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The New Relevance of Rationing

By Ben Davies

Decisions about how to allocate healthcare resources can be divided, somewhat crudely, into macro– and micro-level choices. Roughly speaking, macro-choices are policy choices, often made outside any clinical setting, e.g., by government. For instance, it is a macro-level choice which treatments to fund to what degree, and how large the health budget should be as a whole. Micro-choices are the choices people make with a particular budget, generally in clinical settings. For instance, it is a micro-level choice which patients to admit to intensive care, and how to prioritise individuals for organ transplants.

Macro-level decisions are taken at greater remove from the specifics of any individual patients. They work, by necessity, with a greater level of generality. Micro-level decisions are often shaped and constrained by macro-level decisions: for instance, it may be a macro-level choice that certain features of patients are not to be considered, or must be considered, at the micro-level. Some people may worry about macro-level decisions because of their tendency towards aggregation, and inability to see the patient as an individual. And there is certainly a case for medical professionals to ensure that they consider the individual before them, and how they might upend the assumptions contained in a policy set at the macro-level.

However, it is also true that an increase in micro-level decision-making may not be a good thing. For one, it places much greater demands on medical professionals. Indeed, one criticism that applies to many proposed criteria for healthcare decision-making—including personal responsibility, or attempts to place greater weight on benefits for those who have been worse off across their lives—is that if such features have to be judged at the micro-level, this would cause significant administrative and other strains on the healthcare system.

What’s more, an increase in micro-level rationing may be a sign of failures at the macro-level. The UK’s National Health Service (NHS) is currently undergoing an extraordinary confluence of pressures. For instance, a recent newspaper report from the north-western city of Liverpool had the following quote attributed to an emergency clinical support worker at a hospital in the area:

“We have patients having heart attacks who we don’t have trolleys or beds for, so they are sat waiting in chairs. We are having to ration care, having to decide who gets the next trolley with 20-30 people waiting for it”.

What’s more, the head of the region’s hospital trust has urged people not to seek Accident & Emergency (A&E) hospital care unless their situation is “life-threatening”, a sentiment echoed elsewhere in the country. This is part of a longer-term trend that has seen A&E waiting times increase, which the King’s Fund has attributed to, among other things, increases in demand; staffing pressures; and possibly health improvements which mean people who previously would have needed to be hospitalised can now be treated without being admitted. This request might be seen as a form of ‘ultra-micro’ decision-making, where decisions about resource allocation are partly placed in patients’ hands as they are explicitly given a choice to seek less urgent forms of care, or not to seek care at all.

All this raises a conundrum for those of us who work on resource allocation. In one sense our work might be seen as more relevant than ever; given strain on health services, it is no bad thing to think about how to make micro-allocation decisions fairly.

But it has always been important to keep one eye on the macro-level. The conundrum at this point comes if we think that the pressures on health services, and the increased need for micro-level and ultra-micro-level decisions, could be alleviated by different choices at the macro-level, such as additional spending, or greater efforts to stem declines in staff by compromising with healthcare unions. This is not to say that these decisions would make the pressure go away; but they might make it less severe.

Insofar as this is the reality of the NHS, it is surely preferable for difficult decisions to be made on justifiable grounds. That is the basic case for researchers in resource allocation to think about micro-level decisions, and to try to formulate ways to make them fairly. It is of no use to someone who faces a difficult micro-level decision to be told that they ought to have more colleagues, more beds, more time.

But there is a clear risk here, of a failure to see the wood for the trees. In more political terms, there is a danger of simply accepting systemic factors which shape our reality, rather than critiquing and pushing back against them. At some point, the answer to “How do we choose between these patients?” is, ‘You must, but you can’t.”

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6 Comment on this post

  1. Decisions on resource allocation are local. That is the luck of the draw, no matter where one lives. Insofar as this blog originates in the UK (as far as I understand it), local resources there are different to those where I live (USA). As resources are concerned, it is reasonable to infer the disparity will always be as it is, although factors such as pandemic may alter this somewhat. I don’t know if this relevance-of-rationing notion is either over-prescriptive or over-protective. I would suspect, as the article as much as states, demographers and economists HAVE incorporated pandemic thinking into the rationing discussion and decisions made, or forthcoming. Friends and relatives reside in various parts of the world including UK and Canada. Some are interested in this and other issues that might ripple into their lives; affect other friends and loved ones who reside in UK specifically: these are primarily life-long activists who yet care about the bigger picture. Others are more-or-less embittered expatriates, living out their lives in greater contentment than they found in the USA. Insulation against rationing may be thinner where they now live. Contentment is worth the risks.

  2. This article is excellent and identifies fundamentals within healthcare when resources cannot meet demand. I wonder what would happen if AI was used in these difficult circumstances to assist with the decision making processes. Would patients be informed of this and how well would it sit with them?

    Maybe an interesting topic to have as a debate within the framework of bioethics.

    1. Thank you very much. Yes, there are certainly people thinking about the use of AI in this area. My view is that AI might help with execution of particular rationing principles, but can’t substitute for ethical discussion in deciding what those principles ought to be.

  3. I hate to burst anyone’s balloon. However, as I opined on another blog, ethics and morality are just not troubling to a great may people today, because they know those things are not troubling to a great many more. There are few consequences that have a lasting effect which matters. Put more colloquially, within a half-century window: there is no such thing as bad press. Recent political and economicfigures have taken full advantage of this and turned the tables on their opponents. Today, I received an email, admonishing me to desist from submitting comments that added nothing to the discussion. In fewer than ten words. I replied, in kind, saying:sure. The blog owner is big stuff. See, there was no tedious rhetoric in my brief comment. It did not even challenge the blogger’s position(s). He is important—has a high opinion of himself. In fewer words, YAWN.

    1. Thanks Paul – just for avoidance of doubt in case anyone misreads your comment, that email wasn’t from me! You’re obviously very welcome to keep commenting here.

      I agree that there are serious challenges in getting people to pay attention to ethical considerations. I am a bit more optimistic than you about this: I think that most people do care about ethics, but are prone (and this includes ethicists) to self-serving thinking.

      It’s not clear to me that having a “lasting effect” should be the only consideration: if I cause someone to be in serious pain for five minutes, for no reason, that might not have any lasting effect, but is still wrong!

  4. Back to you, Ben. And thanks, as well. Different take on ethics and morality: today, I viewed a broadcast on police involvement in traffic enforcement. How this might no longer be expedient. I did not understand the alternative or even if one was being proffered. But it reminded me of a lesser-known film, featuring Sylvester Stallone, Wesley Snipes and a well-regarded actress whose name escapes me now. The film was Demolition Man. Stallone was revived from cryo-death, to assist modern law enforcement with apprehending Snipes’ character, who was a criminal and anarchist.(this is not a sexist thing—she was good in Speed, too, with Reeves and Dennis Hopper.) So, the Demolition film portrayed retrospective remediation: we cannot cope with current affairs, so let’s bring back a Neanderthal—to cope with one. Do overs are dangerous. Oh,hell—don’t we know this yet? Brings me back to the problem. How about you? Stallone is a thinker. Very few get that, unless they have paid attention….

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