The assumptions of ethical rationing: An unreasonable man’s response to Magelssen et al.

Abstract

Contributors to the debate on ethical rationing bring with them assumptions about the proper role of moral theories in practical discourse, which seem reasonable, realistic and pragmatic. These assumptions function to define the remit of bioethical discourse and to determine conceptions of proper methodology and causal reasoning in the area. However well intentioned, the desire to be realistic in this sense may lead us to judge the adequacy of a theory precisely with reference to its ability to deliver apparently determinate answers to questions that strike most practitioners and patients as morally arbitrary. By providing ethical solutions that work given the world as it is, work in clinical ethics may serve to endorse or protect from scrutiny the very structures that need to change if real moral progress is to be possible. Such work can help to foster the illusion that fundamentally arbitrary decisions are 'grounded' in objective, impartial reasoning, bestowing academic credibility on policies and processes, making it subsequently harder for others to criticise those processes. As theorists, we need to reflect on our political role and how best to foster virtuous, critical practice, if we are to avoid making contributions to the debate that not only do no good, but may even be harmful. A recent debate in this journal illustrates these issues effectively.

‘If he dies with the papers of his brother, his brother will be considered dead’. Moral understandings of health professionals about the use of deception to overcome restrictions in access to healthcare

“…We note remarkable similarities between this notion of a necessary lie and Richard's notion of therapeutic privilege, justifying the use of deception towards patients in some highly exceptional situations, in spite of the general rule of informed consent. 18 Loughlin 23 points to the potential subversive and political meaning of invoking professional ethics to challenge bedside rationing. He states that following one's moral remit, when a system prevents health professionals from giving people the care they deserve, creates a political imperative for change.…”

“…35 Although the confidential relationship between health professional and patient does offer some protection from external interference, this dyadic relationship is, in many cases, insufficient to offer an individual patient comprehensive, state-ofthe-art healthcare, given the current complexity and sub-specialization of the healthcare system. An exclusive focus on professional integrity -as Loughlin 23 and Wyller 24 propose -puts too much emphasis on the individual health professional. We cannot expect that health professionals will claim their professional autonomy regardless of the potential losses or retaliations by their employing organizations and wider society.…”

“…In the last few years, there has been a considerable debate on ethical bedside rationing. [21][22][23][24] This debate focuses on policies imposing a given resourceallocation in a context of scarcity of healthcare resources. 21 With regard to the question whether rationing by health professionals is acceptable and/or unavoidable, Magelssen et al 22 advocate that bedside rationing in healthcare is unavoidable and that it is reasonable for health professionals to portion out healthcare resources and decline certain health services to patients, based on bioethical theories providing guidance on how to ration ethically in particular cases.…”

“…Whereas rationing is defended on macro-utilitarian grounds, deontological approaches stress a primary obligation of health professionals to the patient in front of them, 21,24 claiming that the 'ethos of the profession' entails the implicit need to challenge underfunding or restraints that are perceived as arbitrary. 23 Therefore, Loughlin 23 advocates for a strategic attitude of 'critical citizenry' when a system prevents health professionals 'from giving people the care they deserve'. For Wyller 24 'rationing is the hallmark of politics' and the need for bedside rationing by health professionals should be limited and confined to the political practice as far as possible.…”

“…At the macro-level, health economists allocate funds for specific illnesses and groups, based on QUALY's treatment-efficacy and the consequentialist promise to offer the highest net total of health. 23 Migration policies exclude specific groups, based on administrative status, membership and the communitarian promise to protect the health of the community. Yet in both contexts, questions arise with regard to competing interests (promoting one group's needs might lead to rationing the care for another) and the problematization of partiality of the health professional (e.g.…”