Bentham in a Box; Technology Assessment and Health Care Allocation

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Bentham in a Box

Technology Assessment and Health Care Allocation

Jeremy Bentham, the founding father of utilitarianism, would have been delighted by technology assessment. Contemporary health policy planners are, unwittingly, aping the great man's felicific calculus, as they attempt to discern the efficacy and safety of magnetic resonance imaging or cardiac bypass surgery or extracorporeal shockwave lithotripsy. They try to design methods to calculate the effects of these technologies on mortality and morbidity and to compare the costs of one to the costs of alternatives. In recent years, the methods of technology assessment have been refined, but they remain, in essence, a copy of Bentham's proposal to plan and effect a rational course of action and to create a rational world.

The great philosopher and social reformer is, of course, still with us in a dessicated form. He bequeathed his body to the fellows of University College, London, and to this day his mummified figure is encased in a glass box, sitting in his favorite chair, dressed in his own clothes, his waxen face peering out with a bemused smile. He is trundled out from time to time for sherry with the dons. Bentham in his box is, in my opinion, an apt symbol for the boxed-in felicific calculus that is modern technology assessment. It is constrained from drawing into its calculations certain crucial elements and thus, like the mummy of its founder, it is but the lifeless, impotent relic of a powerful and vital way of thinking about, and dealing with, the world.

I venture this bizarre and exaggerated image in order to make vivid my thesis about our current efforts to allocate health care resources and to ration medical technologies. We labor under a cribbed, cabined, and confined way of thinking about allocation of medical care; we are as constrained as the great man in his box and we cannot, any more than he can, exercise power and control over the distribution of health care. I shall explain my thesis in several steps: first, by saying something about the philosophers' endeavors to elucidate a theory of justice about health care; second, by relating my personal experience with technology assessment; and third, by stating the reason why I believe we have, and are possibly destined to have always, a boxed-in approach to the problem of health care resource allocation.

First, a word about the philosophers' endeavors. During the last few years, the attention of philosophers has been drawn to the problem of justice in health care. A somewhat neglected problem, it moved up the agenda with the research generated by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research for its report, Securing Access to Health Care. Many fine studies were prepared in the course of that research. At the same time, in the political and social world, the costs of care had caught the attention of policymakers and the Reagan administration had begun its retreat from--or should we say, its attack on--the federal subvention of health care in the United States. The conceptual problem and the practical difficulties combined to bring the issue of just and fair allocation of health care to the head of the agenda. A few years ago this topic was always the last session in bioethics conferences.

The philosophers rightly noted that a theory of justice was needed to resolve the practical problems of just and fair allocation. Several very interesting attempts have been made to supply this theoretical approach. All those efforts have their strengths and weaknesses, which I shall not detail here. I merely want to point to an issue little noted by the philosophers, because of the level of generalization at which they work. All efforts to sketch a theory of justice about health care refer to the utility of medical intervention. It is obvious that there is a problem of just distribution only if that which is to be distributed is a good. …