Rationing health care: will it be necessary? Can it be done without age or disability discrimination?

• Author: Kapp, Marshall B.

Rationing Health Care: Will It Be Necessary? Can It Be Done Without Age or Disability Discrimination?

Is Rationing Health Care Necessary?

Arguing about the necessity for some form of health care rationing no longer is a very fruitful enterprise. National spending for health care is out of control (1) and it would be ostrich-like indeed to deny the proposition that, at some point and to some degree, the public demand and need (understanding that these two concepts are not logically synonymous but are extremely difficult to separate in practice) for medical services will exceed our society's economic capacity (and not just our willingness) to satisfy that appetite. The key inquiry, thus, must focus not on the eventual necessity of health care rationing, but on how this can be accomplished, in terms of both process and substantive outcomes, in the most ethically, legally, and politically tolerable manner.

Before leaving the threshold necessity question, however, one must explore the possibility that, even if a rationing requirement cannot be avoided altogether, the relative scarcity (to demand) of medical resources underlying the rationing requirement at least can be mitigated. To the extent that the use of available medical resources is optimized, the point at which the most gripping rationing dilemmas must be confronted would be altered and the severity of rationing strategies may be softened. The need for rationing would remain, but the nature of its legal, ethical, and political implications would be affected. Thus, while working on the supply side of the equation will not by itself resolve the rationing issue in a completely satisfactory way, it can exert a fundamental impact on how society chooses to deal with (i.e., ration) the demand side.

What alternatives are feasible for delaying and/or mitigating the resource scarcity, and hence the rationing necessity, problem? First, we could spend more on health care, both in absolute dollars and as a percentage of gross national product. Although we would reach a point at which we were both broke and still desirous of more health care, pouring more money into the coffers certainly would push back the threshold at which the most troubling rationing dilemmas became unavoidable. This alternative is neither politically feasible for the foreseeable future, nor probably socially desirable, unless we wish to debate at future forums the absolute scarcity of resources for education, welfare, national defense, the physical infrastructure, and so on.

One method of optimizing the use of scarce medical resources that is both politically feasible and legally and economically desirable is the elimination of futile, nonbeneficial medical interventions. There is no obligation, on any ground, to provide futile treatments to patients. (2) Before we progress - or regress, depending on one's perspective - to rationing schemes based on cost/benefit analyses, involving ethically loaded judgments about comparative need and social equity, we ought first to look toward ferreting out medical interventions that carry with them no likelihood of benefit at all. (3)

One promising development in this sphere is the growing attention, among government and foundation sponsors of health services research and among various medical professional organizations, to the process of better technology assessment and the development of better clinical standards founded on empirical evidence of which interventions really contribute to more positive patient outcomes. (4) This technology assessment/clinical standard-setting trend holds the promise of eliminating many common and costly medical practices that are widespread due more to habit, history, irrational fear of litigation, or reimbursement incentives than to any convincing proof of medical efficacy. Significant medical resources (even if never totally enough) could be transferred from useless (and not infrequently harmful or painful) medical interventions to those with a greater chance of success.

Another method of reducing the provision of futile, nonbeneficial medical interventions and thus enhancing the availability of resources for positive purposes is to encourage a fuller informing of patients, families, and medical professionals about the likely inefficacy in many situations of expensive, as well as intrusive, medical interventions such as cardiopulmonary resuscitation (CPR) and intensive care units (ICUs). There is a popular, and often erroneous, perception that the higher the technology and the more of it, the higher the quality is of medical care being received. In fact, if patients, their families, and their physicians were privy to more complete information about the proven inefficacy of certain advanced medical technologies in particular circumstances, and the very negative prognoses associated with the use of such technologies in those circumstances, many medical interventions would be used more clinically discriminately and appreciable resources could be conserved. (5)

Referring specifically to older persons - the chief focus of this article - one British observer of the American health scene has noted that "the inappropriate deployment of medical interventions, insofar as it occurs, is not impelled by the demands of the elderly or their families so much as by professionals setting the wrong objectives or working under extraneous and unnecessary pressures from the administrative arrangements for funding or the fear of litigation." (6)

A related strategy for reducing medical resource scarcity in an ethically, legally, and economically beneficial manner would be to encourage, indeed to enforce, more respect by physicians and health care facility administrators for the wishes of patients and families to limit aggressive, expensive medical interventions at the end of life where, in the value calculus of the patient and family, the foreseeable burdens of continued treatment outweigh the benefits. (7) This author has suggested recently (8) that, both to foster patient autonomy and save money for more beneficial medical purposes, third-party reimbursement for medical services ought to be linked to demonstration of informed consent to those services, such that interventions for which there exists no clear documentation of informed consent by an authorized decision-maker would go uncompensated.

In the final analysis, however, it must be conceded that, even if the strategies proposed for mitigating the resource scarcity problem succeed well, their implementation would only delay and soften, but not eliminate, the rationing conundrum. The contribution of these strategies would be valuable, but not sufficient. There is still only so much wasteful and inappropriate treatment to be squeezed out of the system, especially where older patients are involved. Even Daniel Callahan has admitted that "[r]ight now, the very old do not receive a great deal of high-technology medicine" (9) for the treatment of acute problems; instead, most expenditures for older persons are devoted to long term care of chronic disabilities and ailments. Reluctantly but inevitably, we therefore must turn our attention to an exploration of different rationing methods and their political, legal, and ethical dimensions.

Methods of Explicit Rationing

There are essentially three ways in which rationing of medical services as a means of controlling expenditures might be achieved. Most drastically, the government could outlaw the provision of specified medical services (e.g., heart transplants) to specified groups of patients (e.g., people more than sixty-five years old), at any price and regardless of source of payment. Neither the patient nor the physician or other gatekeeper would have any discretion in such a model. Some philosophical proposals for health care rationing according to age - such as Veatch's "egalitarian justice over a lifetime" theory, which posits a straight priority claim to medical resources in inverse proportion to chronological age (10) (the "Fair Innings" concept), and Daniels'...