rationing medical care

Allocation of scarce medical interventions [-including beds in intensive care units, organs, and vaccines during pandemic influenza-] is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria. During the 1960s, committees in Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependants as criteria. How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested. Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multiprinciple allocation systems. We evaluate three existing systems and then recommend a new one: the complete lives system.

Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. We do not regard ability to pay as a plausible option for the scarce life-saving interventions we discuss. ….

The complete lives system [that we recommend] discriminates against older people. …. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Govind Persad, Alan Wertheimer, Ezekiel J Emanuel, “Principles for allocation of scarce medical interventions”, Lancet, Vol 373 (31 January 2009), pp. 423-431. (Free download, registration required.)

The authors claim BS, PhD and MD degrees, respectively, and work in the Department of Bioethics of the National Institutes of Health (NIS) in Bethesda, Maryland, USA. Dr Emanuel (1957-), who, as Director of the Department, is the superior of his co-authors, is currently Special Advisor for Health Policy to Peter Orszag, the Director of President Obama’s Office of Management and Budget.

Dr Emanuel has become a figure of controversy in the US healthcare debate. Note that he and his co-authors rule out a market solution – increasing price to the point that demand equals supply – in the case of medical interventions. Most – though not all – Canadians would agree. The same is true, I believe, of Europeans. But in the United States, many favour treating health care like any product or service, to be distributed by ability to pay, perhaps with some minimimal distribution of free services to the poor. This, after all, is the way that food, which is essential for life, is distributed: food stamps for the poor, market prices for everyone else.

Dr Emanuel and his colleagues raise very serious and very difficult ethical issues. As Princeton philosopher Peter Singer recently explained, rationing of health care is inevitable. A public debate over how we ration is necessary. Should the wealthy be allowed to spend their own money to jump to the head of the queue? Countries such as Canada and the United Kingdom, with single-payer systems of health care, explicitly prohibit this. The United Kingdom does allow any citizen who has the desire – and the means – to do so to leave the public system and access private health care. Canada so far has not granted its citizens this freedom, but the US border, and a system where health care is rationed only by price, for most Canadians is only a short drive away.

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