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  • Triage vs Surge pricing

    Posted by TM Lutas on July 27th, 2017 (All posts by )

    Sarah Hoyt’s site has an interesting article entitled The Free Market versus Death Panels. I recommend it in general but it misses one point that I think deserves some examination. There is one exception to the market rule that is so embedded in our social mores that both market and non-market advocates alike pass over it. They shouldn’t. It’s called triage.

    I have never met a free market advocate of medicine who does not recognize and accept non-market allocation in terms of emergency care, specifically when medical treatment systems and personnel are overloaded. When you have 10 operating theaters and 50 people who need surgery, who gets in first and who gets in last? The market would institute surge pricing and let the ill or their care circles sort out how much they can wait. Triage orders it so that the fewest number of people die.

    It’s an important footnote to recognize triage and to explain *why* that limited exception is ok, properly fenced off with limiting principles so the exception doesn’t swallow the rule, and what is the reason we’re all generally ok with triage causing more suffering and against surge pricing.

    First is to note that triage causes excess suffering because it is designed, and functions well at minimizing loss of life at the cost of extending suffering for those condemned to delays in treatment by the triage system. We’ve all made a moral decision that some non-fatal suffering is an acceptable payoff for a reduced fatality count when medical systems are overwhelmed and resources have to be quickly, efficiently deployed to reduce fatalities.

    It’s important to cover these things because they take away all the central planner’s best arguments away from them when you reconcile the free market with triage. Solidarity, the common good, human decency, these are the heartstring appeals of the statists who falsely claim that free market medicine will cause wicked outcomes because the market has no sense of solidarity, the common good, or human decency.

    These statists are wrong. But they have to be shown wrong. Examining triage is a very good way to do it.

     

    46 Responses to “Triage vs Surge pricing”

    1. Tom Crispin Says:

      Another way to phrase it (maybe someone else can say this better) is that a situation requiring triage is inside the OODA loop of the surge pricing system

    2. dearieme Says:

      Free markets sound such a good idea that you in the US really should try them. The descriptions I’ve read of your medical system makes it sound like a hotbed of cronyism, cartels, freebooting, and racketeering, mysteriously exempt from your laws that are meant to exclude market abuse.

      In the UK we combine the NHS with a small free market sector for anyone who wishes to use it.

    3. TM Lutas Says:

      Tom Crispin – Surge pricing vs Triage have very little difference in reaction times. Both are very fast. No OODA loop differences so far as I can see, just different rationing criteria and results.

    4. Tom Crispin Says:

      TM Lutas – My bad. I was too expansive in my conception of surge pricing.

      Thanks

    5. Brian Says:

      1. I’ve known numerous people from England who had to deal with utterly insane wait times, like 9 months to see a nerve specialist for a wrist injury, etc. That’s not due to triage, that’s just a completely broken system.

      2. Does anyone remember The Long Winter by Laura Ingalls Wilder? The town is in desperate straits, and Almonzo makes a dangerous multi-day trip to get food, and when he returns to town with it the shopkeeper plans to charge exorbitant prices for it (i.e., surge pricing), until he is informed that he is free to do so, but he’ll be ruined come spring because no one will ever shop from him again. In the modern world we’ve lost the ability for shame to regulate behavior in these problematic situations.

    6. dearieme Says:

      “I’ve known numerous people from England who had to deal with utterly insane wait times …”: they are free to change queues and ‘go private’. When I’ve gone for private treatment I’ve negotiated the price (because I’ve never had UK health insurance).

      It’s been years since I heard of a nine month wait. Your info may be out of date.

    7. Mike K Says:

      ” a small free market sector for anyone who wishes to use it.”

      The last time I looked into this is was 25% of the population of southeast England, around London and environs.

      That is the only area of Britain with a positive GDP.

      “Doc Martin” is an excellent primer on the NHS in practice. Comedy is usually more truthful in what people laugh at.

    8. Brian Says:

      “It’s been years since I heard of a nine month wait. Your info may be out of date.” Possible. That particular story was from ~2002 or so.

    9. DirtyJobsGuy Says:

      I think you need a better word than ‘triage’. In it’s classic origin it was a cruel necessity of battlefield surgery. Those who would recover without assistance were told to wait, those who would die no matter what assistance could be provided were told to wait and those likely to recover only if operated on were assisted. In todays ER’s only the first group is told to wait so there are only two groups. As the commenters above noted, this first group is the one everyone worries about. My (limited) experience with ER’s is that there is a further division in the first group. One are those who are worried they might be in greater distress and need a quick consult. The other is a group (largely Medicaid) who see the ER as a 24 hour clinic with relatively short appointment times. If we treat the last group as a special case and focus on the “worried” group it helps see the issues. No one in this group wants to go to the ER if they could avoid it. But they need more than a quick evaluation that they at not immediately at deaths door. Perhaps a 24 hour clinic (with a higher price) attached to the ER could then take over this group. Most people would pay the difference recognizing the additional immediate service.

      Once again the US Small animal veterinary services provide an example of how this works. My vets provide excellent same day appointments and services during quite adequate working hours. After hours services are provided by a local Vet ER staffed by very competent veterinary surgeons and staff. These cost more but are accessible and available. Over the years our family’s dogs have experienced a wide variety of issues involving surgeries, emergencies, specialists and more. Once when a surgery required additional operations afterwards (successful) we were personally called by three vets to check on the patient’s progress. Without the burden of mandated cost controls they can allocate costs where they are important based on their experience and choices. I often think they look like a typical human practice 40 years ago in the US!

    10. dearieme Says:

      “The last time I looked into this is was 25% of the population of southeast England, around London and environs.” That’s small because you can bet that nearly all those people use the NHS for dramatic life-threatening illnesses.

      “That is the only area of Britain with a positive GDP.” That could be related to the detail of GDP calculation, where all government expenditure is treated as contributing 1:1 to GDP. London is where all the highly paid state lackeys are, and the various parasites who live off government – lawyers and so on.

    11. TM Lutas Says:

      Brian – I agree with you that a 9 month wait for a nerve referral is a sign of a broken system. The culprit is the NHS and it used socialism to misallocate resources. We are agreed.

      Triage is different than socialism.

      Triage is, however, non-market allocation of resources in a very limited set of circumstances.

      Dearieme – apparently last year the cataract surgery wait was 15 months:
      http://www.telegraph.co.uk/news/2016/09/21/patients-wait-up-to-15-months-for-cataract-ops-in-devastating-lo/

      DirtyJobsGuy – Walk into any inner city emergency room and hang around for any significant period of time, but certainly no more than a week and you’ll see triage in action. In fact, you might see it in action right in front of you as you walk in the door.

      You’re absolutely right that an urgent care clinic might very well help handle a number of cases to divert the supply of cases away from the overwhelm scenario where triage is invoked in the ER. But no matter how well your normal management is, an overwhelming disaster with thousands of casualties, maybe from a gas line explosion, maybe from a terrorist attack, whatever, triage is what you’re left with. We all accept it, from the socialists to the free market advocates. What does that say about us?

      I’m trying to point out that it demonstrates that a good number of accusations that the statists level at the free market advocates are false and defamatory because if they were true, free market advocates would not accept triage and would actively fight against this system. Yet we don’t do it.

    12. Mike K Says:

      “In todays ER’s only the first group is told to wait so there are only two groups.”

      Not in a disaster situation, which is what triage was invented for. I can recall having four helicopters circling over out trauma center helipad. They each had an injured child from an incident on Camp Pendleton where a drunk driver went up on the sidewalk and hit a group of children walking to school.

      One helicopter pilot said his child passenger had died and I waved them off until I got the others.

      You’re absolutely right that an urgent care clinic might very well help handle a number of cases to divert the supply of cases

      We had a group of pediatricians set up an after hours clinic called “Kids Doc” that they staffed among themselves and which ran from 5 PM to about midnight, as I recall.

      It worked well and gave them all 6 nights a week off.

    13. Subotai Bahadur Says:

      Dearieme:

      My daughter studied for a term in Britain in 2004, so this might be a bit out of date, but then again she was in Chelsea and Westminster Hospital in Kensington, London. At the time, it was literally the newest and most modern hospital in the UK, and Kensington is not exactly a slum.

      She saw two financial “triages” that murdered [former Peace Officer and word chosen carefully] two patients.

      Even the newest hospital in Britain had open bay wards like in the Harry Potter movies. When she went in with diabetic ketoacidosis, there were no beds in a female ward, so they put her in a geriatric male ward figuring they were relatively harmless.

      Next to her was a man on a ventilator tube. Muckety-muck doctor and flunkies came in and pulled the separating curtain, which was all that separated them. My daughter was awake, aware, and oriented times 3. Doctor told the man next to her that they needed the bed in the ward. He was not sick enough to go to ICU. And he had no one to care for him at home, so they could not release him. So they were going to remove his ventilator tube, and he would be dead in a few minutes. And the flunkies removed the tube. The man fought, vainly, for his life, and my daughter heard him gasp his life away. But you Brits say that our medicine is “corporate” and “heartless”. At the same time, you murder people for the convenience of the system, and in the case of Charlie Gard, you forbid parents to try treatment outside the country at no cost to the NHS just to demonstrate that you are not only subjects, but chattel, to the almighty State.

      Across the aisle was an elderly man who had broken his hip. His wife explained what had happened to him [in less technical terms than I use, but I speak “medical”]. He had survived the 6 month wait for surgery. That 6 month wait has been standard for a long time, and I think it is still standard. There is a reason for that. A broken hip means you are bedridden until after surgery. For an elderly person, 6 months of being bedridden means that you are almost certain to start getting deep vein thromboses [massive blood clots breaking off the vein walls] and fatal strokes. It saves the State money if the old people die.

      The man was an anomaly. He survived the wait, but the anesthesiologist let him come up to high during the surgery, the gag reflex kicked in, he vomited and aspirated, and ended up with aspiration pneumonia. Which is hard to treat, so they didn’t, and his wife watched him slowly die. The State does not consider you a human being. It considers you a unit of labor that if it is too old or too injured/sick to supply taxes needs to be killed off.

      TM Lutas mentioned cataract surgery wait time being 15 months in Britain. I know people who have had cataract surgery. Once it is diagnosed as necessary, and the patient decides to do it, it is usually no more than 2 weeks and usually less. It is a common enough procedure that there are specialist surgery clinics all over, including one in my small mountain town.

      Mind you, the NHS chattel reading this probably won’t believe that. I was talking to a Canadian woman who was bragging about her country’s version of NHS over our “heartless” medicine, and when I detailed how I was able to get surgery on a knee [old ACL injury I got tired of putting up with] from first telling my GP that I wanted to finally get it fixed on Monday, to an MRI on Wednesday, to an Orthopedic Surgeon appointment on Thursday, to the surgery on Friday; she flat called me a liar, saying that was physically impossible. By the way, it all happened in my small mountain town.

      Government medicine, in my experience, is always of lower quality, less available, and more primitive than private medicine. It is triage to save money for ever-growing administrators’ salaries.

      And since Obamacare is going to be made permanent by the Republicans, maybe we ought to insist that Brits and Canadians not be allowed to have visas to enter the US unless they purchase an Obamacare compliant insurance policy for cash in advance so they can keep what they consider to be the advantage of government neglect.

    14. dearieme Says:

      ‘the cataract surgery wait was 15 months’: but there is no “the” wait. ‘The shortest waiting times were in Luton, Bedfordshire where on average, patients waited just two weeks between outpatient appointment and surgery’

    15. dearieme Says:

      ‘But you Brits say that our medicine is “corporate” and “heartless”. ‘ I’ve never said that in my life. I have opined that, judging (only) by what I read on the web, it seems to be pretty corrupt and that some aspects seem not discernibly different from a racket. But then anything that involves politics in the US is going to seem corrupt.

      You seem to assume that I am a fan of the NHS but I am not. Yet American arguments against the NHS seem to me to be often foolish and ill-informed, like many American beliefs about that awful place “abroad”. I cite, for instance, the oft-repeated nonsense about gun ownership being banned in Britain and Australia, or even across Europe.

    16. Brian Says:

      An insane amount of mental anguish has been stirred up by the Democrats about the issue of health care. It almost got several GOP congressmen killed several weeks ago, and it will inevitably get some of them successfully killed, because if anything the Dems are getting more and more extreme in their rhetoric.

      And it’s all complete lies. Who thinks that if their child is born with serious medical needs it will be uninsurable for life as a pre-existing condition? Who could think that? Who thinks that if Obamacare is even slightly modified they will suddenly lose their own employer-based insurance? Have they never bothered to look into how insurance works in this country at all?

      The fact is we will have something like “Medicare for all” as soon as the Dems ever get Congress and the presidency back. It will be passed by completely lying about how much it will cost, same as all the other BS the government does.

      But we have to understand that people don’t want health insurance. What they want is for someone else to pay for their health care. We should probably start calling it “Charlie-Gard-Care” because that’s what you’re going to get.

    17. dearieme Says:

      “We should probably start calling it “Charlie-Gard-Care” because that’s what you’re going to get.” Can you explain what you mean by that?

    18. Brian Says:

      I have no desire to get into a debate about this, but this article does a mostly pretty good job hitting the right points:
      https://www.bloomberg.com/view/articles/2017-07-27/how-bureaucracies-creep-into-life-and-death-medical-decisions

    19. dearieme Says:

      @Brian; bless Megan, but she’s talking tosh.

      First the headline (which she may not have written): “How Bureaucracies Creep Into Life-and-Death Medical Decisions”. But bureaucracy had nothing to do with it; it was the doctors who concluded that the child was being subjected to needless pain and suffering without any hope of recovery. They were too polite, or circumspect, to say that the parents were torturing their son by indulging themselves by a wallow in sentimentality, but I dare say that’s what some of them felt.

      “For children, it is the right of parents to make that choice”: no, that proposition is rubbish – it is not the law of the land in England, and I’d be disappointed if it’s the law of the land in all fifty states of the US. (But if that guess is wrong, do say so.)

      Since her premises are wrong I haven’t bothered reading the rest. I don’t need another dose of ignorant or malign American grandstanding on this sad case.

    20. Mike K Says:

      the anesthesiologist let him come up to high during the surgery, the gag reflex kicked in, he vomited and aspirated,

      A patient having a hip done would normally be intubated for this very reason.

      If they were doing it under spinal, which is possible, the risk of vomiting is why patients are kept NPO from the night before.

      I have seen a “high spinal” in a 15 minute excision of a pilonidal cyst, in which the patient is face down. The reason was the union rules at Kaiser which stipulate that the anesthetists (they are all nurses) must take their scheduled lunch break and cannot put it off even for a half hour. Union rules and the spinal got too high while the relief anesthetist was in charge. The patient was in his 40s.

      In 1995, I was a consultant from Dartmouth who went to England to help practice managers learn how to cope with “Fundholding” in which the Thatcher government was trying to get some market mechanisms into the NHS. I learned a lot about primary care in the NHS and the reform was probably helping but Labour got back in and that was the end if it.

      In Fund Holding. the GP gets a budget for his/her own patients. The GP can then refer, like American GPs do, to hospitals and specialists who do a better job of informing the GP and responding in a timely manner. The GP can also drive harder bargains on price. We (there was another doc who was an HMO medical director) set up negotiation game playing and talked about how a free market in health care might work. The early reports were that service was much better and more timely.

      Then Blair cancelled the whole thing.

    21. Jonathan Says:

      Dearieme:

      You are begging the question. The doctors may usually be right in such difficult cases, they may have been right in this case, but it should not be their decision. This was not a case of parents withholding the accepted treatment from a suffering ill child, but rather a case on the margin where the English docs could do nothing and the parents wanted to try an alternative that they believed had a chance of helping. What would it have cost the NHS docs and bureaucrats to give the parents their way? What principle, other than govt authority, would doing so violate?

    22. TM Lutas Says:

      Dearieme – I was not careful enough and should have said “up to 15 months”. Since I included a link I would hope nobody was actually led astray. That being said, the days of rationing by making people wait unconscionably long for lifesaving surgeries are clearly still with the NHS. People apparently are sometimes waiting months to get hip surgery for example. My larger point remains intact.

      Socialized medicine rations by delaying treatment and is non market. Free market medicine people hate that.
      Free market medicine rations by raising prices until the market clears. Socialized medicine people hate that.
      Triage rations by condemning people to die in order to save the maximum number of lives. Both socialized medicine and free market medicine people accept this non market rationing scheme.

    23. dearieme Says:

      “You are begging the question.” Oh no I’m not.

      “The doctors may usually be right in such difficult cases, they may have been right in this case, but it should not be their decision.” It wasn’t their decision, it was the court’s decision because that’s the law of the land. In our crowned republic we still often have rule of law. I prefer it to rule by public hysteria and grandstanding by politicians (or Popes), but your taste may differ.

    24. TM Lutas Says:

      Jonathan – For the record, I disagree with you that the doctors may usually be right in such cases. In fact, that’s a variable, not a constant because what the doctors are applying when they make such decisions is not solely medical knowledge but medical knowledge plus conservation of resources, in other words economic thinking.

      The medical knowledge of the professional community is to be respected. The economics going into their thought process may be worse than the family uses, as the Charlie Gard case illustrates.

      We are not, at present, properly confronting the emerging medical knowledge that we have been killing people by withdrawal of resources who were perfectly aware of what is going on but are locked into their bodies, unable to communicate the horror of their murder being planned right in front of their eyes. This particular scenario will be fixed late in the socialized medicine countries because they’re strapped for resources and care for such people is expensive, long term, and may be for the rest of their lives. The medical knowledge says not to withdraw care. I am not brave enough to count up the butcher’s bill of how many we’re killing every month because we just can’t afford it.

    25. Brian Says:

      “because we just can’t afford it.”
      But the disgraceful thing is that we can, if we actually wanted to. CA, for instance, spends more that $0.50 of every dollar on the school system, and the spending keeps going up while the results keep going down. And the problem isn’t that education is hard or particularly expensive, it’s that education is not actually the purpose of those running the system, who think it actually is doing what it’s supposed to do–spend lots and lots of money, for the benefit of a few. Similarly for “health care.” Similarly to how commie countries have famines even in the midst of bumper crop yields.

    26. Mike K Says:

      Having lived with this dilemma for years, I have a couple of comments.

      To get an idea of what medical care in Britain was like before the NHS, several books by AJ Cronin are helpful. Several of his novels were about doctors and how they lived plus his autobiography describes his own experiences.

      We dealt with the uninsured and there was a good system before Medicaid called The County Hospital. The County hospitals were destroyed by Medicaid as it would not pay for care unless it was delivered by a doctor who was not in training. Eventually, teaching hospitals got around this by having the attending surgeon, for example, sign a form that he or she had been present the whole time and had supervised the operation. Many of these forms were dishonest and a few doctors I know were prosecuted, usually because of other reasons but it made a handy club.

      When Medicaid (MediCal in California) first went into effect, I actually knew young doctors who quit residencies to open “MediCal Mills.” The system was designed to measure and pay for things that could be measured, not traditional medicine. Hence the corruption was there from the beginning.

      Now, the illegals dominate emergency rooms and the County hospital, which has deteriorated badly since 1965.

      My brief experience with the NHS was in 1995 and we quickly noticed that the makers of immunization solutions funded doctors’ pediatric waiting rooms and refrigerators. There was nothing wrong with that but it was an example of private enterprise influencing the design of offices.

      The Fund Holding was making a difference in that GPs were better informed about their patients who went into hospital and I believe waiting times were reduced because the specialist and hospital who provided better service got more referrals of paying patients.

    27. Brian Says:

      Mike: Is it true that Medicaid/Medicare basically ended charity hospitals because they made it illegal to change anyone less than the government rates for those programs? I.e., you couldn’t run a hospital where you gave free care to poor people anymore?

      I get the reason the NHS was created, but we don’t have a class system in America so there isn’t the same sort of strong antagonism among the “labor” against the system, despite the best efforts of the left. Although it definitely seems like there is more and more bitterness and anger at the system among the have-nots then there maybe ever has been. The left misreads it completely, of course. They think that the poor should hate Donald Trump for being rich, when the poor know it ain’t the Donald who has screwed them over.

    28. Jonathan Says:

      TM Lutas: “may”

      Dearieme: How many DHS docs were willing to publicly disagree with the court? Rule of law is desireable but it’s not an end in itself.

    29. dearieme Says:

      “I get the reason the NHS was created, but we don’t have a class system in America”. Non sequitur of the month. (Obviously untrue too, but that’s another matter.)

      The idea of an NHS was promoted by Beveridge, an economist, in a wartime report. The policy was adopted by the Conservative and Liberal parties pretty quickly, but only slowly and reluctantly by the Labour Party. But it was Labour that won the ’45 election. Implementing an NHS was a job given to Nye Bevan, a hot-headed Welsh marxist. And that’s why we got an NHS of a peculiarly awful design. What the bugger a “class system” has to do with that isn’t clear to me.

    30. dearieme Says:

      “How many NHS docs were willing to publicly disagree with the court?” What an odd question: what on earth are you driving at? The tradition in Britain is to criticise court decisions as much as you like but to accept them. If you don’t like them you can agitate for a change in the law. Or do you mean that docs ought to think that the courts decided wrongly as a matter of law? But the case went to four courts, all of which (I understand) made the same ruling. And even as conceited a mob as doctors aren’t likely, on the whole, to view themselves as better lawyers than the judges.

    31. Brian Says:

      When I’ve read accounts from Labour (sp?) supporters from the late 1940s, not just the outright commies at the higher levels, it’s clear that their support for nationalizing industry after industry, especially the health system, is tied up with bitterness, anger, and resentment towards the upper classes. They don’t want to reform the system, they want it smashed and upended and taken away from those who have established it. They seethe with resentments towards what they see as the paternalism behind the pitiful benefits they’ve been given, and they don’t just want themselves to gain, they want those above them in the class hierarchy to lose. I’m not here to debate the legitimacy or not of those feelings, and such inclinations are far outside of the American experience, but it seems to me that these deep-rooted class problems explain the support for the NHS at the time of its formation, and through to today. If you think I’ve badly missed the mark, feel free to correct me.

    32. Jonathan Says:

      What an odd question: what on earth are you driving at?

      Do the docs see themselves as primarily patient advocates or govt functionaries?

    33. dearieme Says:

      @Brian: I think the worship of the NHS stems above all from the mere coincidence that its formation coincided pretty well with the start of the age of widely available antibiotics, so that for the first time in history doctors could do far more good than harm. Suddenly there’s an NHS. Suddenly your wife could be cured of something or other. Post hoc ergo propter hoc. Hurray for the NHS!

      If it weren’t worshipped it could have been reformed long ago into a better system like, for instance, those of France, Singapore, or various other advanced countries. Or Iceland: I once heard a woman at a dinner party rave about how good the Icelandic system was. But you know how odd the opinions of foreigners can be about countries of which they understand rather little.

      The reason the Labour Party was originally agin the notion of an NHS was the fear that such a system would please the workers, who would thereby become even less interested in red revolution than they usually were. (It’s worth remembering that in an era when by far the majority of the population considered itself working class the Labour Party didn’t manage to win 50% of the vote. In fact it never has in its history.)

      @TML: I’ve seen no evidence that the Charlie Gard case had anything to do with “resources”; the doctors simply thought that the little boy was being made to suffer horribly for no good reason. Resources would matter enormously, of course, if the problem arose a thousand times, but economic thinking seems to have played no part in this case. Maybe it ought to have done – after all, every decision involves opportunity costs – but apparently it didn’t.

      @Jonathan: “Rule of law is desireable but it’s not an end in itself.” Just a few posts back I was instructed that “our great conservative theorist Russell Kirk” argued that “it seems to me that there are three great bodies of principle and conviction that tie together what is called modern civilization. … The third is a complex of social and political institutions which we may call the reign of law …”.

    34. dearieme Says:

      “Do the docs see themselves as primarily patient advocates or govt functionaries?” I think hospital doctors tend to see themselves as heroic savers of life, bless them. In private I more often hear them complain about being subject to frustrating bureaucracy than about economic constraints; in public, of course, they – or their trade unions – always bleat about economic constraints, as if they should be above such mundane matters. A chap doesn’t want to be sacked, after all, by suggesting in public that the chief executive of his hospital is an incompetent, self-aggrandising ass.

      Meantime, I read that the American system of health care drives people to suicide.
      http://thenewamericana.com/2017/07/28/trump-made-us-jump-new-york-couple-blames-suicide-health-care-costs/

      But I decline to take such a yarn at face value.

    35. dearieme Says:

      Meantime, here’s a question. A child in the US has Charlie Gard’s condition. His doctors have given up all hope of saving him. His mother wants life support switched off to spare him more suffering. His father wants the boy kept alive as long as possible. Who decides? What’s done? In Roman Law it would be simple, of course, but what about in New York Law, or Californian Law, or Texan Law?

    36. Mike K Says:

      Probably an ethics committee. Since the lawyers got involved that is usually what happens.

      I have had a family take a vote on whether to do a useless procedure on a dying man. They voted 5 to 4 to do it.

      I remember a Muslim family that demanded a brain dead parent stay on life support. I don’t recall how that turned out.

      I was once fired by a son who was angry I was trying to keep his father alive, The father had benign disease (gallbladder disease missed by the idiot internist for a week) and was in his 60s.

      I told him I would not turn off the respirator and he would have to get another doctor to do it.

      I kept treating the man and, when they finally got the stupid internist who had botched the case originally to take over, he survived off the respirator. About a week later, they asked me to take over again. We avoided each other but he recovered and went home to New Jersey,

      The story is in my book.

    37. dearieme Says:

      “Probably an ethics committee.” What, essentially a kangaroo court? Good grief.

    38. Brian Says:

      But in Charlie Gard’s case the parents were in agreement. There is no jurisdiction in the USA where what happened in the UK would happen.

      IANAL, but in your hypothetical it would depend I think strongly on custody issues and what legal status the father has.

    39. Mike K Says:

      you couldn’t run a hospital where you gave free care to poor people anymore?

      I’ve never heard that and the nuns that ran St Joseph’s hospital in Burbank had a policy of never turning away anyone who could not pay,

      That, of course, was in the dark ages.

      What is a policy now, I believe, is that a hospital with a contract cannot offer a lower price to cash customers. Doctors are under the same constraints although it is usually ignored.

      Medicare had the same rule but it is law. If you offer patients a cash price when you are participating in Medicare, it is a crime. It is even a crime of you don’t collect the copay,

      Everything now is contracts.

      Dearieme, doctors considered themselves patient advocates when they were in private independent practice. Most of them now are employees.

      In the NHS, the issue I think, is that doctors are employed by the NHS, which is of course the largest employer in Britain. A friend of mine, 20 years ago, spent a couple of weeks doing a locum tenens in Ireland. A locum is a sort of temp job for doctors.

      He told me that his day was mostly filling out work excuse slips and, if he questioned an obviously able bodied applicant, he got threats to go to the local authority. We see a similar thing on “Doc Martin,” which I assume is fairly representative,

    40. dearieme Says:

      “But in Charlie Gard’s case the parents were in agreement. There is no jurisdiction in the USA where what happened in the UK would happen.”

      “what happened in the UK”; in what sense? Are you really saying that no state has laws to protect the child from his parents’ cruel decisions – that they may treat him as a chattel?

      “doctors considered themselves patient advocates when …”: I have no idea what that means. Can you translate from the American, please?

    41. Brian Says:

      Mike: So it sounds like you’re agreeing. Before Medicare the nuns could have said “This procedure has a cost of $500, but you are unable to pay so for you the price is $0.” After Medicare that would be illegal.

    42. Sgt. Mom Says:

      Dearie – the Charlie Gard case hit on a couple of raw nerves in the US. It may be that the poor little tyke would not have had anything like a meaningful existence, given the medical condition that he suffered from – but who decides to continue a treatment, or withhold it, pleading suffering of the patient? The parents, or an assortment of medical/judicial authorities. That’s the rub – who decides, when it comes to brass tacks.
      Certainly there are parents who have decided – for some reason or another – to reject conventional treatment for their kids for perfectly survivable conditions. Some have rejected very basic medical intervention on religious grounds, and that’s where the discussion gets down into the weeds. I believe that only a handful of fanatics defend this. (The determined anti-vaccine folks are another category entirely.) And there are certain parents who have basically induced medical crises in their kids out of some twisted wish for attention. (There was a particularly horrible case of this in San Antonio some years ago. Munchhausen By Proxy, it’s called. Mike K probably knows more about this than I do.)
      But there was the case of Justina Pelletier, who also suffered from a rare and crippling condition – and the medical authorities at a Boston hospital came to the conclusion that it was all psychosomatic, and possibly Munchhausen by Proxy – and removed the kid from the custody of her parents on those grounds – on the grounds that this was absolutely necessary for her welfare. https://www.nytimes.com/2015/07/12/opinion/sunday/the-new-child-abuse-panic.html?mcubz=2
      Surprise – her condition worsened, and her parents fought for a year and a half to get her returned to them. Really, I am convinced that half the reason that Boston Children’s fought so hard against the suit by her parents – was that they realized belatedly that they were hideously wrong and couldn’t admit it.
      So – given this medical-authority kerfuffle, and the general unhappiness over how under an over-arching government health care scheme would operate in real time, and how brutally skeptical Americans have become when it comes to anything government-operated … this is why the interest in Charlie Gard. Because we can all visualize some faceless, unaccountable medical bureaucrat deciding that the life of someone dear to us has no long-term value to the State.

    43. Ginny Says:

      I suspect a part (a small part perhaps) of the strong feelings over the child is that Americans just don’t trust bureaucrats, the government – we would rather have civic organizations doing some things, being responsible ourselves for other things, as free a market as is possible for a service or good, and in general, well, having liberty and being free.

      Our affection for the 2nd Amendment (which I have come late to but now understand its importance), our distaste for eminent domain policies, our belief in all the distinctions Hannan describes as conflicts between England and the EU – well, the pain of the child, our identifying with the parents, etc. may be the emotion but the knee jerk (and sensible) reaction we generally have is, leave us alone, leave them alone. Don’t get into someone’s family, bed, or – well most especially – conscience.

    44. dearieme Says:

      “Because we can all visualize some faceless, unaccountable medical bureaucrat deciding that the life of someone dear to us has no long-term value to the State.”
      But the case was nothing to do with bureaucrats, or of value to the state. The court was deciding on the value of his life to the little boy.

      “Americans just don’t trust bureaucrats, the government”: but the case had nothing to do with the government, except in the sense that some earlier Parliament must have passed the relevant laws.

      “an over-arching government health care scheme”: if that is meant to imply that the NHS was central to the dilemma, that’s wrong. If Charlie Gard had been in a private hospital the same law would have applied.

      I think y’all are going into a default American mode of hysterical and sentimental ignorance. Let me try again.

      The law stipulates that the child’s interests, the child’s rights, come first. The court views the parents mainly in terms of their duties to the child, not in terms of some supposed right to treat the child as a chattel. The courts get involved when there is a dispute about how to treat the child – that’s why my hypothetical case of a parental disagreement is (if I may say so) well chosen. Mike suggested that if the parents disagreed then in the US an “ethics committee”, God help us, would decide. In the England and Wales the case would go before a proper court just as it did for Charlie Gard. In his case it went to a sequence of four courts: High, Appeals, Supreme, and even European. Which would you rather have: some local kangaroo court making a decision, or properly constituted law courts, with their rules of evidence, their transparency, and their dispatch? (In the UK we also have the advantage that our courts are popularly accepted to be remarkably uncorrupt; you may not have that advantage.)

      If you want to keep the emotional level cool I suggest you focus on hypothetical cases. I propose you decide how you’d like those dealt with, or discover how they would be dealt with in some of your states. You may care to invent further hypotheticals: e.g. both the parents are alive and available, but both are insane, or mentally defective. Should they be free to do whatever they like with the child? Are the courts to have no power to protect the interest of the child? Really?

      Consider another case. Father wants the child to be allowed to die; mother has long since vanished, whereabouts unknown. The mother’s parents, the child’s grandparents, want more treatment for the child. What then? The answer is (as I understand it) that the courts would recognise the grandparents as having a proper interest in the case and would therefore be prepared to hear the case. Similarly if the father had abandoned the child earlier, and then the child’s foster parents wanted treatment to continue.

      The court asks a preliminary question: does this person have a qualifying interest in the case – if so it will hear the case. Then it asks one dominant question: what is in the child’s interest? In the Charlie Gard case the court decided, in accord with precedence (and, for all I know, with statute law), that the doctors treating the child should be heard in court. The court appointed a lawyer (“guardian”) to represent the child. The parents were represent “pro bono” (if I have the jargon right). And so matters proceeded. Almost everything I’ve seen from the US on this matter doesn’t even get the fundamental facts right. Gusts of windy emotion are no way to settle the serious business of life. Mr Ted Cruz and Mr Paul Ryan, for example, should be thoroughly ashamed of their contributions.

    45. Mike K Says:

      “doctors considered themselves patient advocates when …”: I have no idea what that means. Can you translate from the American, please?

      Doctors used to be independent business men. Mostly men but not all.

      They served patients as clients in a private transaction. When I began in practice (1972), most insurance was “indemnity style,” which means it paid a flat fee for procedures.

      An appendectomy might be $500. Hospitals charged by the day, say $50 per day, ICU might be $500 per day.

      Blue Cross, which was started by the hospital associations, paid hospitals on an annual cost basis. After the War, general insurance companies began to write policies for employers and compete with Blue Cross, which was seen as a creature of the hospital associations and too expensive.

      As part of their competition strategy, insurance companies which had no experience in health care, began to demand itemized bills. They wanted to know the cost of each syringe and each dose of medicine.

      That set off the wild inflation of cost. Ten dollar aspirin tablets and so on.

      Doctors got into the same situation by demanding payment of “Usual, Reasonable and Customary fees.” That set off fee inflation and entangled doctors with insurance companies, It would have been far better to leave indemnity style insurance alone as those covered “insurable events,” like heart attacks and appendicitis. Pretty soon pediatricians wanted insurance to pay for well baby visits. Those are NOT “insurable events.”

      When my older children were born in 1965 to 1969, there was no insurance for childbirth. The cost for mother and child, with five days in the hospital, was about $250. total.

      When my fourth child was born in 1980, insurance paid and the price was about $6,000.

      Once we got entangled in negotiating with insurance companies, we lost independence. By 1985, in California at least, doctors were having to sign contracts and abide by price schedules.

      We were employed by the insurance company, not the patient. A GP friend of mine practiced in San Clemente and was the busiest GP there. Most of his patients were employees of the city. The city signed a contract with an HMO and he was asked if he would join the HMO as a provider. He declined and his patients all left him.

      The same thing happened in Canada.

    46. PenGun Says:

      “The same thing happened in Canada.”

      Yeah if my medical card does not work, I won’t be using your services. You find that surprising?

      Your medical system, once again:
      http://carnagepro.com/pics/graph-growthofphysicians-administrators.jpg

      It’s a huge scam to burden your country with wildly over priced care. You do appear to go along with these arrangements rather easily, so I guess you have it coming. I thought independent thought, was important to Americans.