Academic journal article
By Katz, Meir
American Journal of Law & Medicine , Vol. 36, No. 1
For years, commentators have debated how to most appropriately allocate scarce medical resources over large populations. In this paper, I abstract the major rationing schema into three general approaches: rationing by price, quantity, and prioritization. Each has both normative appeal and considerable weakness. After exploring them, I present what some commentators have termed the "moral paradigm" as an alternative to broader philosophies designed to encapsulate the universe of options available to allocators (often termed the market, professional, and political paradigms). While not itself an abstraction of any specific viable rationing scheme, it provides a strong basis for the development of a new scheme that offers considerable moral and political appeal often absent from traditionally employed rationing schema.
As I explain, the moral paradigm, in its strong, absolute, and uncompromising version, is economically untenable. This paper articulates a modified version of the moral paradigm that is pluralist in nature rather than absolute. It appeals to the moral, emotional, and irrational sensibilities of each individual person. The moral paradigm, so articulated, can complement any health care delivery system that policy-makers adopt. It functions by granting individuals the ability to appeal to an administrative adjudicatory board designated for this purpose. The adjudicatory board would have the expertise and power to act in response to the complaints of individual aggrieved patients, including those complaints that stem from the moral, religious, ethical, emotional, irrational, or other subjective positions of the patient, and would have plenary power to affirm the denial of access to medical care or to mandate the provision of such care. The board must be designed to facilitate its intended function while creating structural limitations on abuse of power and other excess. I make some specific suggestions on matters of structure and function in the hope of demonstrating both that this adjudicatory model can function and that it can do so immediately, regardless of the underlying health care delivery system or its theoretical underpinnings.
Health care is not cheap. Far from it; in 2009, health care spending in the United States consumed a projected $2.5 trillion or 17-3% of the gross domestic product (GDP).1 In the same year, the average American spent $923 in "out of pocket" health care expenses.'2 While the cost of America's consumption is high relative to the rest of the world, the excessive and growing cost of health care is a global problem. In 2006, total health care spending amounted to 15.8% of the GDP of the United States, 10.0% of the Canadian GDP, 11.0% of the French GDP, and 8.1% of the Japanese GDP.3 Those numbers have been steadily climbing. In 1980, the respective percentages of GDP were 8.7%, 7-0%, 7-0%, and 6.5%.4 Recent estimates suggest that total health care spending in the United States will reach a staggering 19-3% of GDP, or nearly $4.5 trillion, by 2019-5 The same estimates suggest that 2019 per capita expenses will reach $13,387 and out of pocket consumer expenses will reach $1390 (a 50% increase from 2009 out of pocket levels).6 Many commentators have declared that if limits are not placed on access to health care (limiting access being the preferred or most direct means of limiting consumption), health care expenditures can easily reach 100% of GDP in industrialized nations, even without accounting for wasteful expenditures.7
Just as medical resources are costly, so are they scarce. This relationship between cost and scarcity is not merely coincidental; they each cause the other. As scarcity increases without a corresponding reduction in demand, rudimentary price theory dictates that price will increase. Multiplied over a population, these conditions result in decreased access to care and ultimately the death or suffering of individuals who are denied access. …