Published 10 October 2008, doi:10.1136/bmj.a2047
Cite this as: BMJ 2008;337:a2047

Editorials

Where are we in the rationing debate?

Improved tools and public participation can inform fair systems

Three linked articles (doi:10.1136/bmj.a1850; doi:10.1136/bmj.a1872; doi:10.1136/bmj.a1846) take different perspectives on the need to allocate limited resources for human health fairly.^{1 2 3} Norheim examines clinical priority setting, which occurs implicitly or explicitly in clinicians’ daily practice. He courageously proposes that clinicians should integrate concern for cost effectiveness and health inequalities into decisions about clinical priority setting, and describes an elegant way of measuring inequalities. Donaldson and colleagues argue convincingly that explicit attention to comparative costs and relative values, using methods like programme budgeting and marginal analysis, can allow "genuine" reallocations. Finally, Daniels and Sabin draw on experience using their framework, "accountability for reasonableness," as a guide for priority setting in three different locations.

The articles present valuable arguments, although a few types of methods of resource allocation are missing. While Donaldson and colleagues dismiss incentives as "smokescreens" used to avoid hard decisions, market-like approaches to allocation can be found in almost every system. User fees, privately purchased services or insurance, and competitive bidding comprise just some of the mechanisms that reflect market principles. Donaldson and colleagues correctly point out that allocating health services purely by price ignores the many ways that markets fail to achieve optimal allocation of health care. Important unanswered questions remain, however, about when and if market-style approaches could contribute to fair allocation schemes given the extent to which health services (intensive care beds, physical therapy, acne treatment) vary in necessity, demand, and patients’ sensitivity to price.

Democratic deliberation and public participation contribute to the legitimacy of health spending priorities.^{4 5 6} These ideas also receive scant mention. Although Daniels and Sabin previously agreed that public participation can be an element of an accountable process,⁷ their framework does not require public engagement. Donaldson and colleagues take a dimmer view of public participation, arguing that fair processes run the risk of finding the wrong answers or avoiding tough choices. Norheim, in contrast, argues that the value choices necessitated by priority setting (for example, trade-offs between equity and maximisation of health) "must involve the public through deliberation." How to involve the public, however, remains a challenge. Thorny questions about representation, procedures, and influence (the extent to which public participation affects decisions) have yet to be settled despite considerable experience in participation.^{8 9}

Global budgeting, which constrains the availability of resources such as operating theatre time or imaging equipment, relies largely on implicit (clinical) rationing. Doctors, particularly in the United States, are reluctant to take on the role of rationing. Yet studies show that doctors can accept that role, that they can ration using clinical criteria (such as severity of illness), and that the public expects doctors to provide leadership in resource allocation policies.^{10 11 12} Norheim provides ethical reasoning and cogent examples illustrating how doctors can ration prudently and with integrity. He begins by referring to the inevitable nature of clinical priority setting in daily practice but quickly turns to guidelines and other systematic ways to compare alternative spending options for populations rather than individual patients. This turn is natural when the concern is for fairness, impartiality, and justice. Still, clinicians would benefit from clearer guidance about the particular, individual, and inherently partial spending decisions they must make every day.¹⁰

Important debates about societal priorities for health and healthcare services have been ongoing for decades. What progress have we made? Firstly, as Donaldson and colleagues emphasise, we have enhanced our ability to remove priority and funding from existing services, rather than merely evaluate new spending priorities. Secondly, we can incorporate measures of equity and distribution, like the Gini index Norheim describes, into decision making. Thirdly, healthcare professionals are starting to grapple with how to ration ethically and equitably, contributing clinical judgment, leadership, and "front line" expertise to create more just and efficient healthcare systems. Fourthly, the turn in focus from total agreement on distributive principles to designing fair processes has infused new energy into the debate. Research that critically examines such processes must continue.^{8 9} Finally, accountability for reasonableness can be used to design and evaluate allocation processes in a variety of settings, using these and other methods, and perhaps in broader discussions about health inequalities.

Most allocation efforts focus on the distribution of healthcare services, which we assume contribute to better health. Reallocating other types of resource (for example, employment, education, and clean environments) would probably contribute more to improving life expectancy and health than reallocating health services. A broader view of justice should include social conditions that influence health.^{13 14 15} No allocation of resources, no matter how just, however, can ensure an equal distribution of health; illness remains, at times, an unlucky event no amount of social engineering or healthy behaviour can prevent, and no amount of resources can cure.¹⁵ We should not forget that, besides improving health, health care meets the vital social need to care for the ill. We have made substantial progress in developing economic tools—including programme budgeting and marginal analysis and increasingly sophisticated measures of health status, outcomes, costs, and equity—that contribute greatly to informed deliberation about health and healthcare spending priorities. We need to find equally sophisticated ways to evaluate to what extent those tools, and which methods of public deliberation, improve the accountability and legitimacy of health spending decisions.

Cite this as: BMJ 2008;337:a2047

¹ University of Michigan Medical School, Ann Arbor, MI 48109-0429, USA, ² University of Michigan School of Public Health, Ann Arbor, MI 48109-2029, USA

Analysis, doi:10.1136/bmj.a1850; doi:10.1136/bmj.a1872; doi:10.1136/bmj.a1846

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Daniels N, Sabin JE. Accountability for reasonableness: an update. BMJ 2008;337:a1850.[Free Full Text]
2. Donaldson C, Bate A, Brambleby P, Waldner H. Moving forward on rationing: an economic view. BMJ 2008;337:a1872.[Free Full Text]
3. Norheim OF. Clinical priority setting. BMJ 2008;337:a1846.[Free Full Text]
4. Goold SD. Allocating health care resources: cost utility analysis, informed democratic decision making, or the veil of ignorance? J Health Polit Policy Law 1996;21:69-98.[Abstract/Free Full Text]
5. Fleck L. Can we trust "democratic deliberation"? Hastings Cent Rep 2007;37:22-5.[Web of Science][Medline]
6. Gutmann A, Thompson D. Deliberating about bioethics. Hastings Cent Rep 1997;27:38-41.[Medline]
7. Daniels N, Sabin JE. Last chance therapies and managed care. Pluralism, fair procedures, and legitimacy. Hastings Cent Rep 1998;28:27-41.[Web of Science][Medline]
8. Contandriopoulos D. A sociological perspective on public participation in health care. Soc Sci Med 2004;58:321-30.[CrossRef][Web of Science][Medline]
9. Abelson J, Pierre-Gerlier F, Eyles J, Smith P, Martin E, Francois-Pierre G. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med 2003;57:239-51.[CrossRef][Web of Science][Medline]
10. Hurst SA, Forde R, Reiter-Theil S, Slowther AM, Perrier A, Pegoraro R, et al. Physicians’ views on resource availability and equity in four European health care systems. BMC Health Serv Res 2007;7:137.[CrossRef][Medline]
11. Miles S, Bendiksen R. Minnesota public opinion on health care resource allocation. Minnesota Med 1994;77:19-23.
12. Strauss MJ, LoGerfo JP, Yeltatzie JA, Temkin N, Hudson LD. Rationing of intensive care unit services. An everyday occurrence. JAMA 1986;255:1143-6.[Abstract/Free Full Text]
13. Daniels N. Equity and population health: toward a broader bioethics agenda. Hastings Cent Rep 2006;36:22-35.[Web of Science][Medline]
14. Powers M, Faden R. Inequalities in health, inequalities in health care: four generations of discussion about justice and cost-effectiveness analysis. Kennedy Inst Ethics J 2000;10:109-27.[Web of Science][Medline]
15. Goold SD, Solomon S. Where can we find justice? Am J Bioethics (in press).

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