefits.

"We have to get a wide range of people engaged in the discussion," said Gebbie, now Clinton's top adviser on AIDS. "Once we all admit that we will not have an endless pocketbook for health and illness treatment, then you have to talk about what's the smartest thing to spend this on. And I think you have to start acknowledging that some of the things we are capable of inventing and capable of doing to sick people don't always have a lot of payoffs."

Dr. Willard Gaylin, a psychiatrist and co-founder and president of the Hastings Center for bioethical research, writing in the current issue of Harper's Magazine, argues that the Clinton plan would do little to discourage the prevailing attitude among Americans that they are entitled to whatever medical science can deliver, no matter what the cost.

"Unless we address such basic, almost existential questions, we stand little chance of solving our nation's health care crisis," he wrote.

He praised the Oregon plan, which takes effect next year, for confronting "the uncomfortable truth that people cannot have equity in their health care system without setting limits."

But the President and Hillary Rodham Clinton, the prime architect of the President's proposal, maintain that such explicit rationing is not yet needed. In fact, they insist that their plan will ease the pressure to impose rationing.

"This is very important--in this system we do reallocate some resources to more heavily emphasize preventive and primary care," Clinton told journalists this week.

"The system we're in now has severe rationing of care in all kinds of ways but it's just arbitrary and unnoticed," Clinton said. "But we believe that, until we get the pricing system straightened out and have . . . basic preventive care . . . we can't (address) that question."

Mrs. Clinton said the current system forces "difficult choices every day" that are "driven by the way we finance health care" instead of "the ethical decision-making of a caring society.

"I want doctors, once again, to make decisions on what they think is best, instead of calling some 800 number to ask some insurance executive whether they can give a blood test."

Others said they fear that opening a public forum on rationing would distract from Clinton's major goals: achieving universal health coverage for all Americans and making the system more efficient.

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