Rationing Healthcare

Rationing typically refers to the distribution of some good or service insufficient in supply to meet the available demand for it. Most people think of rationing as a situation when scarce commodities such as fuel during wartime are not sufficiently [Page 1021]available. The fuel available could be rationed by price and given to the highest bidder, but such price rationing is seen as unfair. Thus, a system of allocation is designed that seeks to incorporate broader values such as equity, need, potential benefit, fair share, positioning in the queue, and so on.

The situation best exemplifying such scarcity in contemporary America is the lack of available hearts, kidneys, livers, and lungs for transplantation, where need in many cases far exceeds supply. Almost everyone regards price rationing for such available organs as unfair, so an alternative distribution system must be designed. Such distributions have been called “tragic choices” because there is no correct answer on how to do this.

Some analysts note that many of the instances in medicine referred to as rationing do not involve scarcity in that the needed supply is available but consumers are unwilling or unable to pay the price demanded. However, most instances of scarcity are imposed by policy choices reflecting culture and ethical values. There are numerous ways to increase the availability of scarce organs were we not bound by our values and norms. These include allowing people to buy and sell them, paying relatives to agree to the use of organs of their loved ones who no longer have brain function, or appropriating the organs of people who are brain dead by fiat regardless of family wishes. Or we can do what occasionally has been done in China-take the organs of prisoners following execution or solders killed in war. We can even imagine societies where people are bred for spare organs. Most societies view all the above solutions to scarcity as unethical.