Allocating Health Care: Cost-Utility Analysis, Informed Democratic Decision Making, or the Veil of Ignorance?

Abstract

Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.

The doctor-patient relationship

“…It allows physicians to be better advocates for their patients and allows patients some power by virtue of the personal relationship they have with this physician. Patients value continuity in and of itself, apart from its effect on health outcomes, 40,41 although its current value seems to be about $15 per month in added premium. Industry estimates are that an average patient will change plans and doctors if continuity Review contracts for potential effects on doctor-patient relationship Structure employer contracts to encourage accountability to members Promote candor in advertising (and elsewhere) JGIM costs more than $180 per year.…”

Les politiques sociales et l’équité. Un programme de recherche

“…Le succès prodigieux d'un John Rawls et de sa Theory of Justice (1971) ne peut être dissocié de cet aspect proprement méthodologique : avant d'être une oeuvre de philosophie morale, le livre est d'abord un modèle d'argumentation rationnelle, fondée sur l'examen rigoureux de propositions cohérentes et interdépendantes, réunies dans une même représentation de la justice sociale (Boyer, 1988;Pettit, 1980). Cela dit, l'application de la méthode axiomatique aux problè-mes sociaux ne donne pas toujours des résultats probants, malgré plusieurs tentatives de très bon niveau dans le domaine de la santé (Goold, 1996;Veatch, 1991Veatch, et 1981Daniels, 1985). La nature des questions en examen y est peut-être pour quelque chose, car les « choix tragiques » (Calabresi et Bobbitt, 1978) et autres situations de crise ne s'accommodent pas facilement d'une démarche souvent artificielle, plus occupée de sa propre logique que de l'adéquation du modèle à la réalité.…”

The role of bioethics and business ethics

“…Several authors argue that greater oversight of health care plans should include committees involving providers and patients as well as administrators in policy decisions. [17][18][19] Such oversight measures are necessary if the recently reconstituted clinical triad is to be truly relational and accountable, and able to assume the difficult charge of adjudicating conflicting needs and goals of the individual patient and insured population.…”