One of my favorite children’s stories is by Alfred Noble, called “The Boatman.” It is about a grasshopper walking down the road, and during his journey he comes upon a small puddle. As he begins to step over the puddle, he is confronted by a little mosquito in a boat who tells the huge grasshopper that he is not allowed to cross the puddle unless he – the mosquito boatman – ferries him across.

Now, the grasshopper is orders of magnitude larger than the tiny mosquito in the tiny boat. There is no way he could possibly comply with the demand that he be carried.

As the grasshopper tries to discuss this problem rationally with the mosquito, he is repeatedly told, “Rules are rules!”

Real world facts, as put forth by the grasshopper, fail to have any impact on the mosquito’s thinking, as the mosquito keeps repeating that the grasshopper must get into the boat. Finally, to break the impasse and get on with his journey, the grasshopper very politely, and with all attempts at being serious, lifts the mosquito – boat and all, and carries him across the puddle in one step. At the far side he replaces the mosquito/boat into the puddle and profusely thanks the tiny insect boatman for the excellent journey. The mosquito, totally oblivious to the absurdity of the situation, replies that he is always glad to be of service, then sits in his boat waiting for the next customer – as Grasshopper continues down the road.

What a perfect metaphor for Medicare regulators. Doctors and hospitals, acting like the grasshopper, try to carry on with the business of actual patient care while the Medicare folks enact inane restrictions, monitor for compliance and generally get in the way of progress. This was most recently evident in the sad flak over a 10-year-old’s request for a lung transplant.

Commentators are willing to give U.S. Secretary of Health and Human Services Kathleen Sebelius a “pass” in this case, not blame her for essentially condemning the child to death, saying that she is “not denying care,” just reaffirming that the girl needs to be treated according to the rules.

But no one takes a step back to point out that the rules can be patently absurd. In this case, a 12-year-old qualifies for an adult lung transplant, but a 10-year-old does not. Now, this restriction is no doubt based on averages – for example, it is probable (and I am not a transplant surgeon, so I am speculating based on the way this works generally in medicine) that on average, a 10-year-old is too small for the size of an adult lung. So in a situation where resources are scarce, one does not want to waste a precious lung only to find it doesn’t fit. But perhaps this child is larger than average. Perhaps a lung is found from a small donor.

There are a myriad of potential exceptions to the “average” that are used to guide medical therapy. In the real world, physicians deviate from the norm every day, taking into account this infinite variability in human physiology. But government rules never do. Government rules are fixed, determinate and more than occasionally based on outdated or an incorrect understanding of science.

Rules also help absolve one of guilt in an immoral system. Except in very blatant cases, it was difficult to assign blame to individuals involved in the Nazi death machine. Everything was done according to rules and a bureaucratic mechanism that fragmented the process so no one individual was at fault. In the physician-run euthanasia program, candidates were selected by local physicians who themselves never participated in the final decision, nor in the killing. Then the “patient’s” records were reviewed by a committee in Berlin or at some other location a good distance away from the actual person being considered for death. When the decision was made to “do them in,” so to speak, this was carried out by yet a third group of people who, unlike the referring physicians, had no personal relationship with the victim. It is the third group of people who are generally remembered as war criminals – the transporters, prison guards and death camp attendants. They are the ones who were punished after the war, but they are not the ones who set the process in motion. They did not write, nor administer the rules. The death machine churned on because of the countless input of faceless bureaucrats who pushed paper – setting train schedules, ordering Zyklon B, hiring camp guards and, yes, writing the rules.

Free-market medicine is not perfect. In a free society, people are free to make bad economic and personal decisions. But if people obtain medical care in the same way they purchase cell phones and Apple iPads, using their own money and decision making, the ability for systemic widespread medical murder, the ability to disenfranchise whole segments of society is also avoided.

It should be chilling to all seniors, and to all parents of young children, that the architects of the current plan use age as a major determinant of who gets medical care in the future. The people who are writing the rules today truly believe that they have formulas for determining whose life is more valuable (the “disability-adjusted life year”). And they base it on age and disability factors. If you are under two, or over 60 years old, you will not be given medical care dollars because you are not as worthy as the 30-year-old, tax-paying citizen.

When government pays, government makes the rules. When you pay, sometimes with help from your friends, family, church, workplace and community, you decide.

What is your choice?

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