The Ethics of Health Care Rationing

An Introduction

Greg Bognar, Iwao Hirose

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000541441
• Edition: 2
• Topic: Philosophy
• Subtopic: Philosophy History & Theory

The rationing of health care is universal and inevitable, taking place in both poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources.

The Ethics of Health Care Rationing is a clear, timely, and much-needed introduction to this important topic. Substantially revised and updated, this second edition includes new chapters on disability discrimination and age discrimination, and on the price of drugs and medical therapies. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics:

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• What sort of distributive principles should we rely on when thinking about health care rationing?
• What is the relation between ethics and cost-effectiveness in health care?
• How should we think about controversies surrounding discrimination over disability and age?
• How should we approach controversies surrounding rationing and the price of pharmaceutical drugs and medical therapies?
• Should patients be held responsible for their health?
• Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality?

Throughout the book, examples from the United States, the United Kingdom, and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading, and discussion questions have also been updated, making this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work.

1 Ethics and health care

DOI: 10.4324/9781003050216-2

1.1 The vaccination programs

Imagine that your team of public health experts has a contract with the government of a remote, tiny island state to vaccinate children against a fatal disease. The disease threatens only children, and each child has an equal chance of contracting it. The vaccination has no side effects and provides total immunity against the disease.

Altogether, there are 1,000 children on the island. Eight hundred of them live on the coastal plains, and 200 live in remote mountains. It costs only $1 to vaccinate a child who lives near the coast, but $4 to vaccinate a child who lives in the mountains. It costs four times as much to vaccinate the children in the mountains because it is difficult to reach them.

The problem is that you are only given $800 for this work (this is a very poor country). Your team cannot vaccinate all the children. Because of logistical reasons, you have to choose between two ways of organizing your vaccination campaign. The two programs are:

1. vaccinating every child living on the coastal plains, but none of the children living in the mountains;
2. vaccinating half of the children who live on the coastal plains, and half of those who live in the mountains.

Which program would you choose?

If you choose Program A, 800 children will be vaccinated. They will be protected against the disease. If you choose Program B, half of the children on the plains and half of the children in the mountains will be selected randomly. In the end, 500 children will be vaccinated – 400 on the plains and 100 in the mountains.

We often present this example to our students. We ask them to make a choice between these hypothetical programs. We get very consistent results. A majority of the students in any class chooses Program A, but there is always a fairly large minority that chooses Program B. Students disagree about the right choice. We have never met a class where there was anything approaching consensus in favor of either program.

Next, we ask a follow-up question from those who are in favor of Program A.

Here is the question. Suppose that just as you are about to leave the island with your team, you get a call from the Ministry of Health. They are happy to tell you that the government has given you another $800 for a second round of vaccinations. Even better, they also have vaccinations available against a second disease. This disease is just like the first: it only affects children, it is invariably fatal, all children have the same chance of contracting it, and anyone’s chance of contracting it is equal to the chance of contracting the first disease.

At this point, you have a meeting with your team to discuss your options. For logistical reasons, you must choose between the following two programs:

3. vaccinating all the children who live in the mountains against the first disease;
4. vaccinating all the children who live on the coastal plains against the second disease.

If you choose Program C, you will vaccinate all the 1,000 children living on the island against the first disease. If you choose Program D, you will vaccinate 800 children against both diseases. In the first case, you will provide 1,000 vaccinations to 1,000 children; in the second case, you will provide 1,600 vaccinations to 800 children.

Would you choose Program C or Program D?

In our experience, an overwhelming majority of the students who favored Program A chooses Program C. We have met very few students who favor A and D.

Those who favor Program A in the first question usually give the following explanation for their choice. The vaccination confers a great benefit – immunity against a fatal disease. It is very important to provide this benefit to as many children as possible. Of course, Program A leaves out the children who live in the mountains. But for each child that you could vaccinate in the mountains, you can vaccinate four children on the plains. Choosing Program A is justified by the benefits that would be bestowed on a greater number of children.

Those who favor Program B have a different explanation. They argue that it is wrong to exclude the children living in the mountains. It is not their fault that they live in a remote place. There is something unfair about discriminating against some of the children merely because they are growing up in less accessible places. If not all of the children can be vaccinated, you should at least give an equal chance to all of those who live on the coastal plains and all of those who live in the mountains. To these students, this seems to be a requirement of fairness.

Remarkably, those who choose A and C tend to give a similar explanation for choosing Program C in the second question. For these students, maximizing the benefits of vaccination is the most important consideration in the first question. But the consideration of fairness appears in the second question and becomes more important than benefit maximization – even if very few students might be able to explain what precisely they mean by fairness.

At this point, those who favored Program B – vaccinating half of the children on the plains and half of the children in the mountains – also get a second question. Here is their question. Just as you are preparing to leave the island, you get a call from the Ministry of Health. You are given another $800 for vaccinations. You have to decide between two programs:

5. vaccinating the remaining half of the children who live on the coastal plains and the remaining half of those who live in the mountains;
6. vaccinating all the children who live on the coastal plains against the second disease.

If you choose Program E, you will end up vaccinating all the 1,000 children living on the island against the first disease. You will end up giving out 1,000 vaccinations to 1,000 children. If you choose Program F, you will end up vaccinating one half of the children on the plains against both diseases, the other half of the children on the plains against the second disease only, and one half of the children in the mountains only against the first disease. Altogether, you end up providing 1,300 vaccinations (800 + 400 + 100) to 900 children.

Which program would you choose?

In our experience, a large majority of those who favored Program B in the first question favors Program F in the second question – even if there are typically some holdouts favoring B and E. Program F usually gets a comfortable majority. When asked to explain their choices, students often say that although they continue to believe that it is important to avoid the unfairness of choosing Program A in the first question, they acknowledge that the greater benefits of Program F can tilt the balance in the second question. After all, if you implement programs B and F, you will vaccinate nine-tenths of the children against at least one disease and a significant minority against two.

When we present these questions, we emphasize that we are not looking for “right” or “wrong” answers. Rather, what matters is what we can learn from the answers about our moral beliefs. And the lesson is clear: most people who consider this example believe that it is important to choose the course of action that will bring about the greatest benefits – but they also believe that it is important to allocate resources in a fair way. Of course, we will need to say a lot more about the requirement of fairness. But one thing we can already say: fairness and benefit maximization can, and often do, conflict. It is important to find the right balance between them. This book is about how we can do that.

1.2 The ubiquity of rationing health care

The story of the vaccination programs is a thought experiment. By asking you to make moral judgments in hypothetical situations, it is designed to shed light on the ethical principles that are relevant to the distribution of benefits in conditions when resources are scarce. Philosophers often use thought experiments to help analyze difficult questions. They often involve an element of science fiction: you are asked to imagine that you are a brain in a vat or you are teleported to another planet or you are deceived by an evil demon. But the vaccination story is different. It is not entirely fictional. It is modeled on a real-life ethical dilemma.

In 2003, the World Health Organization (WHO) and the Joint United Nations Programme on HIV and AIDS (UNAIDS) launched the “3 by 5” program. The aim of the program was to provide antiretroviral therapy to three million people with HIV/AIDS living in developing countries before the end of 2005. Even if successful, the program would have reached only a fraction of those who could have benefited from the therapy. In the end, the target was met only in 2007. At the end of 2011, around 6.65 million eligible patients in developing countries received antiretroviral therapy, up from 400,000 in 2003. But still less than half of eligible patients had access to therapy. (The targets of the recent 90–90–90 program are that by 2020, 90 per cent of all people living with HIV should know their HIV status, 90 per cent of all people with diagnosed HIV infection should receive sustained antiretroviral therapy, and 90 per cent of all people receiving antiretroviral therapy should have viral suppression. Although there has been a lot of progress, the world has missed these targets too.)

One controversial aspect of rolling out the initial 3 by 5 program was whether delivery should focus on urban or rural populations. In developing countries, there is a shortage of HIV clinics and health facilities. Concentrating delivery in urban areas ensured that more patients could be reached, but it made the program inaccessible to rural populations. Patients living far from cities could not reach the facilities because of long distances, bad roads, and their inability to pay for transport. Some experts argued that the program should focus on those areas where the infrastructure is already in place in order to reach as many people as quickly as possible. Others argued that rural populations should not be neglected, even if fewer patients can be served as a consequence.

Thus, policymakers faced the same dilemma as our students in the classroom. The choices they made, however, had real consequences. For some people, they were a matter of life and death. But national guidelines for implementing the program often treated such dilemmas as merely technical questions: matters that require the expertise of medical doctors, economists, and policymakers. The ethical nature of the dilemmas was rarely acknowledged, and the choices were made without consulting the citizens of these countries.

It is understandable that hard ethical choices are sometimes treated as technical questions. The policymakers who were responsible for broadening access to antiretroviral therapy had to set priorities among competing resource uses. They had to engage in the rationing of health care. But the idea of rationing health care makes people uncomfortable. It entails that there are patients who could benefit from care but have to do without it. Many people get upset when they hear or read stories in which someone is denied potentially beneficial (maybe even life-saving) medical care. In many countries, the very idea of rationing health care is taboo. Politicians who talk about it risk their prospects for reelection. So it is not surprising that rationing choices are often hidden behind technical or medical language.

Still, it is not right. It is the responsibility of policymakers to reflect on the values they take into account when they make choices about the use of social resources – both in health care and beyond. It is our right as citizens to demand that social choices that can potentially have a great effect on our lives are made in a transparent and accountable manner. It is also our responsibility to think through the ethical issues faced by our society. We should have the chance to contribute to their discussion and resolution. To do that, we need a basic understanding of medical and economic matters; but what we need most is ethical argument. Medical doctors and economists can help us understand technical matters, and philosophers can help us with the ethical argument.

So, the first point we want to make is that the rationing of health care is an ethical issue. We all have a stake in getting it right. Next, we want to argue that health care rationing is ubiquitous. It affects all of us.

Some readers might think that the rationing of health care has little to do with their society. Where they live, there is a well-functioning health care system. They might think that rationing is something that takes place mainly in resource-poor environments or the least developed countries. True, the 3 by 5 program targeted middle- and low-income countries. But it would be a mistake to conclude from this one example that only these countries should be concerned with rationing. In fact, rationing is universal. It takes place in poor as well as affluent countries, in publicly funded health care systems as well as in private health insurance.

Other readers might associate the rationing of health care with government – in particular, with faceless bureaucrats in drab offices making life-and-death choices. In the vaccination program, you probably assumed that you were working for the government or perhaps an NGO (nongovernmental organization). But you would have faced the very same choices if you were a private contractor with expertise in public health campaigns. The need to set priorities in health care is not limited to government-run health care systems. Private actors, including insurance providers, need to do it just as much.

Neither is it the case that rationing is an exception in affluent countries, rather than the rule. Most people in affluent countries could probably mention organ transplantation as an example of health care rationing. Because there are many more patients than available organs, patients everywhere are placed on waiting lists. Tragically, some of them die before a suitable donor is found. Waiting lists are a form of rationing. It is not difficult to see how they raise ethical issues. Should priority be given to the patients who have waited the longest or to those who need an organ most urgently or to those whose survival prospects are the best? Clearly, these are partly ethical, rather than merely medical questions.

And surely, all of our readers can mention the COVID-19 pandemic that put the issue of health care rationing in the limelight. As we are writing this, health care systems around the world are still under enormous pressure. We already know that tragic choices had to be made. Moreover, the vaccines that have been developed against the disease could not immediately be produced in sufficient quantities. It was necessary to set priorities among different patient groups. Who should be vaccinated first? Should it be the young or the old? Is it fair to give priority to essential workers or those who have dependents? Clearly, these are partly ethical, rather than merely technical questions.

These examples are familiar. But they are also the most unusual. They concern extreme cases of scarcity and public health emergencies. In such cases, rationing might be unavoidable. But what about our claim that health care rationing is ubiquitous?

In a way, what is rationed in these examples are people. Patients are matched to resources. The examples present choices about who gets medical treatment or who gets it before others. They make good topics for debate, but they are far from being ordinary. Most rationing choices are not like this. They do not concern setting priorities among patients. They concern setting priorities among treatments, services, pharmaceuticals, medical procedures, and so on. They concern what to provide in the health care system and how to provide it, and not to whom to provide it.

Health care rationing is the controlled allocation of scarce health care resources. Occasionally, it takes the form of selecting particular patients or patient groups. But usually it takes the form of setting priorities among interventions. By “intervention,” we mean any use of resources in the health care system that aims to address health problems or the risks of health problems. By “resource use,” we mean any mobilization of human, physical, financial, or other sorts of assets to achieve these aims.

Thus, when the government decides which pharmaceuticals to subsidize from the health care budget, it engages in rationing. When it decides in which city to build a hospital or clinic, it is an example of rationing. When it introduces a cancer-screening program, it is rationing health care. All of these decisions require resources that could be spent elsewhere. Implicitly or indirectly, all such decisions determine who will benefit. Patients of subsidized medicines have to spend less than others. Residents of the city in which the hospital is built have better access to specialist services than others.

Private health insurance is no different. When an insurance provider decides which treatments to include in its plans, it engages in rationing. When it determines the co-payments, its choice is an example of rationing. When it refuses to provide coverage for people with preexisting conditions, it is, obviously, rationing health care by excluding these people.

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