Should Healthcare Resources Be Subject to Rationing?



PRO (yes)

Daniel Callahan, PhD, Director of International Programs at The Hastings Center, wrote in his June 1994 article, "Setting Limits: A Response," that appeared in The Gerontologist:

"We could not possibly guarantee indefinitely to the growing number and proportion of the elderly all of the potentially limitless fruits of medical progress at public expense without seriously distorting sensible social priorities...

The average per capita costs of the elderly are significantly higher than for younger people. Public policy must take account of, and work with, those averages... Age matters...

It matters when, as we can now see, meeting the health care costs of the elderly as a group begins to threaten the possibility of meeting the needs of other age groups. In the nature of the case, moreover, there are no fixed boundaries to the amount of money that can be spent combating the effects of biological aging and attempting to forestall death in old age. It is an unlimited frontier. One could say exactly the same thing about trying to save the life of low birthweight infants... There are no end of possibilities there as well, and thus, some very good reasons to set limits to those efforts... It is no more an anti-aging act than it is an anti-baby act to set limits (for instance, on neonatal care) in order to avoid pursuing unlimited, potentially ruinous possibilities."

June 1994 - Daniel Callahan, PhD 



Leonard Fleck, PhD, Professor of Philosophy at Michigan State University, wrote in his May-June 2006 article "The Costs of Caring: Who Pays? Who Profits? Who Panders?" that appeared in The Hastings Center Report:

"We need to reject the view that we have a moral obligation to spend any amount of money to save all lives and life-years that medical technology permits. The result of adopting this view would be a gross distortion in our society's health care priorities that would not be just, compassionate, or prudent...

Literally dozens of extraordinarily expensive cancer drugs and medical devices are now entering the market. All of them are 'effective'-they prolong life. But the added time is often measurable in weeks and months, not years, which yields very high cost-effectiveness ratios-literally hundreds of thousands of dollars per quality-adjusted life year (QALY). Aggregate costs for all these treatments can quickly mount into the tens of billions of dollars. This has two morally problematic systemic consequences: employers drop or drastically restrict health insurance, and health priorities get skewed in ways that are both unjust and uncaring.

As the cost of health insurance to employers mounts by double digits, more drop coverage as an employment benefit or increase copay requirements substantially. In either case, the economically disadvantaged have less access to needed health care than those who remain well insured and well paid...

I have argued elsewhere that the need for health care rationing is inescapable."

May-June, 2006 - Leonard Fleck, PhD 



Henry Aaron, PhD, Senior Fellow at The Brookings Institution, wrote in his Jan. 30, 2006 article titled "A Healthcare Prescription That's Hard to Swallow; Rationing May Be the Only Way to Ensure That Access for All Remains Affordable," published in Los Angeles Times Commentary:

"Seven U.S. workers in 10 still get health insurance coverage as a fringe benefit of employment. But perhaps not for long. Healthcare spending gobbled up nearly $2 trillion in 2004, and it has grown about 2 1/2 percentage points a year faster than income for decades...

The truth is that sensible rationing may be the only way to make sure that fair access to healthcare for all remains affordable. The U.S. can no longer afford to offer every available service no matter how high the cost or how small the benefit to the patient. Intelligent healthcare rationing -- limiting the availability of care that costs society more to produce than it is worth to patients -- is not a horror to be avoided. It's a regretfully necessary limit to sustain fair access to healthcare that is worth what it costs.

To see the connection between rationing and affordable care for all, one must recognize that insured patients pay little of the cost of their own care when ill. So they quite understandably want everything that might conceivably add even some tiny benefit -- the extra test that provides hardly any information at all, the surgery that is little or no better than watchful waiting, or the costly patented drug that is little or no better than the inexpensive generic...

At current trends, [healthcare] will require more than one-third of the nation's output by 2030. This means we would have to double both income and payroll taxes just to maintain current levels of healthcare for the elderly, disabled and poor. Unless we squeeze out services that are worth less than they cost -- in other words, unless we ration -- even cost-effective care will become unaffordable...

Failure to ration, however, will mean that the cost of caring for the aged, disabled and poor will require astronomical tax increases -- and that working Americans will have less money to spend on anything other than healthcare. Employers will find it increasingly unattractive to sponsor coverage for workers, and workers will refuse increasingly costly coverage. What Winston Churchill said of democracy may also apply to healthcare rationing: the worst system -- except for all the others."

Jan. 30, 2006 - Henry Aaron, PhD 



CON (no)

Wesley Smith, JD, Consultant to the International Anti-Euthanasia Task Force, wrote in his 1997 book Forced Exit:

"Futilitarianism, as it is sometimes called, is social Darwinism. It proposes that the old, the dying, those on the margins, and the profoundly disabled must be pushed out of the lifeboat in order to allow others in or, indeed, to keep the boat afloat...

[Daniel] Callahan's [Director of International Programs at The Hastings Center, a bioethics think tank] embrace of health-care rationing based on futilitarianism is helping drive medical ethics toward extremely dangerous and rocky shores, namely, that individual medical treatment decisions can be based ethically on determinations of 'social consensus and political will' rather than on private determinations between patient and physician...

The belief that the health-care system will be destroyed unless we cease spending so much money on dying people is fundamentally misguided...

Even rationing advocates admit that there is little money to be saved by forcing people out of desired end-of-life treatment opportunities...

It may be worthwhile to reduce overutilization of marginally beneficial treatment...but achieving mandatory restrictions by pitting different populations against each other in the political process hardly seems an appropriate way to establish an ethical health-care delivery system."


1997 - Wesley J. Smith, JD 



The National Right to Life Committee's Burke Robert Powell Center for Medical Ethics Director J. Balch, JD, wrote on the organization's website in an article titled "Medicare Vote a Spectacular Victory in Pro-Life Fight Against Rationing," (accessed on Sep. 6, 2006):

"Americans as a whole can afford to obtain unrationed health care. It has become fashionable to deplore the 'rising cost' of health care. What too few people appreciate is that:

1) Adjusted for inflation, the cost of health care per year of life saved has actually been falling; what has been happening is that we are devoting a rising proportion of our resources to health care with resulting large increases in longevity and better health. In other words, we are not paying more for the same level of health care, but somewhat more for a much higher level of health care.

2) We have been able to devote more resources to health care because rising productivity in other areas has freed up those resources…

In short, we shouldn't bemoan the fact that we are spending more and more on health care--we should be grateful that our country's tremendous productivity enables us to spend more and more to save lives and improve health!...

Since its inception, the pro-life movement has fought just as hard to safeguard the lives of the vulnerable elderly and people with disabilities from euthanasia as to protect the lives of the unborn from abortion. We have long recognized that government-imposed rationing of medical treatment necessary to save life is a form of involuntary euthanasia."

Sep. 6, 2006 - National Right to Life Committee 



Amitai Etzioni, PhD, University Professor at George Washington University, wrote in his June 11, 1988 article "Spare the Old, Save the Young," that appeared in The Nation:

"[Daniel] Callahan's call [to ration health care for the elderly] raises the problem known among ethicists and sociologists as the 'slippery slope.' Once the precept that one should do 'all one can' to avert death is given up, and attempts are made to fix a specific age for a full life, why stop there? If, for instance, the American economy experiences hard times in the 1990s, should the 'maximum' age be reduced to 72, 65--or lower? And should the care for other so-called unproductive groups be cut off, even if they are even younger? Should countries that are economically worse off than the United States set their limit, say, at 55?...

In addition to concern about slipping down the slope of less (and less) care, the way the limitations are to be introduced raises a serious question. The advocates of changing the intergenerational allocation of resources favoring rationing health care for the elderly but nothing else. This is a major intellectual weakness of their argument. There are other major targets to consider within health care, as well as other areas, which seem, at least by some criteria, much more inviting than terminating care to those above a certain age. Within the medical sector, for example, why not stop all interventions for which there is no hard evidence that they are beneficial... Why not take the $2 billion or so from plastic surery dedicated to face lifts, reducing behinds and the like?...

If we cannot stop people from blowing $25 billion per year on cigarettes and convince them to use the money to serve the young, shouldn't we at least cut out public subsidies to tobacco growers before we save funds by denying antibiotics to old people? And there is the matter of profits. The high-technology medicine Callahan targets for savings is actually a minor cause of the increase in health care costs for the elderly or for anyone--about 4 percent. A major factor is the very high standard of living American doctors have, compared to those of many other nations... Another important area of saving is the exorbitant profits made by the nondoctor owners of dialysis units and nursing homes. If we dare ask how many years of life are enough, should we not also be able to ask how much profit is 'enough'? This profit, by the way, is largely set not by the market but by public policy."

June 11, 1988 - Amitai Etzioni, PhD