I quickly read through looking for how Feinberg’s insights into who gets what, can help us with the cost aspect of medical futility: who should get what care?
The one aspect of all his deliberations that stood out to me is this: all his dealings were public, and everyone knew what everybody else was getting. "People will always count other people's money"
At the lowest transaction level, perhaps many of us would be outraged that the xray that costs $100 in a local clinic runs $2000 in some institution -- who's to know? Maybe it is $10,000. Nobody posts prices. I liken this to going to the gas station without a price sign outside, telling the attendant "fill it up with super!", and perhaps charging $50/gallon gas to my "travel credit card" (I’m not paying, “insurance” is). If I had any idea the price was $50/gal, I'd drive right past the place. My point is, most of us don’t know even if it is billed out at $500/gal.
It seems clear that one important factor in addressing cost, is a high level of transparency that is reflective of Feinberg's balance between stinginess and generousity: who gets what ? Do we feel that physicians or surgeons deserve what they are paid (do you know your doctor’s income? how about your health plan administrator)? it's already clear that good, conscientious nursing assistants are underpaid for what they do. How can we make up our minds whether it's ethical or supportable (or even forgiveable), if we don't even know who is getting what ? THAT's the first thing that's broken about the cost of healthcare: it's completely opaque black box.
If we are to make an ethical determination relating to the cost of health care, (is it just? is it ethical?), one of the essential changes is the transparency of costs: how much does it cost, and where does it go? The cost factor in medical futility, is a piece of this larger societal issue and cannot be separated.
Another member of the committee points to the inelasticity of price vs demand/supply in healthcare: right now there is a glut of lobsters in the market: $3.99/lb because the supply is huge. When the supply dries up next year, prices will be back to $9, $12, $14/lb. Prices in healthcare related transactions don’t move like that, so those costs don't respond to normal market changes.
There is also the matter of immediacy: If you need that appendectomy, you're not likely to quibble on price or shop around.
Another non-market feature of many healthcare costs seems to be a large gap between the price of a drug or service, and the incremental cost of delivering it (what does it really cost to manufacture one more pill? trivial! yet the price doesn't drop no matter what else happens...).