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Spring 2002
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Allocation
of Resources
Case Study 3 – Rationing
the Decisions about Health Care Programs: An Exercise.
From
Case Studies p 147-150
The
Federal Government has placed a cap on any new health care expenditures.
The eight programs listed below have been proposed for funding. The
total cost of all programs would be $30 billion, but only $17 billion is
available. Which programs would you select for funding? Rank them in
order of priority, and distribute the available funds.
Continuation of
Renal Dialysis Program ($2 billion annually for 75,000 persons)
- Institution of a
Comprehensive Prenatal Health ($2 billion annually. Black infant
mortality rates are double those of white)
- Expansion of
Neonatal Intensive Care Technology ($1.5 billion annually for
200,000 infants)
- A Totally
Implantable Artificial Heart Program ($3 billion annually for 25,000
people, when perfected)
- Health Insurance
for the Uninsured -- employed and unemployed and their family
dependents who are not covered by private insurance, Medicare, or
any other insurance program-- ($8 billion annually for 25 million
people)
- Expansion of Cancer
Research (by $2 billion annually)
- Improve Health Care
Coverage for the elderly ($10 billion annually for 27 million
persons)-- Many elderly require long-term care in skilled nursing
facilities. They are admitted as private-=pay patients and “spend
down” to Medicaid eligibility only after their assets are
depleted.
- Continuation of
Support for Persons in Persistent Vegetative States (e.g., Karen
Quinlan), with artificial feeding and hydration, antibiotics, etc
($1.5 billion annually for 10,000 persons)
** What ethical principles
support your allocation of the $17 billion available?
NOTES:
The programs listed above are all legitimate contenders for funding. The
figures given for each are approximate, but not unrealistic. Many other
programs could be listed or substituted for some listed here. The
overall assumption of a ceiling on expenditures for health services is
daily more evident.
There are many ways to choose which programs to fund. The list below is
a sample, together with a justification for each choice. There is no
single right set of choices, but discussion of what and why we choose as
we do should move the discussion beyond the purely intuitive or
emotional level and allow for debate on the merits of each program.
Pure
Egalitarianism – would refuse to consider the particular
merits, efficiency, or needs of he recipients of each program and
simply divide all the available monies equally. Each program gets
equal shares (and most are underfunded), at $2.1 billion.
- Equitable
Egalitarianism – would give each program an equal percentage
of its request, roughly 50 percent. Unlike pure equality, here needs
and numbers come into play after considerations of equality.
- Assist the
neediest first, or the most ill first -- This policy would
seek to rescue those nearest to death. In this scheme renal dialysis
and neonatal intensive care units and persons in persistent vegetative
states would get their full requests first, likely followed by the
artificial heart program.
- Seek the
greatest good for the greatest number – Here “good” must
be defined, but at least one way to determine this is to ask which
programs will effectively help the largest number of persons. This
mode of reasoning would likely place health insurance for the
uninsured at the top of the list, followed by improved health care for
the elderly.
- Choose in
accordance with Long-Range Efficiency and Effectiveness – In
this mode of reasoning, priority will be given to prenatal programs,
which are quite effective in avoiding many neonatal problems, and
cancer research. Both programs appeal to a preventive emphasis and
eschew expensive and frequently ineffective rescue efforts.
- Act on the
principle of Restorative Justice – choosing this principle,
greatest assistance would be given to those whose maladies are caused
or exacerbated by previous social or economic injustices. If this
logic is followed, prenatal programs (which affect many minorities)
and insurance for the unemployed (losers in a competitive economy)
would be given top priority. Cancer research might also be a favorite
under this system of allocation, since some forms of cancer seem to be
prreviewent in lower socio-economic groups and may be the result of an
environment more foul for the poor than for other citizens.
- Honor
Long-Standing Obligations – Here a moral criterion for
ranking programs is loyalty to those who have previously been treated
or to whom one owes fidelity due to past obligations. Following this
criterion would place renal dialysis patients and the elderly at the
top of the list. Both groups, it could be argues deservedly expect our
care because of our past relations with them.
- Draw the
winners from a hat – this is the lottery approach, used as a
measure when all programs are thought to be equally meritorious or
when the relative worth of the programs affected cannot be (or should
not be) judged. Proponents of a lottery say is gives everyone an equal
chance. Opponents claim it is like “throwing dice” and is a choice
“by default”.
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