Tayler Lamagna

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Health Care Allocation

Health care in the United States is in dire need of allocation. Although a difficult
topic to agree on, both Gail Povar (GP) and Salmaan Keshavjee (SK) have their own
ideas on how to go about allocating. In GPs article, Ethics in Practice: Managed Care
and the Changing HealthCare Environment, he accepts that health care and the current
system is not going to change and instead comes up with ways in which health care can
focus on patient centered care. In the article, In Medicine and money: the ethical
transformation of medical practice, SK writes about his experience in health care and
how health care has become a business rather than caring for patients.
The problem that often leads to tension is making micro-allocation decisions. It is
tough, and nearly impossible, to establish a just gradient and rate who needs health care
more. Macro-allocation is somewhat easier for us to accept as a society, I believe,
because it doesnt point fingers at any one person like micro-allocation does. It doesnt
require someone to decide which specific person deserves health care more. With the
libertarian view, health care is available and distributed based on what someone can
afford. Its more of a natural lottery, which is good for the people who are born into a
family with money and bad for people who are born unlucky and require more health
care than usual (Veatch). This view points out that no one deserves health care and health
care should be earned. With the utilitarian view, health care benefits the most it can,
basically the best bang for your buck. The tough things is comparing health care options
and deciding which one is better. With the utilitarian view, this is not possible. The
egalitarian view believes that health care should be distributed evenly with the intentions

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of being fair. But with this view it is impossible to determine which patients deserve
health care more (Veatch).
In SKs article, he angrily rants about his personal experience working in health
care and observing the problem with health cost reductions. When he was a medical
student, he witnessed a man with end stage liver cancer. After suggesting an albumin
transfusion for the patient, a senior resident shot him down saying it was too expensive
and the patient was going to die soon anyways. It is a scary thought that doctors are more
concerned about the cost of treatment rather than if it will actually help the patient. SK
believes this may lead to the creation of a generation of doctors more concerned with
reducing costs than providing the best care to the patient (Keshavjee, 272). So instead of
focusing on the patient, doctors are more concerned about keeping costs down. Health
care is treated more like a business and the concern is focused primarily on money, which
isnt right. This disrespects the patients autonomy because he doesnt have the option to
choose which treatment he would want in this situation. Instead, he has doctors making
that decision for him without him even knowing. Interestingly, despite the increased perpatient cost at for-profit hospitals, death rates are 6% lower at not-for-profit hospitals
(Keshavjee, 272). The big issue to me is the misuse of beneficence. If doctors are using
cost reduction in treatment, patients are not going to get treated fully. This will result in
more doctor visits, which ultimately would lead to more expense in the end. Although
SKs solution to this problem is not clear, he points out that patients put their trust in
doctors to make the right decision related to their health treatment. He said the focus
should be on patient centered care and medical school should be implementing this early
into future doctors minds.

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In GPs article, he proposes a list of solutions if problems do arise in the existing

health care today. He accepts that health care will stay the same and instead of finding a
solution, he offers help to the patient, clinician, and anyone else involved in the health
care setting deal with ethical dilemmas. I personally like GPs idea because its important
to consider how to deal with the current health care system if things do not change
anytime soon. I like the thought of the clinicians allowing patients to trust that they will
choose the best treatment for them (Povar, 131). As in SKs article, patients need to feel
like they can trust their clinician and that they wont just go for the most cost-effective
treatment. Its also very important for doctors to be truthful in their documentation
(Povar, 132). They shouldnt be allowed to list a false diagnosis in order to get a greater
reimbursement. I believe the guideline about health plans being required to explain the
reasoning their coverage would help with micro-allocation decisions. They should not
be required to cover cost-ineffective compared with therapies for the same condition
(Povar, 133). I believe GP was referring to comparing cost-effectiveness to cost-benefit.
But this doesnt guarantee that health providers would be measuring the right things.
Because that is a two dimensional question, there are better ways to answer these microallocation dilemmas. If GP were to look at the difference between cost-effectiveness and
cost-benefit this would be a three dimensional question and a more just way to allocate.
Both SK and GP provide great options for allocating health care. Micro-allocation
can cause tension and stir up debate when having to choose which patient deserves which
treatment. I believe the best way to bring about change to our health care today is to
integrate different ideas of all aspects. This seems like an impossible task, which is why
health care allocation hasnt gotten very far in our country. There is not one single just

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way in doing so. Integrating the libertarian, utilitarian, and egalitarian will provide
maximum benefits for all. As for the future, I do believe we will see a change. I dont
think there will ever be a perfect health care system but as long as we consider the
patients needs, health care should improve. After all, patients should have the right to
autonomy no matter what.