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Ethics and effectiveness: rationing healthcare by thresholds of minimum effectiveness

BMJ 2011; 342 doi: (Published 17 January 2011) Cite this as: BMJ 2011;342:d54
  1. Alena M Buyx, assistant professor/director12,
  2. Daniel R Friedrich, research associate1,
  3. Bettina Schöne-Seifert, professor and chair of bioethics1
  1. 1Institute for Ethics, History and Philosophy of Medicine, University Hospital Münster, Germany
  2. 2Nuffield Council on Bioethics, London WC1B 3JS, UK
  1. Correspondence to: A Buyx abuyx{at}
  • Accepted 10 November 2010

Alena Buyx, Daniel Friedrich, and Bettina Schöne-Seifert argue that basing rationing decisions on clinical effectiveness rather than cost effectiveness would be fairer and could make it more acceptable

Scarcity of healthcare resources calls for fair, acceptable, and ethically justified ways of allocating and rationing care. Particularly in financially difficult times, this is a formidable challenge. So far, no developed country has managed to introduce criteria for fair rationing that have remained undisputed. This is not surprising. Rationing healthcare by definition goes beyond eliminating waste1 and thus requires difficult moral choices.2 Whoever gets afflicted, it almost always hurts, and cuts must therefore have sound ethical justification. Cost effectiveness in particular—one of the main criteria used by the National Institute for Health and Clinical Excellence (NICE) in funding decisions—has long been attacked for ethical reasons.3

One simple criterion for rationing that has been paid little attention is minimum effectiveness thresholds. Although public debates show increasing reservations about expending enormous effort for very small clinical benefit,4 medical interventions with only minimal effects seem to be part of today’s regular medical practice. For example, some of the newly approved monoclonal antibody drugs for end stage cancer at best prolong patients’ lives for a few weeks or months without any substantial improvement in their health related quality of life. Reasons for the prevalence of such treatments are manifold: in many Western countries, doctors prescribe the drugs because they are (often wrongly) afraid of legal liability or dread to admit that “there is nothing more we can do”; patients dwell on unrealistic hopes; and relatives have trouble facing their loved one’s end.5 6

We think it is irrational and wrong to ration clearly effective treatments while offering others that promise very low individual benefits. Before other cuts are considered, …

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