Ethics of rationing health care servicesBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6974.261c (Published 28 January 1995) Cite this as: BMJ 1995;310:261
EDITOR,—Unlike Raanon Gillon,1 I find myself agreeing with the King's Fund when it advocates the formation of a Oregon-like commission modelled on the Nuffield Council of Bioethics to start the process of rationing of specific services.2
Gillon doubts whether it is morally safe to use, as he sees it, “populist solutions in distributive justice such as have occurred in Oregon … and technical and simplistic economic solutions such as the system of costed quality adjusted life years (QALYs).”1 Instead he favours seeking ways of “muddling through elegantly” as advocated by Hunter in Rationing Dilemmas in Health Care.3 Gillon is offended by moral choices being converted into apparently scientific numerical methods and formulas.
His criticism seems to centre on the notion that every case must be considered on its merits. By focusing on the admittedly pseudoscientific formulations used (Alan Maynard described the ranking process used in Oregon as nothing more than a crude guesstimate),2 he fails to address the underlying issue of whether it is morally right in principle to decide on what a person is entitled to expect from the health service and what that person should not expect from the health service. Surely one person's elegant muddling is the same as another's irrational decisiveness. How are we to tell the difference?
In a just health system a patient should be able to expect equality of access to health care which is free at the point of service,4 in the way which was originally intended 46 years ago. To my mind, this is not to be achieved by elegant muddling. Elegant muddling implies an unwillingness to face up to hard choices.
Gillon quotes Calabresi and Bobbitt, who suggest that health professionals are like jugglers trying to keep too many balls in the air5; like the juggler we must do our best to improve our juggling skills to keep more balls in the air for more of the time and to avoid letting any ball stay on the ground for too long.
Working as a general practitioner in the NHS for the past 10 years I too have often used the analogy of the juggler: all the balls are not equal—more harm is caused if we drop some balls than if we drop others. I together with many of my colleagues have become demoralised and exhausted juggling with so many balls. Every so often someone throws yet another ball our way. We are finding that it is less and less enjoyable to juggle—what is more, we are dropping more and more balls and too many are getting damaged.
In my metaphor the balls represent medical condition-treatment pairs. An imagined contract with our patients might to like this: would you allow us to drop breast reconstruction after mastectomy so that we can guarantee that we will always be able to treat triple vessel coronary disease within three months? By advocating explicit rationing, I am suggesting that we health workers drop some of the balls so that it becomes a joy to juggle again. The consequence of this is that the balls which really matter will stay in the air.