Core idea and purpose
Rationing between competing health care needs is unavoidable (Bognar & Hirose 2014; Ubel et al. 1996). Such rationing ought to be morally justified. It is generally accepted that in order to be morally justified, rationing must be non-discriminatory and cost-effective (Baron 1995; Rawlins & Dillon 2005). Given conventional concepts of cost-effectiveness, resources spent on old and disabled people are spent less cost-effectively, ceteris paribus, than resources spent on young and non-disabled people. Yet since giving lower priority to such groups can be discriminatory, we face a health care trilemma involving the following three claims:
- A morally justified scheme of health care rationing does not discriminate against any groups (The Non-Discrimination Claim).
- A morally justified scheme of health care rationing is cost-effective (The Cost-Effectiveness Claim).
- A cost-effective health care rationing scheme discriminates against old people and disabled people (The Incompatibility Claim).
These three claims form a logically inconsistent set. Hence, we must reject at least one of them. Unfortunately, each of them is very plausible and widely accepted (Ubel 2001; Dolan et al. 2005; Nord et al. 1999; Persad et. al 2009; Sundheds- og Ældreministeriet 2016). The Non-Discrimination claim reflects that people should not be treated differently on the basis of membership of socially salient groups, e.g., rationing should not be racially discriminatory. The Cost-Effectiveness Claim reflects that health care resources should be spent in ways that maximize the goodness of health care outcomes, i.e., we should avoid waste. The Incompatibility Claim reflects the widely shared assumption that health care cost-effectiveness means maximising the sum of QALYs (QualityAdjusted Life Years) (or some related unit, e.g., DALY) within the relevant budget constraints (Gold et al. 2002; Bognar 2008, 2010, 2011; Singer et al. 1995).1 Ceteris paribus, a treatment that saves the life of an old patient will result in fewer extra life years and at a lower level of health than the same treatment offered to a younger patient (Brock 1989, 2004, 2009; Tsuchiya 2000). Accordingly, we will get more QALYs from spending a fixed amount of health care resources on young rather than on old people. Hence, cost-effectiveness favours giving lower priority to and thus discriminates against elderly patients (Harris 1987; Farrelly 2008; John et al. 2017). A similar argument applies to disabled patients, since, ceteris paribus, on standard measures of QALY one extra life year for a disabled person results in fewer extra QALYs than an extra life year for an ablebodied person (cf. Dolan et al. 2005; Gold et al. 2002; Hadorn 1991; Harris 2005; NICE 2008). This project explores how we should respond to the healthcare trilemma.
Website: https://ps.au.dk/en/research/research-projects/non-discrimination-in-health-care/research
