The real ethics of rationing

Introduction

Since 1996, the BMJ has published a series of articles about the nature of rationing in health care, several by the Rationing Agenda Group, an influential group of policy advisers.1 This brief essay will question some of their arguments and then suggest that the real ethics of rationing should first address the sociological and managerial forms of inequality, power, and privilege upstream that force rationing downstream at the point where doctors treat patients.

There is a strange kind of schizophrenia in the arguments about rationing. One part holds that funding for the NHS is adequate and likely to be so for the foreseeable future2; another holds that rationing takes place in the NHS and always will, because rationing is inevitable.3 Yet these two central themes of policy are not joined. Surely the amount and kind of rationing, affects perceptions of the adequacy of funding. If it does not, then “rationing is inevitable” can be a paternalistic justification for playing Scrooge. It can justify as low a level of funding and supply of doctors and nurses as those in power want. If we conclude from the start that we can never adequately meet all needs, why bother trying to meet them as inadequately as we do already? Why not cut the NHS budget by 10% or 20%?

“NHS funding is fine”

If we examine the funding article2 of the Rationing Agenda Group3 more closely, we learn that the extra burdens of aging fall within the projected growth of real NHS expenditures and that changes of morbidity will neither accelerate nor retard expenditures. The authors show that so called efficiency and activity gains are increasing faster than expenditures. Expectations may change, but they are subjective, political, cultural, and impossible to predict; so on balance NHS funding is likely to be …