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Desperately Seeking Solutions: Rationing Health Care

BMJ 1999; 318 doi: (Published 02 January 1999) Cite this as: BMJ 1999;318:64
  1. David Price, research fellow.
  1. Social Welfare Research Unit, University of Northumbria

    David J Hunter

    Addison Wesley Longman, $14.99, pp 176

    ISBN 0 582 28923 8

    Rating: Embedded Image

    Healthcare rationing, according to Professor Hunter's summary of the rationing debate, is inevitable and, since the case of “Child B,” which exploded the myth that the NHS would pay for any treatment, we all know that it is inevitable. However, rationing is difficult to justify, he says, because society is not yet ready for clear rules about when to deny medical care to people in need of it. The “hard-nosed rational rationers,” the ones who seek general principles, may be pursuing an “intellectually irrefutable case,” but life is too complex for their explicit approach. Far better, he says, to sustain the irrationality of implicit rationing in the clinical relationship while at the same time insisting that doctors stop acting as patient advocates. If anybody asks, let doctors do the explaining. In other words, give rationing the cloak of medical respectability.

    But the Child B case did not explode any myths. On the contrary, the health authority called it a decision made in the best interests of the child. The rationers' case is intellectually refutable because no single deductive principle can govern medical decision making, and it is a mistake to suppose otherwise. Reasoning on a case by case basis is not irrational, it is about deciding what to do for the good of the patient. The American experience of litigation over managed care provides ample evidence of the pitfalls of confounding health care with corporate resource management. And there is much more to be said about the reopened anti-NHS argument of the 1940s, the “insatiable demand” argument, which predicted (inaccurately) that a service free at the point of need would be swamped. For example, Hunter's historical account fails to consider the huge surge in private healthcare investment since the mid-1980s. Curtailing a comprehensive service in this context has the effect of making room for private enterprise.

    In Hunter's account there are no right answers; the object is to rationalise decisions already made, and it is acceptable to leave open to question whether a person in need of medical care should receive it. This should be hard to swallow for a profession dedicated to different ends and involved in actions which have real and pressing consequences.

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