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FEATURE: Vidhya Alakeson Why Oregon went wrong BMJ 2008; 337: a2044 [Full text]

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Should key workers take priority in rationing decisions?

Jonathan H West   (17 October 2008)

All animals are equal, but some are more equal than others

Matt Thomas   (22 October 2008)

Re: Should key workers take priority in rationing decisions?

Jonathan H West   (25 October 2008)

Should key workers take priority in rationing decisions? 17 October 2008
Jonathan H West, Consultant in Obstetrics & Gynaecology Royal Devon & Exeter NHSFT Send response to journal: Re: Should key workers take priority in rationing decisions?	The feature 'Why Oregon went wrong.' Vidhya Alakeson. BMJ 2008; 337: a2044 and subsequent related articles in the same edition reopens the debate on how best to prioritise Healthcare Resources. For the most part the authors look at the problems of rationing for health insurance companies and the NHS as being comparable, but there is a fundamental difference that I would propose should be much more explicit in any state-funded provision. This is that special consideration should perhaps be given to any provision that is of net economic benefit. This is best exemplified by the following three examples: a key healthcare worker - perhaps a consultant surgeon - is unable to work because of a health problem that may be minor in terms of its consequences to his or her health and the treatment of which may have a low priority behind those with more serious health problems. The adverse consequences of conventional rationing decisions may be much greater, however, due to the need to delay or cancel the treatments of others until the surgeon's condition has been dealt with. A key politician similarly may have a non- life-threatening problem that may not qualify for prompt treatment - or possibly treatment at all under certain rationing regimes - but his or her value to the nation may be so great in economic or strategic terms that to deny or delay treatment may be to disadvantage all those others whose treatments depend upon the benefits of that person's activities. Finally let us say that our society has a demographic problem with an increasingly aged population structure and fertility treatments to encourage the birth rate might have been demonstrated to be of net long-term economic benefit. Should NHS treatment for the surgeon, the politician or the subfertile couple be given any special consideration or priority? Alternatively should they or where relevant their employers be expected to arrange treatment for them privately? Or should they be denied treatment or take their turn and everyone be disadvantaged in the interests of fairness, equality, or rationing based purely on clinical considerations such as quality adjusted life years (QALYs)? Competing interests: None declared
All animals are equal, but some are more equal than others 22 October 2008
Matt Thomas, SpR Anaesthesia Bristol BS2 Send response to journal: Re: All animals are equal, but some are more equal than others	Mr West prefers a rationing principle based on societal worth or merit. Priority is given where the cost of the intervention is low and the potential benefit (defined let us say as overall contribution to GDP) is high. Utilitarian principles are certainly one way of allocating resources, but are likely to lead to unpalatable conclusions. For instance, a more efficient (not to mention quicker and more certain) way of addressing the balance between the elderly and the working age population would be to cull all economically unproductive (i.e. making negative net contribution to GDP) individuals over retirement age, rather than making fertility treatment available to non-fertile couples. (For that matter, why choose non-fertile couples for this experiment? Surely targeting couples who have previously proved their fertility would be more likely to produce the required number of workers). Perhaps a more serious point is the abandonment of the core NHS principle of fairness. Mr West, by virtue of his social class and choice of place to live, is already at a significant advantage in terms of health than the majority of others in this country. He has, or is more likely to have, the resources to have private medical treatment should he so wish. The same is true of doctors as a whole. We should be very careful indeed of setting ourselves up as chosen ones deserving of a greater share of the cake than those suffering real hardship and deprivation who are unable to make a case for themselves. We are part of a community, and should understand our role in rationing in that context, not set out to get more for ourselves. Competing interests: None declared
Re: Should key workers take priority in rationing decisions? 25 October 2008
Jonathan H West, Consultant in Obstetrics & Gynaecology Royal Devon & Exeter NHSFT Send response to journal: Re: Re: Should key workers take priority in rationing decisions?	Dr Thomas completely misses the point. The health of some workers may be a prerequisite to providing healthcare for others - either for economic reasons or even directly. Unpalatable or not this is the plain truth and is not related in any way to any judgement about the intrinsic worth of one person's intrinsic merit versus another. The argument that this may lead logically to a cull of the elderly is a non-sequitur. One might just as well say that Dr Thomas would prefer to see the elderly suffer and die rather than provide treatment to those who could help them. Competing interests: None declared