Allocating health resources ethically: new roles for administrators and clinicians

Rationing of health care is an inevitable correlate of living in a world of finite resources. It is morally necessary. The Hippocratic ethic commits clinicians to do whatever will benefit the patient and therefore must be abandoned in a world of moral rationing. After looking at some unacceptable preliminary strategies, two patient-centered adjustments in the Hippocratic ethic, adopting a more objective standard of patient benefit and adding a principle of patient autonomy, are defended. Still, however, cutting the fat out of the system will not be sufficient. A true social ethic of resource allocation will be necessary. A social contract approach supports a principle of equity as a necessary supplement to utility and cost-benefit analysis. It does not follow, however, that clinicians must take on these social ethical decisions. Clinicians should be exempt from normal social ethics so they are free to pursue the objective welfare of patients (provided they consent to such benefit). Administrators are in no better position to allocate scarce resources. What is needed is input from patients to (a) set categorical limits on their own care, (b) articulate principles for fine-tuning the allocation decisions, and (c) supervise professional agents who will make specific gatekeeping decisions for allocating a pool of resources legitimately thought to belong to the patient population. Neither administrators nor clinicians will be responsible for rationing decisions. In 1989 we spent $604.1 billion on health (U.S. Department of Health and Human Services 1990). That is almost $2 billion a day. Sometimes the benefits are dramatic: the pneumonia cured, the heart transplanted, the children spared from infectious diseases with immunizations that cost only pennies. Even so, the American health care system leaves much to be desired. Many other countries have higher life expectancy at birth. Infant mortality in the United States is far higher than countries like Japan and Sweden (United Nations Children's Fund 1990). If we look at the distribution of health status in the United States, the problems look even worse. Today, depending on the study, about 13 to 15 percent of the population has no health insurance at all (U.S. Bureau of the Census 1989; Short, Monheit, and Beauregard 1989). Another 13 percent is woefully underinsured (Farley 1985). Social variables such as income, education, and race reveal dramatically different health status (Short, Monheit, and Beauregard 1989; Farley 1985). To respond to these needs, rationing will be essential.(ABSTRACT TRUNCATED AT 400 WORDS)