The Ethics and Reality of Rationing in Medicine

Abstract

Health-care reform has remained a controversial sociopolitical issue for the last 2 decades. Part of the controversy at the policy level arises from the question of whether health-care reform will involve rationing medical care. This topic raises fears about unfair treatment of individuals, 1 which have been infl amed by assertions that rationing devalues human life. 2 Physicians have struggled with the controversy surrounding rationing. 3,4 Some deny that rationing occurs and contend that their professional obligations require them not to participate in rationing. [5][6][7] Others admit to rationing 8,9 and see just allocation of medical care as part of physicians' ethical duties. 10 Intensivists share this ambivalence. In a recent survey, only 60% vouched that they provide "every patient all benefi cial therapies without regard to costs." 11 To be thoughtful participants in the social debate about rationing in medicine, physicians must be well informed. The purpose of this article is to address the following topics: (1) the inevitability of rationing of social goods, including medical care; (2) types of rationing; (3) ethical principles and procedures for fair allocation; and (4) whether rationing ICU care to those near the end of life would result in substantial cost savings. What Is Rationing?Although rationing has been defi ned in slightly different ways by different groups, most defi nitions cluster around one central idea: denying a potentially benefi cial treatment to a patient on the grounds of scarcity. 12 The focus on potentially benefi cial Rationing is the allocation of scarce resources, which in health care necessarily entails withholding potentially benefi cial treatments from some individuals. Rationing is unavoidable because need is limitless and resources are not. How rationing occurs is important because it not only affects individual lives but also expresses society's most important values. This article discusses the following topics: (1) the inevitability of rationing of social goods, including medical care; (2) types of rationing; (3) ethical principles and procedures for fair allocation; and (4) whether rationing ICU care to those near the end of life would result in substantial cost savings.

Analysis of referrals and triage patterns in a South African metropolitan adult intensive care service

“…When comparing this figure with international data, it should be borne in mind that many of the refusals in HICs are on the basis of no available bed. [1,2,16] In our study, no patient was refused on the basis of no bed, but patients were accepted for admission pending availability of a bed. This discrepancy in detail reduces the significance of comparisons between our study population and international trends.…”

“…Triage statistics from the USA quote a figure of 15% of referrals refused admission, while in the UK up to 21% of all patients referred are refused admission. [1,2,16] …”

The International Right to Health: What Does It Mean in Legal Practice and How Can It Affect Priority Setting for Universal Health Coverage?

“…Attempting to meet the maximal health care needs of every individual would overwhelm a society's capacity to provide other social goods, such as education and defense. 21 The question, then, is: what is a reasonable principle for allocating resources, and to what body is the decision maker accountable in applying such a principle? Equity and ethics should be critical considerations to ensure proper priority setting.…”

Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis

“…2 However, discussions of rationing over the past 5 years consistently note there is no agreed upon definition, and point out that the term is often used synonymously with ideas such as 'resource allocation,' 'priority setting' and 'cost containment.' [3][4][5][6] The political processes surrounding the Affordable Care Act in the United States, and the National Health Service in the United Kingdom have added to the conceptual and methodological struggle to measure and understand clinician attitudes and willingness to accept rationing either in their own practice or through policy measures. [3][4][5] Even what is considered rationing is unclear; for example, limitations on services by ability to pay, or lack of care resulting from lack of health insurance, is seen as implicit rationing by some definitions, but not others.…”

“…[3][4][5] Even what is considered rationing is unclear; for example, limitations on services by ability to pay, or lack of care resulting from lack of health insurance, is seen as implicit rationing by some definitions, but not others. 2 , 5 , 6 By not directly asking about rationing, Sheeler et al avoided possible reactions to the term itself, and stated this could prompt more professional discourse on the topic. 1 However, given the widespread disagreement on what does and does not constitute rationing, the conclusions drawn could be inadvertently misleading and may be inconsistent with the intent of survey participants at the time they answered the questions.…”