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This original column is provided free for one-time use with author credit at the end. It may be used for background with author credit. Copyright applies.

#190 FOR IMMEDIATE RELEASE: June 30, 2011

No end is easy
By Curtis Seltzer

BLUE GRASS, Va.—My wife, Melissa, and I have two yellow Labrador Retrievers. We adopted Sophie after her owner, a state trooper, was in a terrible wreck that left him paralyzed. Lucy, both calmer and prettier, came from a respected kennel in Charlottesville that had previously sold us Briggs, the best dog we’ve had.

Lucy likes nothing better than to sit in my lap and have me rub her belly and ears. Second-best position is resting her chin on my foot. She’s a sweet, kind animal who tries to do nothing wrong.

She is, however, subject to being led astray and running amok when Sophie decides to go on impromptu, unauthorized rambles. The persuadable Lucy once spent a cold, lonely night in a coyote trap while Sophie waltzed home scot-free.

Lucy is increasingly fragile while seven-year-old Sophie seems to be indestructible. I once ran over her with my farm truck when she darted under the driver-side front wheel during an important chase of a local chipmunk. Truck was a little shaken; munk had the chips scared out of him; dog was neither hurt nor fazed.

Lucy is the house favorite even though we try not to show it. In her eighth year, she is now on her last legs. Rising from her mat has become an evermore heartrending struggle. She spends most days not moving.

We’ve tried several medications for the arthritis in her hips. Some relief came from a nonsteroidal anti-inflammatory drug that now appears to be increasingly less effective.

I am inclined to ration health care; Melissa is inclined not to.

Rationing distributes something scarce or that should be considered scarce. Economists typically define rationing as an artificial restriction of demand.

Cost is a common rationing mechanism—raising price lowers demand, lowering price raises it.

Governments from time to time intervene through mandates or taxes to limit demand. Requiring higher fuel-efficiency standards for vehicles should reduce gasoline consumption. Ever-higher taxes on cigarettes, along with health fears, reduced U.S. per capita consumption from 4,345 in 1963 to 1,619 in 2006, according to the federal Centers for Disease Control and Prevention.

Rationing means different things in different circumstances. One type either gives an equal portion to everyone, which is how a gallon of fresh water might be distributed among adults in a life boat, or a proportionately fair amount to everyone based on need, such as civilian tires during WWII.

A second type has consumers prioritizing purchases according to how much money they have and how much they want something.

“Rationing health care” has come to mean a third type—the prospect of the federal government telling individuals that its programs will not pay for certain services in specific situations because, taken in the aggregate, these services are too costly for the funds available.

Cost-based rationing is what we have now with private insurance companies when they deny certain services in specific situations, and cap expenditures or benefits.

Health care has always been rationed. In the not-so-distant past, if you didn’t have the money or goods to pay a doctor or a hospital, you either rationed yourself out of care or the providers did it for you. Charity care took a small edge off this type of rationing. My community routinely holds covered-dish suppers to help “rationed out” families pay for medical care.

Today, insurance companies, providers and public agencies ration American health care -- who gets what, when, how much, how good and for how long -- because they shape and control the indications for, and costs of, these services.

It’s never been clear to me why I’m better off having an insurance-company bureaucrat who wants to keep costs down rationing my health care rather than a federal bureaucrat who wants to keep costs down making those same decisions. The retired career military guys I lunch with once a month would, I think, vote as one to stick with their federal VA bureaucrat.

As long as we continue with an essentially private-sector system of providing health care that is substantially subsidized by public money, we will inevitably have to ration demand. We probably don’t have the money to pay for all services to all people on demand in perpetuity even if we backed ourselves out of wars and cut programs. I am not optimistic that our hybrid system is capable of controlling costs through competition and rational self-interest.

Since we are paying for Lucy’s care, Melissa and I are the ones who will ration hers, the ones who will eventually decide when her life is to end.

I will use some intuitive, non-numerical yardstick to measure when I think living her present and future is not worth it to her. I’ll also consider the dollar cost of keeping her alive and her decline continuing.

Melissa has always wanted to keep her pets alive as long as possible. I always argue against prolonging the inevitable, unhappy ending. A few more months of burdened existence are not worth a few thousand dollars to me. They are to her. She always prevails.

Some unfortunate people find themselves in Lucy’s predicament—no escape to a happy ending, increasing cost of cure-less care and an inability to express and effect the course they want to follow.

American law doesn’t provide a process for making a humanitarian “put-them-down” decision about fellow human beings who become locked into this destiny.

Oregon, however, does allow a terminally ill patient to request in writing from his or her physician a prescription for a lethal dose of medication to end life. Several checks are built into this process.

Its Death with Dignity Act was approved by 51 percent of the votes cast in 1994 and upheld by the U.S. Supreme Court in 2006.

In other places, even when an individual explicitly states in advance in writing with witnesses that his or her life should be ended in a specific set of circumstances, no legal means exist to carry it out. We don’t choose to be born, and we can’t legally choose when to die.

A statutory process that allows such decisions is subject to mistakes and abuse, both individual and wholesale. The absence of such a process produces the same results. Some desperate people have chosen to starve and dehydrate themselves to death to escape end-of-life “care.” These individuals are the “collateral damage” of a system that refuses to allow individuals to make choices for themselves.

If I had the choice, I would ration my own health care. I see no point in spending hundreds of thousands of dollars to buy myself a handful of miserable months. I see no point in spending my money for this purpose, or that of insurance companies, or that of my fellow citizens.

The irony is that I have the power to choose to ration care for Lucy because I own her, but not myself. If I do not own myself, who does? The Virginia legislature, it appears.

Why are Americans not permitted to ration health care for themselves?

The much harder question is, of course, how to decide what types and amounts of care to buy for everyone, and especially for those who can’t make these decisions for themselves.

Most people would not choose to ration their own care or the care of others. So the system we now use makes these rationing decisions while we pretend that it doesn’t.

For the record, the 15-member Independent Payment Advisory Board that’s set to start in 2014 under President Obama’s health-care law can suggest ways to cut Medicare’s rate of spending growth when a target rate is exceeded, but it is prohibited from recommending “rationing health care.” If rationing health care is off the table, controlling prices is right smack in the middle.

Nothing comes easy or cheap at the end, as we all know. I am missing Lucy as she sleeps on my foot.

Curtis Seltzer is a land consultant who works with buyers and helps sellers with marketing plans. He is author of How To Be a DIRT-SMART Buyer of Country Property at where his weekly columns are posted. He also writes for

Contact: Curtis Seltzer, Ph.D.
Land Consultant
1467 Wimer Mountain Road
Blue Grass, VA 24413-2307

This original column is provided free for one-time use with author credit at the end. It may be used for background with author credit. Copyright applies.

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