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Being creative about rationing

BMJ 1996; 312 doi: (Published 17 February 1996) Cite this as: BMJ 1996;312:391
  1. Richard Smith
  1. Editor BMJ, London WC1H 9JR

    An innovatory theory helps clearer thinking

    Two of the biggest questions in health care are “How much money should we spend?” and “What should we spend it on?” We don't have adequate methods for answering either question, but Ronald Dworkin, professor of law in both Oxford and New York and one of the world's leading thinkers on medical ethics, has developed a theory that provides a means to begin to answer both questions. Last week he presented his “prudent insurance principle” at a meeting in London organised by the Institute for Public Policy Research.

    Current practice with health care expenditure is based—more implicitly than explicitly—on what Professor Dworkin calls “the insulation model.” This postulates that health care is fundamentally different from other goods, that equality of access is essential for health care because it is so different, and that when something can be done acutely to avoid death it should be done (“the rescue principle”). In the United States this principle has led to such inappropriate actions as huge sums being spent to separate Siamese twins joined at the heart even though one will inevitably die and the other has only a tiny chance of surviving and no chance of living a normal life. In Britain large sums of money have been spent to give the teenager Jaymee Bowen further treatment for her leukaemia even though the discomfort to her is high, …

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