Posted by Bill Sandweg on 31 May 2021.
Very few words stir more passion when discussing health care than “rationing.” It sounds terrible. It conjures up images of loved ones being denied life-saving treatment. It gives rise to attention-seeking politicians claiming there are “death panels” coming for you and your grandmother. A phrase with the same meaning, but not the same emotional overtones, is “resource allocation.” Either way, they mean the same thing; rationing is here and has been as far back as you care to look.
Here is an excellent article on the necessity of rationing health care and the ethics involved in that process. I will borrow liberally from it in my discussion below.
Rationing occurs at two levels. The first is the macro level. Societal resources are finite while the needs which must be addressed by those resources are limitless. There is only so much money to go around. Bridges must be built. Armies (perhaps) must be funded. Schools must be built and teachers paid. Healthcare is just another social need, which must be paid for out of limited funds. Most people probably don’t even think of macro allocations when considering rationing of health care, but it is clear that decisions made about macro allocations must, of necessity, affect health care availability and decision making at the individual level.
The second level of rationing is the micro level where decisions are made in individual cases. This is what people think of when they think of rationing.
Sometimes, the rationing takes place in such a way that no one even recognizes it as rationing. When a doctor treats a patient in the ICU, for example, the doctor must decide how much of her time to devote to that patient. The doctor has other patients and has a life away from the hospital as well. As a matter of course, the doctor rations her time with each patient based on a number of factors that probably change from patient to patient and from day to day.
We saw rationing at the height of the Covid pandemic. Ventilators were in short supply and not everyone who might have benefited from being on a ventilator had one available to them. ICU beds and even regular hospital beds were sometimes all in use when a new Covid patient arrived at the hospital. The new patient was often placed in the emergency department or even in an empty cafeteria until a bed could open up. Even more critical than the shortage of beds was the exhaustion of the health care providers themselves. Some got sick and died. Those that managed to make it to work every day were overwhelmed by the workload. Some patients certainly died as a result of the scarcity of medical equipment and medical care.
The article I cited has an enlightening discussion of the various principles, which have been suggested for rationing health care. When you look at them, they are based on reasonable arguments but each of them has some flaws and none solves the problem that we as a people recoil from the death of identifiable patients. We are much more accepting of large numbers of impersonal deaths, as shown by our willingness to avoid those steps which might have saved a hundred thousand lives or more during the Covid pandemic.
Among the suggested principles are (1) Utilitarianism (Get the most bang for your buck, the greatest societal good); (2) Egalitarianism (Everyone gets the same chance at the scarce health care maybe by using a lottery system to decide who gets treated); (3) Prioritarianism (One example would be to give priority to young people).
While rationing of health care is a necessity and already occurs in both obvious ways and ways which are not so obvious, we cannot agree on how to do it in a way which avoids controversy. Rationing is at odds with many basic human emotions. Even when we accept the idea of rationing, rationing always looks better and fairer when it is your family member, who is receiving the scarce treatment, and it is someone else who loses out.
The debate over rationing is not going away anytime soon. You can expect it to flare up from time to time before returning to a smoldering glow. On those occasions when it does command the headlines and politicians are trying to make hay with it, remember that rationing is inevitable and look for the person proposing the fairest solution. Don’t let them just decry rationing and not explain how they would allocate scarce medical resources, including money.