Academic journal article Public Health Reviews; Rennes

Ethics of Resource Allocation and Rationing Medical Care in a Time of Fiscal Restraint - US and Europe

Academic journal article Public Health Reviews; Rennes

Ethics of Resource Allocation and Rationing Medical Care in a Time of Fiscal Restraint - US and Europe

Article excerpt


At some level, all resources are scarce and that is certainly true for health care. In the face of scarcity, resources are either explicitly or implicitly rationed. Rationing of health care limits access to beneficial health care services.1 The central question, then, is not whether health care is rationed, but how, by whom and to what degree. The ethical dilemma is how to balance the precepts of autonomy, beneficence, and distributive justice.2 Autonomy would suggest that individuals have a right to determine what is in their own best interest, though that interest may be limited if exercising that right limits the rights of others. Beneficence means that clinicians should act completely in the interest of their patients, and distributive justice or equity implies fairness and that all groups have an equal right to clinical services regardless of race, gender, age, income, or any other characteristic. The utilitarian perspective would suggest that resources for medical care should be used to provide the greatest good for the greatest number. However, in medical care, the "rule of rescue" is often invoked to provide services to the neediest or the most identifiable. A corollary is that therapeutic services are often given primacy over preventive services regardless of their cost effectiveness. Different countries balance the rights of individuals and the fairness in society as a whole in very different ways and use very different processes for addressing the legitimacy, transparency, and accountability of those explicit or implicit decisions.

Ultimately, rationing has to be assessed against these broader societal and health system goals. Health system goals can be defined in a number of ways. One of the most widely quoted attempts, the WHO World Health Report 2000, defined the fundamental objectives of health systems as improving population health, responding to people's expectations, and providing financial protection against the costs of ill health.3 Health, of course, is not only determined by health care, but also by broader social and environmental factors. While equity in health care financing and in access to health care services can reduce inequities, equity in health outcomes should be another goal of health systems.4,5


All health care systems rely on a mix of public and private systems of financing and decisions on rationing are made by actors in both the public and private sector, with important differences between the United States and Europe. Overall, rationing can affect three dimensions of coverage: breadth (the share of the population covered), scope (which services are covered) and depth (the extent or cost share to which services are covered).5

Implicitly or explicitly rationing the breadth of coverage reduces the proportion of the population eligible for coverage. This can be through means-testing (e.g., excluding those with higher incomes), employment (e.g., excluding self-employed people), pricing them out of the market (e.g., by making coverage unaffordable for people with pre-existing conditions), excluding people from eligibility (e.g., those who do not meet certain residency requirements), or by allowing people to opt out.

Rationing the scope of care by excluding services from the benefits package (which may be implicit or explicit and based on a positive or negative list) reduces the quantity or quality of clinical care. This can be achieved through application of criteria and measures such as effectiveness, comparative effectiveness, or cost-effectiveness, and making use of such tools as health technology assessments (HTAs), clinical guidelines or quality assurance.6 Many health care systems also ration the scope of care by waiting lists.

Rationing the depth of coverage involves user charges. These can be based on the value of health care services and imply selective charges (co-payments) for inefficient services or reduced charges for especially valuable ones (value-based insurance design). …

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