Health care rationing - ethical precepts

The open rationing of health care must be grounded in ethics, since, if we were not primarily concerned with maintaining our fundamental ethical principles, we might as well let the “every man for himself” milieu of covert rationing persist. So it is important to clearly articulate the ethical precepts we will strive to adhere to as we do the actual “dirty work” of rationing – that is, as we prioritize services to determine what will be covered and not covered.

The problem is, rationing itself creates ethical dilemmas. Specifically, as we consider how to ration ethically, ethical precepts, instead of giving us clear guidance as to how to go about prioritizing health care services, create conflict. When we articulate our ethical standards for rationing, then, we are going to have to make some difficult decisions. These ethical decisions will be the most difficult step we’ll have in devising a system for rationing, and potentially will be the strongest determinant of our success or failure. We should therefore consider them in some detail.

Fundamental ethical precepts

There are three basic ethical precepts that are supposed to guide the activities of health care professionals: individual autonomy, beneficence, and distributive justice.

Individual autonomy we have discussed at length. The right of self-determination is not only an important principle of medical ethics, but also is the founding principle of our culture. But autonomy has its limits. When a patient demands that “everything be done,” for instance, he is exceeding the bounds of autonomy if doing everything means that some other individuals would be deprived of what otherwise would be rightfully theirs. Hence, the principle of autonomy itself does not negate the legitimacy of rationing, as some have claimed. This principle merely indicates that, within a system of rationing and bound by the limits of that system, individuals have a right to self-determination.

Beneficence is the precept that requires health care professionals to assure that their activities provide benefit for patients. In terms of rationing, beneficence implies that rationing ought to be done in such a way as to maximize the good (i.e., the total public good) that can be achieved from the limited health care resources available.

Distributive justice is the precept that requires the benefits of health care to be distributed fairly, that is, in such a way as not to discriminate against individuals or groups based on who they are. Distributive justice implies that under rationing, all individuals ought to have equal opportunities to receive medical services, and that such opportunities should not be withheld on the grounds of race, ethnic group, gender, or any other feature that could be used to create a unique category of individuals.

Assuring fairness v. maximizing good

The first thing we need to recognize is that the rationing of health care immediately presents us with a difficult ethical dilemma. (Ethical dilemmas occur when two or more ethical precepts appear to be in conflict.) In the case of rationing, the conflicting precepts are those of beneficence and distributive justice.

If we have to ration health care, we want the rationing process to do two things. We want it to be fair (i.e., we want to adhere to the precept of distributive justice), and we want it to yield the maximum amount of health care benefit for the dollar (i.e., we want to adhere to the precept of beneficence.) Unfortunately, maximizing these two goals is mutually exclusive.

To see why, consider the following illustration. Two men, both age 50, are diagnosed with the same rare form of cancer. We have the means to cure this form of cancer, but unfortunately, we can only afford to treat one of the two men. The first man is otherwise healthy and if cured can be expected to recover fully. The second is bedridden with severe multiple sclerosis, and if cured of cancer will still be severely disabled and will almost certainly have a reduced life expectancy due to that disability. Which man do we treat?

Some would say that, obviously, we should treat the man who is otherwise healthy, since we would be buying him a high-quality life of substantial duration. This would clearly maximize the good we achieve with our money.

Others would point out that the second man (the one with MS) wants to live just as badly as the first man, and that withholding therapy from him just because of his MS is unfair. It is unfair because it would be exposing him to double jeopardy (first jeopardy – he was afflicted with MS; second jeopardy – his MS precludes his receiving cancer therapy). And it is unfair because discriminating against people with MS is, a priori, a violation of the principle of distributive justice. Fairness dictates that all individuals should have an equal claim to the benefits of therapy.

How we decide to distribute our resources in this case (and in every case) depends on how we prioritize these two conflicting ethical principles. Say we were determined to completely maximize fairness. The only way to do this would be to withhold therapy from both men (since this would be the only option that would “equalize” the results). But then they would both die, and our method of distribution would reduce the good we’ve achieved to zero. On the other hand, if we decided to maximize beneficence we would obviously treat the otherwise healthy man; but choosing to do this (since we would be removing the patient with MS from all consideration) would reduce fairness to zero.

Or, we may decide to choose which man to treat by lottery (perhaps even a weighted lottery, giving the man who is otherwise healthy a higher probability of being chosen, in proportion to his better quality of life.) This would split the difference between maximizing fairness and maximizing good. But we would need to understand that, spread out over a large population, this solution (while preserving a degree of fairness) would significantly reduce the overall good we would be able to achieve with our health care dollars.

No matter what we do, then, we cannot both maximize good and maximize fairness. We’ve got to choose between them.

The individual vs. society. The essential dichotomy between maximizing fairness and maximizing good perfectly reflects the conflict we’ve touched upon many times in this book – that between the individual and society. To emphasize fairness is to emphasize the essential worth (i.e., the essential equality) of individuals. To emphasize the overall public good is to emphasize the claims of society. The conflict arises because the claims of both the individual and of society cannot be absolute. Somehow, we need to strike a balance.

In any case, it should be apparent that the basic ethical dilemma inherent in devising a rationing scheme is more than just of theoretical importance. How we deal with our choice of fairness vs. good will go a long way in determining whether open rationing ends up being a significant improvement in what we have now, or whether it ends up as badly as many fear it might.

An argument for giving primacy to fairness

While we certainly ought to try to get as much bang from our health care buck as possible, we should not do so the expense of sacrificing distributive justice. In rationing health care we should strenuously avoid discrimination against individuals or groups by virtue of (in addition to the traditional discriminatory factors of race, gender, nationality, etc.) their genetic makeup, or diseases and disabilities imposed on them by nature.

Why should assuring fairness predominate over maximizing good? Because once we set the precedent of assigning comparative values to human lives based on disease or disability, it will be difficult to turn back but easy to advance. Especially since the stakes are high, the temptation will always be to expand the categories of individuals whose lives are judged to be relatively valueless. We should not assume that we will be significantly more resistant to such behavior than other advanced cultures have proven to be in the recent past.

On the other hand, if we limit good in the name of fairness, we can always come back later (when new data is available, when new treatments are available, when new efficiencies arise, or when budgetary constraints are eased) to expand the list of covered services, and thus expand the good.

Since withheld “good” can be returned whereas “fairness,” once gone, is extraordinarily difficult to regain, the precept of fairness should take precedence. We should try to optimize the benefits our health care system provides to society, but only within the constraints imposed by our belief in the primacy of the individual.

Next: A proposed ethical standard for rationing

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