Pricing Life: Why It's Time for Health Care Rationing

A physician and bioethicist discusses the moral issues surrounding health care rationing, exploring the various ethical and practical issues, and suggesting some ways to ration care in an effective, just way.

Reviewed by Wallace F. Berman, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

This first volume in a bioethics series edited by Arthur Caplan and Glenn McGee is a thoughtful and provoking presentation of the case for using cost-effectiveness analysis (CEA) as a guideline for rationing health care. While four of his chapters are based on previously published articles in medical or ethics journals, Ubel (Center for Bioethics/Univ. of Pennsylvania School of Medicine) is addressing a more general audience here in arguing that physicians must ration health care at the very bedsides of their patients. Health-care rationing cannot succeed if applied only through restrictions imposed by government, third-party payers, utilization review boards, or formulary committees, he contends; doctors must accept the necessity to carry this out. Rationing, he concedes, is an uncomfortable concept for physicians as well as for society; nevertheless, the practice is widespread under euphemisms, such as ``standard of care.'' After examining various ways in which it has been defined, he offers his own definition: any mechanisms, implicit or explicit, that deprive people of beneficial, though not necessary, health-care services. Ubel considers the moral arguments against bedside rationingit violates clinicians advocacy duties; it destroys the trust needed for a good doctor-patient relationship; it opens the door to discriminationand finds them exaggerated. What bedside physicians need, he maintains, is guidance in making difficult rationing decisions, and although CEA not a perfect tool, it is a promising one. Citing the controversy aroused by the Oregon Medicaid program's 1987 failed cost-effectiveness list, he illustrates CEA's shortcomings in capturing community values for setting health-care priorities. Referring to recent research, he considers how community values might be incorporated more fully into CEA to make it a more useful tool. Ubel concludes by predicting that policy experts, clinicians, and administrators will become better at interpreting CEA and using it to make health-carerationing decisions. Serious discussion of a difficult and disturbing issue. (18 illus., not seen). -- Copyright ©1999, Kirkus Associates, LP. All rights reserved.

Ubel (medicine and bioethics, Univ. of Pennsylvania) presents an overview of the moral and methodological conundrums raised by cost-effectiveness analysis (CEA), especially with regard to its role as a guide for how to ration healthcare. Ubel hopes that by viewing health rationing through the CEA lens, politicians, the public, and healthcare providers will be forced to open a debate on which services ought to be offered to everyone regardless of ability to pay and which should be offered according to ability to pay. Managed care, the political, stalemate surrounding healthcare delivery, and economic realities combine to make CEA a reasonable approach to healthcare rationing. Ubel is a persuasive advocate or CEA, seeing it as a powerful tool to help society set its healthcare delivery priorities. Recommended for bioethics and larger health collections.
James Swanton, Harlem Hosp. Lib., New York
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