23 August 2009

This week's best argument for rationing health care

Does she look like Queen Nefertiti? Comparison photos are at the Mail Online link; whether she has been successful or not, the point is that this 49-year-old woman has spent £200,000 on her face...
The mother of three has had 51 cosmetic surgery operations - including eight nose jobs, three chin implants, one eyebrow lift, three facelifts, six mini facelifts, two lip surgeries, five eye surgeries and 20 minor tweaks - in her efforts to recreate herself in the image of the 'Beauty of the Nile'...

She began her transformation in 1987 after deciding that in a past life she had lived as Nefertiti...

I am sure some people will disapprove of me having so many operations but I believe my look is ageless and timeless. Seeing myself looking so much younger makes me feel young and energetic."
Let's all agree on one point - she spent her own money on the surgeries, and with the approval of her family. She has every right to spend her own money as she wishes, and if she prefers to undergo repeated surgeries and help support various medical personnel and medical supply companies rather than buy a Beemer or a flat in Mayfair, then that's her choice. No one should argue with that.

But... for those who argue that unlimited health care is a right, what would you do with this woman (and there are countless people like her who haven't done what she has done simply because they don't have the resources). In a way this is "elective" surgery, but some would argue that she has a type of body dysmorphic disorder and that she needs the plastic surgery for her mental health. She may not be batshit crazy, they would argue, but she needs this just as a teenager might need dental braces or acne treatment.

Finally, note that she does live (as far as I can tell) under the NHS system, and that she did pay for the cosmetic procedures with her own money. I don't know how the British or Canadian systems work, but it appears that one is guaranteed certain basic services and can then purchase additional medical care with one's own funds.

Therefore, there must be some rationing system in place. And any talk of single-payer, "universal" health care in the United States will have to include some provisions for limiting or (warning - scare word coming) "rationing" health care in order to prevent people like the lady above from using up the resources and the funds.

Again, I'm not mocking this lady. Personally I think she looked cute as a button at age 22 before undertaking her face modification quest (photo at the link), but that's her decision. I simply offer her as an example of why "rationing health care" has to be - logically and practically - incorporated into any nationalized health care program.

Photo trimmed from one credited to Murray Sanders.


  1. Would you draw a line between what this woman has done and gender-altering surgery? I ask because some people have used the "body dysmorphic" notion to argue that such surgery shouldn't be covered by insurance--that those who want the surgery should have psychiatric counseling (which presumably would be covered) instead to enable them to live with the body they've got.

    I don't agree, but I'm not sure I could explain why very convincingly.

  2. @Swift - I couldn't even begin to address your question. I may have used the "body dysmorphic" phrase too loosely, but there are lots of those psychiatric-type diagnoses that are hard to define as illnesses since they don't have a structural basis. I should blog some of those... stay tuned...

    Those whose job it would be to ration health care - whether they be legislators writing the guidelines or medical personnel enforcing them - are going to have a very difficult (and publicly unpopular) task. But it's worth noting that such limitations are already being done by the private sector (the infamous and hated "preexisting conditions" being the most obvious examples).

  3. You both bring up a fabulous and respectable points which I haven't thought of before. Although I'm still working on reading the actual document, I've been optimistic about the new health care reform - I feel like change is needed for so many of my friends that can't afford health care. But you're right - this scenario (one which happens greatly in our culture, I'm afraid) is going to be troublesome and needs to have provisions.

    Thanks for taking a random odd story and making it insightful and thought provoking.

  4. It's not only cosmetic surgery which I am worried about being covered in universal health care, I'm also worried about homeopathy, acupuncture, energy healing, laser therapy, and a whole host of alternative medicine treatments (alternative to scientific treatments) being covered. I believe homeopathy is covered in the British system, and it would not surprise me if the future US system included crap treatments too. I think they are MUCH more worrisome than cosmetic/gender reassignment surgery because the former are far more prevalent than the latter.

    Anyway, I think cosmetic surgery should be covered if, after psychiatric evaluation, 1)it is found that the patient is suffering significantly because of it 2)surgery is the cheapest/best way to alleviate that psychological suffering, and 3) there is a very low chance of them getting "addicted" to the surgeries and basically becoming this woman. People like that are NEVER happy with their appearance and would just be money black holes.

    I think gender reassignment surgery would work the same way.

  5. I will preface my comments by stating that I am a Canadian health care provider.

    I can't speak to the proposed legislation in the US, but under our system, gender reassignment surgery is covered in very specific instances. Essentially, if the individual is diagnosed with a condition, and the DEFINITIVE treatment is gender reassignment surgery, it will be covered. Elective procedures, including most cosmetic surgery is not covered.

    Homeopathic care, acupuncture, etc is NOT covered under the Canadian system, however I have a private health insurance plan through my workplace benefits that cover most of those costs. Yes, there is some private health care in Canada.

    Oh, and referring to homeopathic treatments as "crap treatments" seems to demonstrate a lack of understanding of these treatments. You call them "alternative to scientific treatments", when in reality there is scientific merit to many of these treatments, and many people find relief through them.

  6. Ian--you might want to clarify what you mean by "elective surgery." Here's Wikipedia's definition:

    "Elective surgery is surgery that is not urgently required due to an emergency. Elective surgery may be performed for medical purposes, such as cataract surgery, or for other work such as breast implants. These are procedures that the person requiring them decides to undertake, and which may be helpful, but are not necessarily essential.

    "However, the term is not without definition problems. Some countries or health systems for example consider hip replacements as elective surgery, because a bad hip is not life-threatening, even though it may effectively cripple the patient."

    Does Canada's health system pay for cateract surgery and hip replacement? How about reconstructive surgery after mastectomy?

  7. This is the same anon as above.

    Ian- I am fairly well informed about homeopathy and other crap treatments. They ARE just that- crap. The one and only way most of them are "working" is purely by the placebo effect and by the fact that some people find the greater attention they receive by homeopathy/etc practitioners appealing. The placebo effect is also present in scientific medicine, so you can't argue that alternative treatments are fine and dandy because of the placebo effect. You CAN legitimately argue that doctors should spend more time with their patients and so on, but the actual homeopathy/acupuncture/etc. treatments are crap. The science bears this out, alternative medicine simply does not work. In fact, it can be very dangerous because alternative treatments can either replace real treatments or they can delay the use of real treatments until it is too late.

    You mentioned that some of these treatments do have scientific merit, but that illusion comes only from badly-made or badly-publicized studies which seem to show a positive effect. For example, there was a recent study which, if you read it and actually look at the data, showed that acupuncture does not work and is only as good as the placebo. However, in the media it was reported as if somehow acupuncture was working because sham acupuncture was as good as the placebo (??? It boggles the mind).

  8. Swift Loris – Wikipedia's definition differs from mine. This is the OED definition of elective:

    ”adjective 1 relating to or appointed by election. 2 (of a course of study, treatment, etc.) selected by the person concerned; not compulsory.”

    The “person concerned” in my definition of elective surgery is the patient. For example, if a patient's surgeon says they should get a hip replacement, then yes, it will be covered. However, if the patient walks into the surgeon's office and says “One hip replacement please” and in the opinion of that surgeon it is not medically necessary, the surgery would not be covered. This is of course assuming that the surgeon would complete a surgery that he does not deem necessary.

    Cataract surgery is the same. When it is determined it is needed, i.e. the stronger eyeglass prescriptions are no longer effective, etc. the surgery will be covered.

    It should be noted that everything is treated on a case by case basis, and that each province has it's own health care system that is funded federally.

    Anonymous' – I must admit I misread the comment and then exacerbated things by, and then misspeaking (mistyping?) regarding homeopathic treatments. What I meant to say was that you can't simply discount anything that is labeled “alternative medicine”. While there are a lot of treatments that are completely useless, and baseless in science (homeopathy for example), there many treatments with a basis in science i.e. chiropractic care, ultrasound and electrical muscular stimulation for pain etc.

    Other treatments are too new and have not been studied thoroughly enough to be discarded at this point i.e. laser therapy for pain.

    Acupuncture is a different story. The studies that found acupuncture's mechanism of action was the placebo effect are for the most part flawed, simply due to the fact that there is no placebo equivalent to the therapy its self.

    That being said, these alternative treatments aren't covered by the government health insurance plan of my province.

    Oh, and no I am not an alternative medicine practitioner. :-)

  9. again, same anon here.

    Ian- "What I meant to say was that you can't simply discount anything that is labeled “alternative medicine”."

    I sort of agree. On one hand, you're right that some new treatments which have not yet been fully embraced by the medical community MIGHT possibly have some positive effects. On the other hand though, I think that the very fact that something is called an alternative treatment means that it has not been shown to be effective at a level sufficient enough to be widely accepted by the scientific community. As such, these kinds of treatments SHOULD be dismissed in the context of public health care (and by non-experts in the subject, such as patients). IF said treatments show some promise and are plausible (unlike homeopathy), then they should definitely be researched. However, it's not until efficacy and safety have been very well established that they should be included in public health care (or should be sought by lay patients).

    As a last point, I'm sure you're aware that chiropractic care is a mixed bag. There ARE some good chiropractics out there that don't wade into woo, but there are a lot of others which are fully immersed in nonsense. For example, a chiropractic practitioner near where I live has all kinds of BS treatments for allergies, detoxification, osteoporosis, etc.

  10. I tend to agree, and that is in fact how the Canadian system works. My government doesn't pay for my chiropractic visits, that's covered by my own private insurance.

    Speaking of chiropractors, it is a shame that there so many that don't deal exclusively with evidenced based medicine. There are many chiropractic treatments that are very effective for certain illnesses and injuries, but those quacks that indulge in the "woo" as you say, give the rest of them a bad name.

  11. Absolutely. It also sucks that some chiropractors that offer crap treatments also offer good ones though. My mom goes to that chiropractor I mentioned before because he fixed some weird hip condition she had, and now she trusts him far too much and won't listen to me when I tell her about the crappy treatments.

  12. We already ration healthcare; we ration by cost, the same way we ration homeowner's insurance or even car maintenance (when I take my car in for its 6K checkup, I have a choice of three levels of maintenance, depending on how much I want to pay) or education.

    Provide basic coverage for a reasonable fee and leave responsibility for such things as plastic surgery, Viagra and (yes, I'm going to say it) fertility treatments to the pocket of the patient.


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