Rationing: Why It Is Ethical

Why is the prioritization of health care and rationing such a third rail of health care reform? Individuals are continually forced every day to prioritize their own resources, deciding what to use them for and what to forego. The process couldn’t be more familiar.

Since our wants typically outrun our resources, we learn to make the choices and move on to the next ones. So why is the very idea of prioritizing and rationing health care resources so troubling and controversial?

Americans are deeply ambivalent and inconsistent about health care costs and rationing. On the one hand, many like to pretend that rationing does not take place, but on the other hand they fear being denied beneficial care, in particular payment by their health insurance plans for care they need.

Many say that we are a rich country and have no need to ration health care, but on the other hand they resist rising costs of health care, particularly when they result in greater out-of-pocket costs to them. Many say that life is precious and money should not enter into decisions about medical treatment, but on the other hand they resist the ever increasing proportion of both our national wealth and their own wealth that goes to health care. Many recognize the need to limit the use of some health care, but on the other hand resist those limits when they are applied to them or others about whom they care deeply.

Now these inconsistencies might simply reflect a perfectly common and understandable desire to have more of a valued good like health care, but not to pay more for it. For goods that we must purchase in a marketplace, we soon learn that this is not a desire that can be satisfied – if we want more, we must pay more, and so we must decide how much that is worth to us in comparison with other uses for our resources.

Most Americans, however, do not pay out of pocket the full, or even most, costs of the health care they receive. If insurance pays, it is hardly surprising that we do not support rationing which will have the effect of denying some health care to us.

Rationing is the allocation of a good under conditions of scarcity, which necessarily implies that some who want and could be benefited by that good will not receive it. This allocation or rationing can take place by many means. The use of a market to distribute a good is one common way to ration it.

Most Americans reject ability to pay as the basis for distributing health care. They do not view health care as just another commodity. Despite this widespread view, we remain the only developed country without some form of universal health insurance, and so for the 46 million Americans without health insurance their access to health care often does depend on their ability to pay for it.

Rationing largely remains a topic that the public, their elected leaders, and many health care professionals prefer to avoid. The avoidance takes many forms. As already noted, a prominent one is just to deny that significant rationing takes place. When this denial becomes increasingly difficult to maintain in the face of the realities of the health care system, a typical alternative strategy is to condemn rationing as unjust or unethical and so to deny that it should take place.

If people widely believe that health care rationing does not take place, and that if it did it would be wrong, it is hardly surprising that we have not had a responsible public debate about when and how it should be done. But both of these beliefs that health care rationing does not take place, and that if it did it would be wrong, are false.

Perhaps it is inevitable that rationing must occur if others limit resources available to physicians to care for their patients, but many deny that resources should be limited in this way. This is a mistake, however, and it is important to understand why.

As long as there is some limit to the resources available for health care, health care will have to be allocated to those who need or want it – with not everyone getting all they need or want. Allocation in the face of scarcity is inevitable.

The only to avoid scarcity in the health sector would be to provide all services to all patients who are expected to benefit, no matter how small and uncertain the benefits, and no matter how high the costs. This is clearly impossible.

Everyone might benefit from having a private physician accompany us when we travel, or from unlimited resources for research for diseases that we have or have some chance of getting. Everyone may benefit from having an MRI on the very tiny chance that a brain tumor may be causing the headache they are experiencing. Yet none of this would be possible without enormous increases in health care costs.

More important, even if possible, none of it would be rational or desirable. To avoid scarcity by providing everyone with all care of any positive expected benefit would have tremendous opportunity costs.

We would have to devote enormous additional resources to health care that produced minimal benefits when we could have used them to produce vastly greater benefits elsewhere, such as in education or rebuilding the country’s infrastructure. Even within the health sector, trying to provide all beneficial care for some patients regardless of costs would inevitably prevent us from treating other patients who would benefit more.

So the only way of avoiding the need to ration health care would be irrational and undesirable. It would also be arguably unethical. We would have to use resources in a very inefficient manner producing far less by way of overall benefits for the population served than if we did ration care.

And since society has other ethical responsibilities to its citizens in areas such as personal and national security, education, and so forth, failing to ration health care would inevitably result in failing to meet these other ethical and political responsibilities and obligations. How to ration health care is the subject for another blog, but that it is and should be done is undeniable. Health policy analysts understand all this – the momentous task for health reform is to bring the public to understand and accept it.

Dan W. Brock, PhD, is Frances Glessner Lee Professor of Medical Ethics, and Director of the Division of Medical Ethics at the Harvard Medical School, where he also directs the University Program in Ethics and Health. He was a member of the Ethics Working Group of the Clinton Task Force on National Health Reform in 1993 and is an elected member of the Institute of Medicine. His most recent book is From Chance to Choice: Genetics and Justice (with Allen Buchanan, Norman Daniels and Daniel Wikler), and his main current research interests are in health care resource prioritization. This blog draws from his paper, “Health care Resource Prioritization and Rationing: Why is it so Difficult?” Social Research, 74, 1 (2007): 125–148. dan_​brock@​hms.​harvard.​edu; 617–432-5131.

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  1. Alan Jay Weisbard says:

    Thanks to Brother Brock for his customarily clear and acute comments. A couple of questions:

    First, do we have any empirically-grounded evidence of what laypeople think “rationing” means in the health care context? The clearest examples of rationing in American memories are ration cards going back to WWII and gas rationing from the 1970s.
    I don’t think most ordinary folk (those terrified by politicized use of scare words) view “rationing” as fundamentally equivalent to “allocation”, or view “rationing by price” as a form of rationing. I suspect many are just confused about what the word means, or might mean, in this context.

    More specifically, I rather doubt that most non-experts are aware of the degree to which decisions by insurance companies about what they will cover–not to speak of implicit value judgments by physicians about what treatment options they will offer tp patients in particular circumstances–are themselves forms of rationing that are pervasive in contemporary health care (just as many who are terrified about “government bureaucrats” getting between doctors and patients don’t fully realize that the government bureaucrats will have to oust the platoon of insurance bureaucrats currently in place to find room for themselves…).

    It is a rather sad reflection on our politics, and on society’s state of (im-)maturity on these issues, that straightforward, adult conversation on the ruinous implications of pursuing very high cost, very low efficacy medical interventions is (and has been, for decades)so difficult to conduct. Perhaps those with expertise in behavioral psychology and economics could find a better way to frame these issues so that more rational discourse could take place in the public realm.

  2. Joe White says:

    This posting made me want to scream. What is it about so many “ethicists” that makes them blind to choices and consequences?

    Imagine that someone took you into the woods with three other people. The three other people were a young child of no particular distinguishing characteristics, a middle-aged drunkard with a family, and a 75-year-old Nobel Prize winner. They then told you that you had to shoot and kill one of those three people, and that, if you did not do so, the person who gave you the gun would go back and kill your child. What would you do?

    Ethicists of Professor Brock’s ilk apparently could go through all sorts of analyses of the relative costs and benefits from a social or moral perspective of killing each of the three suggested victims. The child has more quality-adjusted life-years, multiple lives depend (not very well) on the drunkard, the Nobel Prize winner has made huge contributions to society but may not have much longer to contribute. But I have to wonder if they would see the quite logical answer:

    Shoot the guy who gave you the choice. Then they can’t go back and kill your child, and the rest of you can all go home.

    I feel this way when someone talks about the great need to ration healthcare. They are either making an obvious but trivial point, or totally ignoring an entire moral and practical dimension.

    The United States spends 16% of GDP on its health care, and there is good reason, from looking at other countries’ systems, to believe we could provide not only as much health but essentially the same basket of services, to all our citizens, for maybe 12% of GDP, if we had financing and payment arrangements more similar to the international standard.

    The most fundamental ethical conflict in our medical system isn’t which care to provide. It is the clash between the self-interest of sick people and the self-interest of all the individuals who make money from the health care system. Yes, resources in the form of money to pay for care are limited. But that does not mean the only choice is to ration care. It can mean that the right thing to do is to pay less to many of the people who are making so much money from the system.

    Some surely deserve their current levels of income. But some of the incomes in our current system provide no social value at all; and others are quite likely significantly higher than they need to be. If we ignore the option of reducing the payments for care, including eliminating the unnecessary non-care, then we are allowing all the people who make those inoomes to tell us, essentially, “shoot the patients but keep us whole.”

    Personally, I find an analysis that ignores this dimension morally reprehensible. It takes for granted the distribution of power and income in the system, assumes it is inviolate, and moves on to which patients to hurt. I don’t see how that is wise or ethical.

    Now, ARE there medical services that should not be provided to some people, at some times? Sure. Any system is a system of social sharing. In that system, we make (or should make) decisions about what services we consider so important that they should be available to all fellow-citizens according to their need. In a decent society (which apparently does not include the United States) there is some guarantee of care to all who need it. But that does not include anything anyone can imagine — cosmetic surgery for vanity purposes for example, or abortion. Any definition of a benefit package “rations” in the sense of deciding what to share, and no benefit package is infinite. In that sense the claim that we need to “ration” is trivial.

    Nor is there anything wrong with saying that care must meet some threshold expectation of actually doing some good in order for it to be the subject of social sharing. The ethical failure occurs when analysts claim that the cost control problems come from failure to “ration” in this sense. If that were true, one would expect the United States to have more physician visits and hospitalizations per capita than is the norm in countries that spend less (all other countries). But that’s not the case.

    Public distrust of “rationing” therefore has three logical bases. The first is a presumption that, if care is really not helpful, it will not be prescribed. That presumption is false in some cases. But, in order for it to be false, one has to have a caregiver who is making a mistake. That brings us to the second factor: the need to choose between trusting one’s caregiver, or trusting some overseer — whether that be a government overseer or a private insurance overseer. The average patient starts out by investing trust in their caregiver, trusting him or her to do all sorts of invasive things, literally putting the patient’s life in the caregivers’ hands. Not surprisingly, the average patient therefore is disposed to, in some ways must, trust the caregiver more than any overseer. The third factor is, the average patient, or at least the average voter, knows full well that there are other ways to save money. The fact that ethicists and many health services researchers do not seem able to recognize that there are alternatives doesn’t mean the public is wrong. So people don’t want to hear about rationing because they don’t like the power relationship it implies and because they don’t think it’s the only option. And they’re right.

    Can we get to a point where “rationing” in the form Professor Brock has in mind may be the best way to control costs? Sure. If we ever get to that point I will be extremely happy (and I should live so long). As it is, there are so many better ways to reduce costs, that it is simply immoral to insist that rationing useful care is the way to start.

    Joe White

  3. bmmg39 says:

    I will be hypocrite if I will say that I don’t need health care in the future. Let’s face it many of us works too hard to gain some benefits like pension plan and health care/benefits when they reached old age. This Public Health care must not be taken for granted by legislative bodies because to us, these will help a lot. Emergency loan might an alternative way to pay our medical and health bill but health care is our privilege. In times of recession we should always have back up plans for our family’s health and our selves as well. We deserve this health care benefits since all our lives we have contributed our all strength to make our economy stable through our profits and taxes.

  4. Alan Jay Weisbard says:

    Peter Singer has a piece on this subject scheduled for publication in the NYT Sunday Magazine on July 19. Here is a link: http://​www​.nytimes​.com/​2​0​0​9​/​0​7​/​1​9​/​m​a​g​a​z​i​n​e​/​1​9​h​e​a​l​t​h​c​a​r​e​-​t​.​h​tml

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  1. […] debating the whole process of rationing: for the media and the politicians to debate the ethics (Dan Brock opines “rationing: why it is ethical in Health Care Cost Monitor for The Hastings C… and philosophy of rationing, and to open the way for a pragmatic, planned approach. It will be […]

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