…… The ethics of rationing begins with two considerations. First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.
…… The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too. The ethical argument about rationing then shifts to the question of the fairest means for allocating scarce resources — whether through the use of a quasi-objective measure such as quality-adjusted life-years or through a procedural approach such as increased democratic engagement of the community.
….. The facts that have recently overtaken this ethical discussion show that waste in U.S. health care, defined more broadly as spending on interventions that do not benefit patients, actually amounts to a much larger sum — at least 30% of the budget — and that this waste is a major driver of cost increases.
….. The ethical question therefore shifts to waste avoidance. Even though the concept of medical futility has had a vexed history, this new ethical question is a subcategory of the futility debate. We used to think that the issue of futility arose only when physicians, in keeping with their professional integrity, refused to offer useless treatment even when patients or families demanded it. We now realize that futile interventions may be administered not solely because of patients’ demands but also by physicians acting out of habit or financial self-interest or on the basis of flawed evidence. The ethics of waste avoidance is thus in part a component of the ethics of professionalism.
…… The two principal ethical arguments for waste avoidance are first, that we should not deprive any patient of useful medical services, even if they’re expensive, so long as money is being wasted on useless interventions, and second, that useless tests and treatments cause harm. Treatments that won’t help patients can cause complications. Diagnostic tests that won’t help patients produce false positive results that in turn lead to more tests and complications. Primum non nocere becomes the strongest argument for eliminating nonbeneficial medicine.
…… In the end, the ethics of rationing and of waste avoidance are complementary, not competing. Perhaps at present, waste avoidance could save enough money to permit both universal coverage and future cost control. As medical technology advances, especially with personalized genomic medicine, we will almost certainly arrive at the day when we cannot afford all potentially beneficial therapies for everyone. The ethical challenge of rationing care will have to be faced sooner or later, particularly when we confront inequitable distribution of health care resources globally.
An ethical mandate to prioritize waste avoidance doesn’t address the political hurdles, of course. Given that one person’s health care expense is another person’s income, we can anticipate pitched battles, accompanied by demagoguery such as talk of “death panels.” Medicine’s role in this campaign will pose a serious challenge to physician professionalism. Will U.S. physicians rise to the occasion, committing ourselves to protecting our patients from harm while ensuring affordable care for the near future?