Will Healthcare Transformation Affect the Rule of Rescue?
In a 1986 edition of Law, Medicine & Health Care, U.S. bioethicist Albert Jonsen described the so-called “Rule of Rescue.” In Jonsen’s words:
Our moral response to the imminence of death demands that we rescue the doomed. We throw a rope to the drowning, rush into burning buildings to snatch the entrapped, dispatch teams to search for the snowbound. This rescue morality spills over into medical care, where ropes are artificial hearts, our rush is the mobile critical care, our teams the transplant services. The imperative to rescue is, undoubtedly, of great moral significance; […]
In a working paper for the Centre for Health Program Evaluation, John McKie and Jeff Richardson subsequently defined the Rule of Rescue as “the imperative to rescue identifiable individuals facing avoidable death, without giving much thought to the opportunity cost of doing so.” Note their use of the key phrase “identifiable individuals.” The Rule of Rescue describes the moral impulse to save identifiable lives in immediate danger at any expense. Think of the extremes taken to rescue a small child who has fallen down a well, a woman pinned beneath the rubble of an earthquake, or a submarine crew trapped on the ocean floor. In these situations, no effort is deemed too great.
The Rule of Rescue has held particular significance in the United States where the importance of the individual has long been a part of our cultural fabric. In the U.S., we tend to count ourselves as not fully human unless we pull out all the stops. Increasingly, however, healthcare ethicists and policymakers are asking whether this same moral instinct to rescue—regardless of cost—should be applied in the emergency room, the hospital, or the community clinic.
Rule of Rescue Examples
Statistics and costs tend not to invoke as much passion among the American public as individual cases of clinical need. For example, it has been estimated that 29,000 children around the world, mostly in poor countries, die every day from readily preventable causes, yet there is no outpouring of media attention, public or private donations or aircraft carriers steaming out to rescue them. We will readily spend hundreds of thousands of dollars on organ transplants and other procedures that may give a few months of limited life to someone, while we don’t spend much smaller sums that could prevent many cases of premature illness and death. The estimated cost for prophylactic Factor VIII to treat one patient with hemophilia for one year is $300,000. Costs of this magnitude have been accepted by public and private insurers in the developed world, even though, in principle, these sums could provide greater overall health benefit if allocated to pay for the unmet healthcare needs of many other patients.
Let’s look at various forms of “rescue care” by nation, comparing the U.S. to major European countries (France, Germany and the United Kingdom), based on Organization for Economic Cooperation and Development (OECD, 2009 data). First, the prevalence of renal dialysis (Figure 1) and kidney transplants for chronic renal failure (Figure 2).
The performance of renal dialysis and renal transplant in major European countries is substantially less than in the U.S. It is not that these countries do not have patients that would benefit from dialysis and transplant. It is a matter of public policy in using renal dialysis and transplant in the treatment of advanced renal failure. The U.S. uses these interventions extensively — European countries much less so.
Now, let’s look at the mortality rate from acute myocardial infarction (AMI) in Figure 3, comparing the United States with major European countries. Once again, it is not that the European countries do not have ischemic heart disease. Rather, the point is that AMI is treated much more aggressively with all potential treatment modalities in the United States compared to major European countries.
Finally, let’s compare mortality rates from cancer between the United States and major European countries, as shown in Figure 4. Cancer is equally prevalent in Europe as it is in the United States, but we tend to treat it much more aggressively here, offering patients every opportunity to be cured, or at least to extend their lives.
Despite spending twice as much as the average Western European country on its healthcare, the United States lags behind on a number of health system performance indicators, including amenable mortality (deaths that could have been avoided with timely and effective healthcare). Examples of such conditions include diabetes and acute infections, as summarized in Figure 5.Figure 5 – Amenable mortality
The Rule of Rescue Impacts Total Health
In terms of “total health” as measured by mortality amenable to timely and effective medical care, the U.S. does not do as well. The reason for this discrepancy is that the U.S. does not focus on primary care and prevention. We place a very heavy focus on rescue care. Many countries outperform the U.S. as a result of better public health, a greater focus on behaviors and better primary care. However, the U.S. performs significantly better for those with severe illness or injury (i.e., in terms of rescue care) as a result of better access to technology, less explicit rationing and easy access to subspecialists.
Going forward, as pressure to control healthcare costs grows and the need to manage precious resources more carefully increases, the broad application of the Rule of Rescue will be increasingly untenable. But the cultural and moral instinct to apply it will continue. The desire to help those weakest among us will remain strong, especially when their small numbers allow us to see them as unique individuals. This will likely be a very difficult cultural norm for American society to manage as healthcare transformation unfolds.
What do you think about the Rule of Rescue? Will it change with healthcare transformation?