Why Oregon went wrong
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2044 (Published 14 October 2008) Cite this as: BMJ 2008;337:a2044
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Mr West prefers a rationing principle based on societal worth or
merit. Priority is given where the cost of the intervention is low and the
potential benefit (defined let us say as overall contribution to GDP) is
high. Utilitarian principles are certainly one way of allocating
resources, but are likely to lead to unpalatable conclusions. For
instance, a more efficient (not to mention quicker and more certain) way
of addressing the balance between the elderly and the working age
population would be to cull all economically unproductive (i.e. making
negative net contribution to GDP) individuals over retirement age, rather
than making fertility treatment available to non-fertile couples. (For
that matter, why choose non-fertile couples for this experiment? Surely
targeting couples who have previously proved their fertility would be more
likely to produce the required number of workers).
Perhaps a more serious point is the abandonment of the core NHS principle
of fairness. Mr West, by virtue of his social class and choice of place to
live, is already at a significant advantage in terms of health than the
majority of others in this country. He has, or is more likely to have, the
resources to have private medical treatment should he so wish. The same is
true of doctors as a whole. We should be very careful indeed of setting
ourselves up as chosen ones deserving of a greater share of the cake than
those suffering real hardship and deprivation who are unable to make a
case for themselves. We are part of a community, and should understand our
role in rationing in that context, not set out to get more for ourselves.
Competing interests:
None declared
Competing interests: No competing interests
The feature 'Why Oregon went wrong.' Vidhya Alakeson.
BMJ 2008; 337: a2044 and subsequent related articles in the same edition
reopens the debate on how best to prioritise Healthcare Resources. For the
most part the authors look at the problems of rationing for health
insurance companies and the NHS as being comparable, but there is a
fundamental difference that I would propose should be much more explicit
in any state-funded provision. This is that special consideration should
perhaps be given to any provision that is of net economic benefit. This is
best exemplified by the following three examples: a key healthcare worker
- perhaps a consultant surgeon - is unable to work because of a health
problem that may be minor in terms of its consequences to his or her
health and the treatment of which may have a low priority behind those
with more serious health problems. The adverse consequences of
conventional rationing decisions may be much greater, however, due to the
need to delay or cancel the treatments of others until the surgeon's
condition has been dealt with. A key politician similarly may have a non-
life-threatening problem that may not qualify for prompt treatment - or
possibly treatment at all under certain rationing regimes - but his or her
value to the nation may be so great in economic or strategic terms that to
deny or delay treatment may be to disadvantage all those others whose
treatments depend upon the benefits of that person's activities. Finally
let us say that our society has a demographic problem with an increasingly
aged population structure and fertility treatments to encourage the birth
rate might have been demonstrated to be of net long-term economic benefit.
Should NHS treatment for the surgeon, the politician or the subfertile
couple be given any special consideration or priority? Alternatively
should they or where relevant their employers be expected to arrange
treatment for them privately? Or should they be denied treatment or take
their turn and everyone be disadvantaged in the interests of fairness,
equality, or rationing based purely on clinical considerations such as
quality adjusted life years (QALYs)?
Competing interests:
None declared
Competing interests: No competing interests
Re: Should key workers take priority in rationing decisions?
Dr Thomas completely misses the point. The health of some workers may
be a prerequisite to providing healthcare for others - either for economic
reasons or even directly. Unpalatable or not this is the plain truth and
is not related in any way to any judgement about the intrinsic worth of
one person's intrinsic merit versus another. The argument that this may
lead logically to a cull of the elderly is a non-sequitur. One might just
as well say that Dr Thomas would prefer to see the elderly suffer and die
rather than provide treatment to those who could help them.
Competing interests:
None declared
Competing interests: No competing interests