Cost containment does not equal rationing, and eliminating administrative waste, medical waste, and unwanted interventions for the profoundly and incurably ill before rationing needed services best realizes the principles of beneficence and justice. However, if rationing of truly beneficial services were needed, the issues become more difficult. If a health care system or program must compromise beneficence because of true fiscal scarcity, how can this compromise be made in a manner that yields the least harm and allocates the harm in the fairest possible way?
Joy Fortune develops Hodgkin’s disease, or cancer of the lymphatic system; she receives radiation therapy and is cured. Jessica Turner is moribund from advanced metastatic cancer of the pancreas. She undergoes chemotherapy and dies within 3 days.
In the event of rationing, science is the best guide: the providing or withholding of care is ideally determined by the probability that the treatment will maximize benefits and minimize harm, that is by the criterion of medical effectiveness. Radiation therapy can often cure Hodgkin’s disease, but chemotherapy is unlikely to provide much benefit to people with advanced pancreatic cancer. If rationing is needed and only one of these therapies can be offered, a decision based on the criterion of medical effectiveness would allow for the treatment of Hodgkin’s disease but not of terminal pancreatic cancer.
If intervention A increases person-years of reasonable-quality life more than intervention B, intervention A is more medically effective. The cost of the two interventions is not considered. Cost effectiveness adds dollars to the equation: If intervention A increases person-years of reasonable-quality life per dollar spent more than intervention B, it is more cost effective. Which is a better standard for rationing medical care: medical effectiveness or cost effectiveness?
If money were not scarce, medical effectiveness (maximizing benefit and minimizing harm) would be the ideal standard upon which to ration care (i.e., the less effective the therapy, the lower its priority on the list of treatments to be offered). But it is unrealistic to pretend that costs can be ignored (Garber & Sox, 2010). Suppose that bone marrow transplantation saves as many person-years of life by treating advanced cancers as does doxycycline by curing pneumonia. The former costs $250,000, while the latter can be obtained for $25. There is no reason to ration doxycycline, as its cost is negligible, whereas to make bone marrow transplantation similarly accessible is costly. Thus consideration of costs is essential if rationing were needed.
Rationing for Society as a Whole
Mrs. Smith’s breast cancer spread to her liver and bone. Twenty years ago, she was told that her only slim hope lies in high-dose chemotherapy with autologous bone marrow transplantation (HDC-ABMT), costing $250,000. Even with the optimistic assumption that HDC-ABMT had a 5% cure rate, screening mammography was eight times as cost effective as HDC-ABMT in person-years of life saved.
In 1991, Dr. David Eddy (1991a) published a compelling article entitled “The individual vs society: Is there a conflict?” Dr. Eddy posed the preceding case of Mrs. Smith. If medical care must be rationed, it seems logical to spend funds on mammography rather than HDC-ABMT because the former intervention is more cost effective. Dr. Eddy did not confine his analysis to cost effectiveness, however, but moved on to the ethical issues.
Each of us can be in two positions when we make judgments about the value of different health care activities. We are in one position when we are healthy, contemplating diseases we might get, and writing out checks for taxes and insurance premiums. Call this the “first position.” We are in a different position when we actually have a disease, are sitting in a physician’s office, and have already paid our taxes and premiums (the “second position”) . . Imagine that you are a 50-year-old woman employed by Mrs. Smith’s corporation . . [The company] is considering two options: (1) cover screening for breast cancer . . or (2) cover HDC-ABMT . . Now imagine you are in the first position . . as long as you do not yet have the disease (the first position), option 1 will always deliver greater benefit at lower cost than option 2 . . Now, let us switch you to the second position. Imagine that you already have breast cancer and have just been told that it has metastasized and is terminal . . The value to you of the screening option has plummeted because you already have breast cancer and can no longer benefit from screening . .
Maximizing care for individual patients attempts to maximize care for individuals when they are in the second position. Maximizing care for society expands the scope of concern to include individuals when they are in the first position. As this example illustrates, the program that delivers the most benefit for the least cost for society (option 1) is not necessarily best for the individual patient (option 2), and vice versa. But as this example also illustrates, individual patients and society are not distinct entities. Rather, they represent the different positions that each of us will be in at various times in our lives. When we serve ourselves in the second position, we can harm ourselves in the first (Eddy, 1991a).
Physicians generally care for patients in Dr. Eddy’s second position—when they are sick. But if the cost of treating those in the second position reduces resources available to prevent illness for the far larger number of people in the first position (who may not be seeing physicians because they feel fine), the individual principles of beneficence and autonomy are superseding the societal principle of justice. One could even say that choosing for individuals in the second position violates beneficence for those in the first position. On the other hand, if all resources go to those in the first position (e.g., to cost-effective screening rather than expensive treatment for those with life-threatening disease), injustice is committed in the other direction by ignoring the costly needs of the very ill.
Clearly, no ideal method of rationing medical care exists. Thus all efforts should be made to control costs painlessly before resorting to the painful limitation of effective medical care. But if rationing is inevitable, a balance must be struck among many legitimate needs: the concerns of healthy people for illness prevention, the imperative for acutely sick people to obtain diagnosis and treatment, and the obligation to provide care and comfort to those with untreatable chronic illness.
Rationing within One Health Program: The Oregon Health Plan
The previous discussion of rationing medical care nationwide presumes a mechanism that redirects savings from interventions not performed toward more cost-effective services. In fact, such a mechanism does not exist nationwide. Only in specific medical care programs do we find a decision-making apparatus for allocating expenditures. One example was the Oregon Health Plan (Bodenheimer, 1997).
In 1994, Oregon added 100,000 poor uninsured Oregonians to its Medicaid program. To control costs, a prioritized list of services was developed, and the state legislature decided how many services would be covered. The prioritized list was based on how much improvement in quantity and quality of life the treatment was likely to produce. The final list contained 745 condition–treatment pairs, and the State of Oregon paid for items above line 574 on the list; conditions below that line were not covered (Kilborn, 1999). What are some of the Oregon Health Plan’s ethical implications?
The plan was more than a rationing proposal; its chief feature was to extend health care coverage to 100,000 more people. That aspect of the Oregon plan promotes the principle of justice.
Another positive feature of the plan was its attempt to prioritize medical care services on the basis of effectiveness, which, if rationing is needed, is a reasonable method for deciding which services to eliminate.
Other features of the Oregon plan must be viewed as negatively impacting distributive justice, or equal access to care without regard for ability to pay.
In 1996, 12% of beneficiaries reported being denied services because they were below the line on the priority list. Of those, 78% reported that the denial had worsened their health (Mitchell & Bentley, 2000). Medical services were rationed for Oregon’s poor but not for anyone else.
The plan targeted beneficial medical services in a state with considerable medical waste. In 1988, many areas of Oregon had average hospital occupancy rates below 50%. The closing of unneeded hospital beds could have saved $50 million per year, enough to pay for some of the treatments eliminated in the plan (Fisher et al., 1992). Oregon did not exhaust its options for painless cost control before proceeding to potentially painful rationing.
By 2004, the Oregon Health Plan had unraveled (Oberlander, 2006). The state entered a period of budgetary woes, new premiums and copays were instituted, and Oregon Health Plan enrollees responded by dropping out of the program. But the bold experiment in rational rationing remains alive in the minds of health care policymakers.
Rationing within One Institution: Intensive Care
Ms. Wilson is a 71-year-old woman with a recently diagnosed lung cancer. Obstructing a bronchus, the tumor causes pneumonia, and Ms. Wilson is admitted to the hospital in her rural town. She deteriorates and becomes comatose, requiring a respirator. By the eighth hospital day, she is no better. On that day, Louis Ford, a previously healthy 27-year-old, is brought to the hospital with a crushed chest and pneumothorax suffered in an automobile accident. Mr. Ford is in immediate need of a respirator. None of the six patients in the intensive care unit can be removed from respirators without dying; of the six, Ms. Wilson has the poorest prognosis. She has no family. No other respirators exist within a 50-mile radius (Jonsen et al., 2010). Should Ms. Wilson be removed from the respirator in favor of Mr. Ford?
Resources may be scarce throughout an entire nation or within a small hospital. Macroallocation refers to the amount and distribution of resources within a society, whereas microallocation refers to resource constraints at the level of an individual physician or institution. Macroallocation decisions may be more significant, affecting thousands or millions of people. Microallocation choices can be more acute, bringing ethical dilemmas into stark, uncompromising focus and placing issues of resource allocation squarely in the lap of the practicing physician. The microallocation choice involving Ms. Wilson incorporates all four ethical principles, which must be weighed and acted on within minutes: (1) Beneficence: For whom? This ideal cannot be realized for both patients. (2) Nonmaleficence: If Ms. Wilson is removed from the respirator, harm is done to her, but the price of not harming her is great for Mr. Ford. (3) Autonomy: Withdrawal of therapy requires the consent of the patient or family, which is impossible in Ms. Wilson’s case. (4) Justice: Should resources be distributed on a first-come first-served basis or according to need?
These are tragic decisions. Many physicians would remove Ms. Wilson from the respirator and make all efforts to save Mr. Ford. The main consideration would be medical effectiveness: Ms. Wilson’s chance of living more than a few months is slim, while Mr. Ford could be cured and live for many decades.
Less stark but similar decisions face physicians on a daily basis. On a busy day, which patients get more of the physician’s time? In a public hospital with an MRI waiting list, when should a physician call the radiologist and argue for an urgent scan, thereby pushing other people down on the waiting list? Situations involving microallocation demonstrate why, in real life, health care professionals are forced to balance the interests of one patient against those of another and the interests of individuals against the imperatives of society.