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Rationing Is Not a Four-Letter Word

Rationing Is Not a Four-Letter Word: Setting Limits on Healthcare

Philip M. Rosoff
Series: Basic Bioethics
Copyright Date: 2014
Published by: MIT Press
Pages: 336
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  • Book Info
    Rationing Is Not a Four-Letter Word
    Book Description:

    Most people would agree that the healthcare system in the United States is a mess. Healthcare accounts for a larger percentage of gross domestic product in the United States than in any other industrialized nation, but health outcomes do not reflect this enormous investment. In this book, Philip Rosoff offers a provocative proposal for providing quality healthcare to all Americans and controlling the out-of-control costs that threaten the economy. He argues that rationing -- often associated in the public's mind with such negatives as unplugging ventilators, death panels, and socialized medicine -- is not a dirty word. A comprehensive, centralized, and fair system of rationing is the best way to distribute the benefits of modern medicine equitably while achieving significant cost savings.Rosoff points out that certain forms of rationing already exist when resources are scarce and demand high: the organ transplant system, for example, and the distribution of drugs during a shortage. He argues that if we incorporate certain key features from these systems, healthcare rationing would be fair -- and acceptable politically. Rosoff considers such topics as fairness, decisions about which benefits should be subject to rationing, and whether to compensate those who are denied scarce resources. Finally, he offers a detailed discussion of what an effective and equitable healthcare rationing system would look like.

    eISBN: 978-0-262-32076-4
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Series Foreword
    (pp. ix-x)
    Arthur Caplan

    I am pleased to present the forty-fourth book in the Basic Bioethics series. The series makes innovative works in bioethics available to a broad audience and introduces seminal scholarly manuscripts, state-of-the-art reference works, and textbooks. Topics engaged include the philosophy of medicine, advancing genetics and biotechnology, end-of-life care, health and social policy, and the empirical study of biomedical life. Interdisciplinary work is encouraged....

  4. Preface
    (pp. xi-xiv)
  5. 1 The “Evil” of Healthcare Rationing
    (pp. 1-34)

    Healthcare in the United States accounts for an enormous percentage of gross domestic product (GDP), more so than any other industrialized nation and hence, any other country on earth. Although the United States spends far more per capita on healthcare than anyplace else, its indicators of population health do not reflect this investment (Stabile et al. 2013).This expenditure has been steadily growing for decades, even though the rate of increase has slowed, probably due in part to economic problems (Hartman et al. 2013). As a 2011 report by the Congressional Budget Office predicted, “Total spending on health care would rise...

  6. 2 Existing Rationing Systems: Organ Transplantation, Scarce Drugs, and Oregon
    (pp. 35-60)

    To begin my argument about the possible acceptability of widespread and tolerable rationing, I will start with a discussion of some existing systems of explicit—what I have called “formal”—rationing arrangements in distinct areas of healthcare. Two of the examples will demonstrate what might be described as the extremes of rationing, in which there is an absolute limit on the available resources, thus forcing the prioritized allocation of the extant supply to recipients whose numbers far exceed the quantity available. The third case (Oregon) is a demonstration of an approach to rationing in which money (not organs or drugs)...

  7. 3 Fairness
    (pp. 61-92)

    In the previous chapters I have introduced some general concepts about healthcare rationing and several of the challenges, especially psychological, that would be potential barriers to overcome in any attempt to convince people that embracing rationing would be in their best interest. However, since the reaction to discussions of rationing are often laden with fairly distraught emotions, often stoked by interest groups who believe they stand to lose something of significance should a universal healthcare system with rationing be implemented, it is also important to discuss other features of any plausible rationing scheme that would help make it palatable to...

  8. 4 The Cutoff Problem, or Where and How to Draw the Line
    (pp. 93-128)

    In the previous chapters I have argued that rationing applied to the entire healthcare system could potentially be acceptable and not especially onerous. Both claims are based on the premise that if it were fairly and justly applied and thus bore some resemblance to existing well-tolerated rationing systems, such as that for the allocation of scarce organs, then it could be similarly well accepted. Indeed, compared to this system, in which there is an absolute shortage of livers, hearts, lungs, and kidneys and where the failure to obtain a transplant is most often certain death, it is doubtful that any...

  9. 5 Losers
    (pp. 129-156)

    In the preceding chapters I have discussed various aspects of systematic healthcare rationing, including features that I have suggested would make a rationing plan fair enough to convince people that it is in their best interests to agree to it. I have coupled this proposal with the assumption that healthcare rationing would have to be reasonably to very generous in its benefits to attract significant public support. This argument is based on the premise that the public already tolerates draconian—but fair—rationing in the organ transplant system, as well as episodically for emergencies and disasters. I have also examined...

  10. 6 Limits to Fairness in a Democracy
    (pp. 157-184)

    In the late winter of 2003 a major medical error was discovered to have occurred at Duke University Medical Center in Durham, North Carolina. Mistakes, many grievous, are unfortunately made every day at hospitals, clinics, and doctors’ offices throughout the United States; as reported by the Institute of Medicine in 2000, as many as 90,000 patients many die each year in the United States as a result of medical errors (Kohn, Corrigan, and Donaldson 2000). Many of these are not noticed or caught by anyone. Some result in major harm to patients and some of these may end up in...

  11. 7 Summing Up
    (pp. 185-220)

    It has been my task in this book to construct an argument to convince readers that large-scale healthcare rationing of a certain kind is potentially feasible in the United States. To do so, I have suggested that the already existing general acceptance of the organ transplant system (for example), in which the stakes of not receiving a scarce good are dramatic and irreversible, leads one to believe that an approach incorporating many of the elements that contribute to its social success (distinct from its medical success) could be assimilated into a much more universal rationing program. Many other authors have...

  12. Notes
    (pp. 221-266)
  13. References
    (pp. 267-306)
  14. Index
    (pp. 307-320)
  15. Back Matter
    (pp. 321-322)