Morris et al (2007) state that no health care system in the world has achieved levels of spending sufficient to meet all its patients’ wants for health care. With an ageing population and new technological advances every day,

 “every new medical development that allows the previously untreatable to be treated is increasing need.” (Naidoo & Wills, 2001 p233)

Demand for healthcare and resources is growing faster than ever, however supply is not. It is evident that all needs cannot be met. Furthermore, with the increasing pressure on resources, people will have higher expectations of health and health care and of the decision making process, this will require decisions to be explicit and evidence based. (Gray, 1998)

Rationing can be defined as the withholding of potentially beneficial health care through financial or organisational features of the healthcare system in question. The definition is wide enough to cover the view that the refusing of treatment perceived to be beneficial should be seen as a question of rationing. (Norheim, 1999) Norheim also states one of the basic assumptions in published reports on priority setting in health care is that services with no documented positive result can be withheld justifiably.

It could be stated that rationing is very unfair, as people living within a few miles of each other here in the United Kingdom can receive different care for the same illness, depending on their local Primary Care Trust. This is what has commonly become known as the ‘postcode lottery’ – a situation receiving much media attention, causing political debate and being branded an ‘unsatisfactory state of affairs.’ There are several stories all over the U.K. regarding patients being denied treatment they desperately need; these stories receiving much national media coverage, and causing much negative thought to any PCT in question.

Rationing also contributes toward health inequalities. One type of rationing is rationing by deterrence. This is when patients are discouraged from seeking treatment, for example by high prescription charges. This is unfair to lower social classes, should we look towards following Scotland’s example in making prescriptions free to all?

There are many questions that are asked as a result of rationing. Is it not morally wrong to withhold treatment from someone who really needs it? Especially when a few miles away, another person could be eligible to receive this very same treatment.

In such situations, decisions have to be made about who is to receive treatment, and it seems vital that these decisions be just: that is, that they be made in accordance with an acceptable principle of justice.
In Kantian ethics, it is motive that is the most important factor in determining what is moral. The overall motive here is to provide healthcare that has a good evidence base and is cost effective. In a sense denying a patient the treatment they need could be described as ‘sacrificing an individual to benefit others’ (denying a patient treatment, and using resources on other patients) - this is wrong according to Kant. Though the motive may also be to give the patient the best care, this is not always possible due to rationing. The sense of duty however is also important, and by denying the patient treatment they need, it could be argued that the medical team are denying their sense of duty which would make the decision unethical. Physicians, because of their training and position in society to heal, must remain moral agents, structuring this into medical practices and hospital settings with existing reimbursement systems and scarce resources must be acknowledged as difficult.

Clinical guidelines from NICE have been developed by a rigorous process using the highest-level evidence base. Their objectives are to reduce the variations in clinical care and end the postcode lottery of healthcare delivery. Given its role in its review of expensive drugs and new health technologies, NICE could indeed be seen as a form of explicit national rationing.

NICE comes under fire regarding its use of the QALY system - The QALY (Quality Adjusted Life Years) is a system that attempts to maximise benefits from healthcare spending, it attaches a value to life or quality of life.

Quigley (2007) states that when we engage in the sort of evaluations inherent in QALYs, we make value judgements about the kind of people that we think are worth the expenditure of public resources. Particularly, we are saying that we think those people who belong to a specific group have more worthwhile lives. By using the QALY we are implicitly (or possibly explicitly) accepting that those patients with a better quality of life and who live longer have more worthwhile lives. Though it may be acceptable to hold a private view concerning this, we must not allow these personal opinions to creep into public policy.
 Some believe QALYs to be ageist because providing treatment for younger people is likely to give a better QALY calculation. Individuals who have a longer life ahead of them, usually a younger person, would gain more from treatment on the basis of their predicted life expectancy in comparison with an older person who would have less years to benefit from a specific treatment.

The QALY by its very nature incorporates specified values (quality of life and life-years), and when these values are the basis of choosing between patients competing for healthcare resources then it can be said to make implicit value judgements on the lives of these patients. Therefore, it is simply a falsehood to state QALYs do not measure the worth of patients because this is exactly what it does. (Quigley, 2007)
It is argued that those who have a disability would be deemed to have a lower quality of life and for that reason would benefit less from treatment for a separate condition than those without a disability who, with treatment could have full health restored.

Claxton and Culyer (2008) on the other hand state NICE evaluates the value of treatments and not of patients. The inherent worth of individuals (for NICE, all individuals have the same inherent worth. For example, people who are known and those who are anonymous, the young and the old, those with very poor health and those with exceptional health. Of course, the measure of health outcome NICE uses is not the only possible one; nor are the social value judgements necessary in the construction and use of QALY the only ones that could be made. The alternatives, however, at best have little more to commend them, some are impractical and are even more controversial than NICE’s choices.

It is, as Claxton and Culyer state safe to presume that there may be no right answer to the dilemma of rationing. Or if there is, there may be more than one.

In my opinion, doctors should be at the forefront of the decision making, hopefully this will lead to ‘good rationing’ and will be more widely accepted by the public – research has shown that the public is far happier when decisions are made by health professionals, and not made by bureaucrats.
The fairest way to ration at the moment is to base clinical decisions on a sound evidence base. There are many ways that have been suggested to make rationing as fair as possible; such as letting the public know decisions that are reached and informing them of why a particular decision was made. It is true that we must have the moral courage to develop them further without secrecy, this echoes the statements made in the first paragraph regarding explicit and evidence based decisions being made freely accessible to all.

References:

Claxton, K. & Culyer, A.J. (2008) Not a NICE fallacy: a reply to Dr Quigley. Journal of Medical Ethics; 34:598-601.

Gray, J. A. M. Evidence-based policy-making in Haines, A. & Donald, A. (1998) Getting Research findings into Practice. London, BMJ Publishing Group.

Morris, S., Devlin, N. & Parkin, D. (2007) Economic Analysis in Health Care. Chichester, John Wiley & Sons, Ltd.
Naidoo, J. & Wills, J. (2001) Health Studies: An Introduction. Basingstoke, Palgrave.

Norheim, O. F. (1999) Healthcare rationing: are additional criteria needed for assessing evidence based clinical practice guidelines? British Medical Journal. 319:1426-1429
Quigley, M. (2007) A NICE fallacy. Journal of Medical Ethics; 33:465–6.

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	Ethics of Rationing Healthcare pdf.