The full debate transcript, video, and a record of the outcome can be found at www. Following is an abridged version of Dr. Kellermann's opening statement. I stand before you tonight not as a RAND analyst, but as an emergency room physician who for more than 25 years cared for sick, injured and dying patients in some of our nation's busiest ERs.
The goal of emergency medicine is to save lives. But the nature of our work also requires us, more often than you'd think, to sit down with a patient or their family and discuss whether initiating extraordinary measures is the right thing to do.
This often happens when a critically ill patient is rushed to the ER in the last stages of a terminal disease. It's remarkable how often primary care doctors never get around to talking with their patients about an advance care plan before that fateful day arrives.
So my colleagues and I end up having the conversation in an ER conference room or the patient's bedside at 2 o'clock in the morning. Sinai School of Medicine in New York. He is Board Certified in Dermatology and Dermatopathology. Disclosure: Dr. Goldenberg has no conflict of interest with any material in this column.
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We want to save the most number of lives that we can. And the way to do that is to be explicit and vote yes for this motion. We should be rationing health care. John Donvan Thank you, Pete Singer. It's Ken Connor. Ken is chairman and founder of the Center for a Just Society. He is a successful trial lawyer. Ladies and gentlemen, Ken Connor.
Ken Connor: Good evening, ladies and gentlemen. Sally Pipes' mother's situation is exhibit "A" for why Americans don't want the government to wind up rationing health care in this country. By contrast, my mom suffered from advanced colon cancer late in life at an older age than Sally's mom. She received aggressive treatment, both surgery and chemotherapy, made a full recovery, and went on to live more than a decade of a good and healthy life, until she finally died at 90 at home in good health in her own bed.
Which system would you prefer? Ladies and gentlemen, I'd like to make three points, if I may, about why government should not be in the business of rationing health care. First of all, health care decisions should be made at the end of life, just as at any other point in life, at the bedside, by the people involved and who are affected, not by bureaucrats at a remote location. Secondly, that rationing is unethical, because it ultimately devalues human life and inevitably winds up punishing the sick and the dying.
Thirdly rationing is the lazy man's way -- lazy man's attempt to balance the budget. It's easier to balance the budget on the backs of the sick and dying than it is to reform your ways of wasteful spending in government and try to wrench money back from the hands of the special interests at home and abroad. So back to the premises, first of all, that healthcare decisions should be made at the bedside.
Americans don't want bureaucratic bean counters in Washington making decisions about what kind of care they're going to wind up receiving at the end of life. Decisions about healthcare and how it ought to be administered and when it ought to be administered ought to be decisions that are made by the patient informed by their doctors and by their families. Decisions about what kind of care will be administered at any given time to any given patient should take into account the needs of the patient.
In other words, healthcare should be both individualized and particularized to the needs of the given patient. A bureaucrat remote from the bedside, hundreds, perhaps thousands of miles away practicing assembly line medicine simply is not in a position to make those kinds of individualized decisions that are required. These are decisions that have to be based real time, sometimes at or a. Kellermann has pointed out. And it's the people who have their feet on their floor -- on the floor in the hospital and their hands on the patient who ought to be making these decisions.
There's simply no way that a government functionary practicing assembly line medicine in Washington can make those kinds of decisions. Healthcare requires the fine edge of a scalpel, not the blunt end of an ax. And patients don't want their doctors straight- jacketed by some bureaucratic straightjacket fashioned in the federal city. They want decisions made by doctors who are taking their interests into account.
They don't some interest that was decided in a smoke-filled room in Washington, in a room that was predominated by lobbyists to be the ones who are making the decisions. And, folks, do we really want the men who are wearing the green eye shades in Washington to be making these kinds of decisions? Should cost be the primary driver of such decision, especially in the zero sum environment that prevails in Washington? I would submit to you, ladies and gentlemen, that when the tradeoffs are made, we don't want decisions about healthcare to go by the board in preference to a new start in green energy or some other pie in the sky kind of effort.
Now, no one is suggesting for a moment that we should not be good stewards of scarce healthcare resources. We absolutely should be. But rationing is not what we need. It's rational care. We ought to be asking ourselves, is the procedure under consideration necessary for the patient?
Is it clinically appropriate? Is the cost reasonable compared to similar services? These are questions that ought to be answered by people with their feet on the ground in the hospital in real time by hospitalization -- hospital utilization committees and not by people who are removed from the bedside.
Now, folks, make no mistake about it, government rationing represents the first step down the road to the utilitarian philosophy of former Colorado governor Richard Lamb who said, "The elderly have a duty to die and get out of the way.
They reject the sanctity of life ethics that has long prevailed in this country, and that maintains that every human life is precious and out to be respected and protected under the law. That view affirms equal protection for all, the old, and the handicapped to the very young and to the very old. Instead the quality of life advocates maintain that we should use quality of life calculus and functional capacity studies in deciding who lives and who dies.
Of course, the elderly and the handicapped who suffer from dementia and disability don't score well using those formulas. And isn't that the point? Ladies and gentlemen, what criteria will the all-wise bureaucrats use to pick winners and losers at the end of life?
Will they be any more successful than they were in picking Solindra and Bright Source and Abound Solar on whom the government squandered billions of dollars? But then again, what does it matter? At the end of life, we're all going to die, right? Folks, I would suggest to you that there are many places that we can look to find the savings that we need to provide appropriate care for the sick and for the dying. Surely, we can spend the money required to render appropriate healthcare to the sick and the dying.
Ladies and gentlemen, I urge you to vote against the proposition because by the time you reach the end of your life, you'll be glad you did. That concludes round one of this Intelligence Squared U. Arthur Kellermann and Peter Singer are arguing for the motion: "Ration end-of-life care. They say that you need to figure out how much saving a life produces in terms of results.
You have to compare that to how the resources could be used elsewhere. The team arguing against the motion, Sally Pipes and Ken Connor, argue that rationing end- of-life care is the wrong way to balance the budget. They say that it would be falling to government bureaucrats to make intensely personal decisions, that cost should not be the driver of a decision regarding the end of life, and that they depict a future where basically the elderly will be thrown overboard.
Now, I notice that the two sides do agree that cost cutting needs to happen, that costs are out of control. They do agree that ideally these decisions will be made at the bedside by doctors and their families. The question is, who ends up controlling where the money comes from. And I want to put to the side arguing in support of rationing end-of-life care, particularly to Peter Singer, this basic question: Is there a way actually to arrive at a dollar value for what a few more months of life would be worth to an elderly person versus what it would be worth to a younger person?
And does that explain whether -- does that price carry over to whether a procedure is worth pursuing or not? Can you put a dollar number on these things? Peter Singer: It's very difficult to agree on dollar numbers.
I mean, healthcare economists try to do it because really what they're doing is they're comparing what you get for your money if you spend it on one thing, let's say saving young people's lives and what you get for your dollar if you spend it on something else, perhaps let's say for cancer where it can only extend life by two or three months at significant expense.
And I think what they can clearly say is we get better value in some cases rather than others. We extend lives for longer for the same amount, or we extend lives for an equal amount for less money. John Donvan You said in your opening remarks that younger lives are less expensive generally speaking to save than older lives with the outcome of a longer life lived because the person's younger rather than older.
Am I reading you correctly? Peter Singer: Well, I think most of us would agree that it's a greater tragedy if a year-old dies because they're in an accident and didn't have health insurance than if an year-old dies. I think, you know, we would feel that people have lived most of their life, achieved most of what they're going to achieve when they die in their 80s, let's say. It's still sad, of course.
I know it's sad. But it's a greater tragedy. It's worth spending more to prevent if we can save the life of somebody who still has most of their life in front of them and still has a lot of things that they can achieve.
Sally Pipes I'd like your response to that in light of your saying in your opening remarks that each of us has the right to live as long as we can. Does age come into it? Do the young -- do the younger have more of a right to live as long as they can than the older? Sally Pipes: No. I believe we all have the right to live as long as we can. Only when someone has died can we actually measure the cost of what the cost of keeping that person alive is. But I think that people should be able to get the best healthcare they can and not have their care rationed by government bureaucrats.
But you know, we all want to live longer lives, have affordable, accessible quality care. How do we do that? Well, we have to make some changes to our health care system. I believe in empowering doctorsand patients, making changes to Medicare and Medicaid, changing the tax treatment because for people who have -- John Donvan Sally, can I interrupt?
But you made that point in your opening statement. And I want to kind of keep on this question that the other side has raised about -- and you were beginning on it -- on this question of older versus younger, that they're -- what they're constructing is the notion that if you save the life of a person who then lives for 50 years, that, therefore, there's more value in that than saving the life of a person who lives for two years.
You get 25 more years of life out of it. And it's a mathematical calculation. And I want to know how that sits with you, that -- to take math and dollars - - and dollar figures to apply to these very sensitive issues. Sally Pipes: Well, I would say I don't think we should be using mathematics to determine this. We should give people the best opportunity to get the best care that they can, regardless of their age.
I mean, if you take an issue like infant mortality, people assume and probably will say, "Well, infant mortality is much higher in the U. You know, Americans have -- we have the best neonatal care. When the children live -- survive a lot more in this country because they have this good neonatal care, in countries in Europe, they determine that as a fetus or a newborn, if under a certain weight and a certain length, they're not counted as a live birth.
So I think we don't want to put dollars and cents on this. We want to give everyone the best possible care. And how we get there is -- well, we can talk about it a little bit later.
And Ken Connor, your partner. Ken Connor: John, I'd like to weigh in against that kind of a calculating. In America, we hold to the proposition that all men are created equal. Equal protection under the law is the hallmark of American justice. And I would suggest to you that any point of view that says that a person's dignity diminishes with age or that somehow their personhood erodes as they get older is a point of view really that is a bankrupt point of view.
And inevitably that point of view will endanger everyone who reaches old age or anyone who should suffer from the slings and arrows of misfortune and wind up suffering a serious illness or injury. Peter Singer: But we haven't said their dignity is less or that their personhood is less. What we said is that they have less years to live. And that's a different question.
Ken Connor: Well, let me ask you this point, if I may, you've been an apologist in your book -- in your books for infanticide, making the point that disabled infants who lack rationality or the capacity to grasp that they existed over time or that they lack some form of self consciousness were somehow not persons and could be disposed of, indeed you've gone so far as to make that argument about all newborn infants, maintaining that within a period of, say, 28 days after birth, parents should be able to decide to get rid of them or not.
Peter Singer: Point of order. This is not the topic we're debating tonight, but I'm happy to debate it some other time. Ken Connor: And here's the point I would make, old people who suffer from dementia often lack self awareness.
They often lack the capacity for rationality. They often lack the capacity to grasp the notion that they exist over time. Would you declare them non-persons and say that they are not worthy of protection and preservation, as you have in the case of -- John Donvan Okay, Art Kellermann, because I'm not hearing them make the argument in thatextreme way, but I want to -- Arthur Kellermann: I just got to get a couple of things sorted out here.
I'm easily confused. I did not -- I just want to make sure I'm at the right debate, because I'm not here to debate Solyndra, Wall Street, ObamaCare, or the presidential election. So second question is are we here to debate an elderly person's right to super expensive care paid for by the government versus simply very expensive care that we all agree is probably a reasonable deal, or are we here to debate whether or not poor people and other folks can get decent care versus no care, because I personally believe in the sanctity of life, but I think the sanctity of life extends beyond birth and goes all the way up and doesn't sort of kick in again the last few weeks before death.
It extends throughout life for the uninsured, the poor, and working class folks, too. And they should be part of this discussion.
Ken Connor: Exactly my point. And the point is, we're going to use some kind of criteria to decide who lives and who dies. And for instance, if the eminent Dr. Singer were to become the rationer in chief in the next administration, what criteria would he use? Would we look at the elderly, the demented, the disabled and say that their quality of life years don't merit preserving their lives? Would we say that, as in the case of the infants that he's identified, that they are not persons whose lives are worthy of protection and preservation?
Ideas have consequences. What we believe determines how we behave, and this logic applies at the end of life no less so than at the beginning. John Donvan Let's take one specific part of your question that relates most closely to this motion, to Peter. And, you know, if you were the rationer in chief --Peter Singer: That's not a very likely scenario.
John Donvan No, it's unlikely to happen for anyone. But do you have a system? Or do you have the outlines of a system? Do you have a philosophy about how this should be approached? Peter Singer: I would try to look at the number of years that we can expect to extend people's lives for a given number of dollars. I would also try to look at the quality of life as well.
Now, that certainly may be affected by dementia, but, in addition, especially with older people, I would hope that they would be encouraged to state their own wishes as to what should happen to them if they become demented, or if other things happen to them.
John Donvan But, Peter, assuming that you're correct, that you're not going to get the job, what body do you see making the decisions? Sally referred to it by its acronym, NICE.
Not everybody thinks it's nice. But what they do is, they try to cost the various treatments that are out there, and they try to get expert data on how long those treatments extend life in a variety of different conditions, and they make recommendations.
They're not binding, but they make recommendations to the local area health authorities throughout the United Kingdom to suggest that this treatment does give value for the money; you should be providing it.
But perhaps this treatment for this specific condition is above the bar that we think reasonable, and you may consider not providing that. And the health authorities then reach those decisions. John Donvan And how often -- if you happen to know -- how often is there a recommendation not to use a particular intervention or treatment? Is it uncommon, or is it pretty common?
Peter Singer: It's relatively common that there are some treatments for some specific conditions that are considered too expensive to provide. And I think that that's going to be inevitable,because medical technology really has no limits to how much it can cost, and the drug companies can charge more.
In fact, drugs are much cheaper in the United Kingdom because the manufacturers know that if they price them very high, they're not going to be recommended by NICE, whereas here they can basically charge whatever they like, and they're still going to get users.
John Donvan Let's hear from your opponent Sally Pipes. People are complaining all the time, even ex-employees at the National Health Service will say, "It's wrong that we cannot get the care we need because it may be medically effective but it's not cost-effective. They don't develop these drugs and medical devices. The United States is the entrepreneurial capital for developing drugs and pharmaceuticals.
John Donvan Sally, one question for you when you were describing what the British are doing, saying no to certain procedures that are not considered cost-effective or not effective enough to justify the cost. Don't insurance companies do that all the time? Would you prefer the government to making decisions about what drugs and treatments you can't, or would you prefer the private sector and insurance companies to make those decisions?
I, personally, want insurance companies --[laughter] I prefer insurance companies. John Donvan Well, you know -- let's -- let's show some respect to this -- can you -- why would you prefer the private sector to do it, to the government? Sally Pipes: Because the private sector provides all things that we -- we can make decisions about what kind of cell phones we want, what kind of bank accounts we want.
The private sector is always good. But the problem in this country is that 50 percent of our healthcare today is already in the hands of government through Medicare, Medicaid, CHIP and the VA system. We don't have a private market. We need to move to a three- year market, get insurance away from employers. And if they don't like the plan or whatever, you're stuck with that. But if you lose your job, you lose your insurance, you go into the private market, you have to buy your insurance with after-tax dollars.
I want to see the tax code changed so that we can move to a more individualized basis on health insurance just like our car insurance, our life insurance, our long-term care insurance. This is the way America works. It's what makes America great. And we don't want to move to a Canadian style single-payer system which I think the president, Nancy Pelosi and Harry Reid, that is their ultimate goal.
John Donvan Let me ask your partner, Ken Connor this point. We do have smaller versions of single payer systems. We have Medicare, we have the Veterans Administration. They have to make decisions. They have to cut costs. Do they need to -- do they need to have a system of rationing in the system that exists now as opposed to -- as opposed to what you're proposing a solution which just is not the world that we're in today?
Ken Connor: Well, I think it's important to understand, as a practical matter, the truth of the notion that he who pays the piper gets to call the tune.
And so it's a practical matter. Whoever's making those payments, in large measure, is going to call the shots. What we advocate, though, in contrast to a central bureaucratized, central planning, decision making process is that we have consumer-driven decision making, informed by medical advice, mediated by markets. We believe that that system is a better system than the government system. We believe that that system is a better system and that those -- that's a better way to make decisions than relegating it to the people who brought us the bridge to nowhere, Solyndra, the Wall Street bailout.
Now, look -- look, folks, plain and simple. There's an economic concept that our physician friend may not be aware of. It's called opportunity cost. And -- and your proposition assumes the fallacy of only two alternatives: Either we recoup the money from the sick and dying, or we don't.
But my point is there are other ways to recoup the money from other areas where we are wasting money. And it's much easier to balance budgets on the back of the sick and dying than to wrench it out of the hands of the special interests in Washington.
John Donvan Arthur Kellermann. Arthur Kellermann: I'm real glad I got a chance to talk. As a doctor, I've got to tell you, I've heard that story before. The story earlier about your mother not getting the colonoscopy she needed. And I feel badly about what happened. But I have to tell you, I don't think a government bureaucrat was the one who made the mistake.
I think you got a bad doc. And the fact of the matter is -- I know this may come as a shock, sometimes Canadians screw up. If they didn't, we'd never win the Stanley Cup. Connor -- Sally Pipes: And Canadians are really nice people. Arthur Kellermann: Yeah. Sally Pipes: And they are very patient, not like patients in need. Connor -- I'm with you, brother, on the market incentive. So let me suggest a market-based solution to what we're talking about. I think there's a big difference between deciding what we as a society can afford to commit folks to get, whether it's in ICU at the end of the life or whether it's at 25 years old when you're trying to get your first job and starting a family.
And let's commit to that level of financial protection and coverage that we all kind of want to buy into. If beyond that, whatever that is, whatever we as a country decide we are prepared to shoulder, you can buy it.
Sally, you could buy it. It's okay with me. But I've got a problem with you using our inheritance to buy your Avastin if we don't have the evidence that it makes a difference.
That's the deal today that 50 million uninsured Americans get, except they don't even get a basic level of coverage. It's all out of pocket, or it's on the charity and mercy of individual doctors and hospitals.
That's a pretty lousy deal. Sally Pipes: Well, when you analyze the Anyone in this country under [unintelligible] the federal law can turn up an emergency room --Arthur Kellermann: I know we take care of them.
Sally Pipes: So but let's look at that We're going to be adding 11 to 12 million more to Medicaid under the Affordable Care Act. Why have these people not signed up for Medicaid? Well, I believe doctors are reimbursed 35 to 42 percent below what they get from treating private patients. So Medicaid patients find it very difficult to get a doctor.
This is only going to get worse. The other point is that there are about 20 million of these people are people that are young people, like a lot of you in this audience. You're between 18 and You're the young invincible.
So you don't. You'll pay out of pocket when you need it. There are only about 9 million Americans who are chronically ill without health insurance for a period of two years or more. Those are the people that I want to take care of and that we should be taking care of. But you know, in the UK, in the country, if you decide that you want to buy Avastin because the actuaries have said your quality adjusted value of life is not worth the 80 to 90, a year for Avastin, you can pay out of pocket.
But you are then out of the national health service. The government says you cannot get any more treatment from the government. And I feel that is not fair. Peter Singer: Yeah, but we don't support that system. I mean, that's not -- Sally Pipes: I know. John Donvan Let me bring in Peter. Let me bring in Peter Singer. Peter Singer: Well, let me just say, I mean, I've spent most of my life in Australia as you can probably tell from the funny way I speak.
And we have universal health coverage, but we also have private insurance. It's not like Canada. You're not out of the Medicare, as we call it.
You're not out of that scheme by taking out private insurance. It just gives you, if you want to do that, extra coverage for various things that you can do. So it's an option and-- John Donvan All right. I don't feel I'm doing a very good job as moderator tonight.
Because I want to shape this back to what we're talking about as a tradeoff of what you get for what you pay, and are you willing to pay it, and is it wrong to deny that payment? Help Login. Search by keyword.
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