Fundholding practice's draft policy on ethical use of resourcesBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7061.883 (Published 05 October 1996) Cite this as: BMJ 1996;313:883
Policy is inconsistent
EDITOR,—The Asbury draft policy on ethical use of resources, a document developed by a fundholding practice to clarify the ethical basis of decisions concerning rationing, contains many inconsistencies.1 Two of these, in particular, must be challenged—namely, those to do with age and patients' responsibility for their conditions.
With regard to age, the authors seem to want to have it both ways. They first reject the view that treatment should be denied on the basis of age but later write, “the patients' ages may be considered and found relevant.” They take this view not because of any medical criteria but because of the “fair innings” argument. In addition to being inconsistent in their views, the authors seem to ignore both the many persuasive arguments against the fair innings argument2 and the difficulty of defining fairness (Rawls, for instance, tried to do so and failed3). They also imply that quality adjusted life years should not be considered in the treatment of patients who are terminally ill but seem to accept that they should be considered with regard to age. Why?
It is not only about age that the authors are in two minds: they take the same stance with patients' responsibility for their conditions. They first reject the idea that treatment should be denied on the grounds that the patient has brought the condition on himself or herself, but then they write, “the issue of a patient's responsibility for having induced the problem might be considered relevant.” It is surprising that the authors have not realised the inconsistencies in their views here. It is even more important that they have not taken account of the fact that if we start allocating health care on the basis of personal responsibility there will be few people eligible for treatment.