Rationing between competing health care needs is unavoidable (Bognar & Hirose 2014; Ubel et al. 1996). Such rationing ought to be morally justified. It is generally accepted that in order to be morally justified, rationing must be non-discriminatory and cost-effective (Baron 1995; Rawlins & Dillon 2005). Given conventional concepts of cost-effectiveness, resources spent on old and disabled people are spent less cost-effectively, ceteris paribus, than resources spent on young and non-disabled people. Yet since giving lower priority to such groups can be discriminatory, we face a health care trilemma involving the following three claims:
These three claims form a logically inconsistent set. Hence, we must reject at least one of them. Unfortunately, each of them is very plausible and widely accepted (Ubel 2001; Dolan et al. 2005; Nord et al. 1999; Persad et. al 2009; Sundheds- og Ældreministeriet 2016). The Non-Discrimination claim reflects that people should not be treated differently on the basis of membership of socially salient groups, e.g., rationing should not be racially discriminatory. The Cost-Effectiveness Claim reflects that health care resources should be spent in ways that maximize the goodness of health care outcomes, i.e., we should avoid waste. The Incompatibility Claim reflects the widely shared assumption that health care cost-effectiveness means maximising the sum of QALYs (QualityAdjusted Life Years) (or some related unit, e.g., DALY) within the relevant budget constraints (Gold et al. 2002; Bognar 2008, 2010, 2011; Singer et al. 1995).1 Ceteris paribus, a treatment that saves the life of an old patient will result in fewer extra life years and at a lower level of health than the same treatment offered to a younger patient (Brock 1989, 2004, 2009; Tsuchiya 2000). Accordingly, we will get more QALYs from spending a fixed amount of health care resources on young rather than on old people. Hence, cost-effectiveness favours giving lower priority to and thus discriminates against elderly patients (Harris 1987; Farrelly 2008; John et al. 2017). A similar argument applies to disabled patients, since, ceteris paribus, on standard measures of QALY one extra life year for a disabled person results in fewer extra QALYs than an extra life year for an able-bodied person (cf. Dolan et al. 2005; Gold et al. 2002; Hadorn 1991; Harris 2005; NICE 2008). This project explores how we should respond to the healthcare trilemma.
Because the health care trilemma involves a strictly inconsistent triad, we must reject at least one or more of the three claims of which it consists. Accordingly, the project’s overall research question is: Which of the three claims – the Non-Discrimination, Cost-Effectiveness and Incompatibility Claim – in the health care trilemma should be rejected? The project will explore three main hypotheses, two of which bear on how to resolve the trilemma and one of which bears on the implications of this resolution for the justification of the rationing in the Danish health care system:
Hypothesis 1:
A health care rationing scheme that discriminates against certain groups can be morally justified (Rejecting the Non-Discrimination Claim of the trilemma).
This hypothesis is grounded in the belief that discrimination is not intrinsically morally impermissible, and that the moral status of discrimination depends on the moral reasoning behind the discriminatory act or policy. Moreover, whether treating people differently amounts to wronging them depends on a number of further factors. Specifically, given that age discrimination against the elderly is compatible with equality of opportunity, age discrimination might be justified. The project aims to show that Hypothesis 1 is true by defending the following two indented claims:
The Strong Incompatibility Claim:
A cost-effective health care rationing scheme discriminates against not only old people and disabled people, but against many other groups as well, e.g., unemployed people and people with mild depression.
If the Strong Incompatibility Claim is true, we face an even more broad-scoped version of the health care trilemma. We expect to be able to show that the strong incompatibility claim is true. Health care cost-effectiveness measures typically ignore indirect health effects (e.g., treating a specialist surgeon, who will then treat other patients, will typically have better indirect health care effects than treating an unskilled person) and non-health related effects – e.g., treating a successful businessperson will typically have better health-care related effects than treating an unemployed person (Kamm 2013; Lippert-Rasmussen & Lauridsen 2010). There is no principled rationale for adopting cost-effectiveness measures that focus only on a subset of benefits accruing from a certain treatment (Broome 1998; Hausman 2015). Accordingly, a truly cost-effective rationing of healthcare resources discriminates against many groups other than the disabled and elderly people.
The Weak Non-Discrimination Claim:
In a limited range of cases, a morally justified scheme of health care rationing discriminates against certain groups, e.g., old people and patients with rare diseases that are difficult and extremely costly to treat.
The Weak Non-Discrimination Claim can be shown to be true given the following two assumptions. First, while there are many conceptions of discrimination for the purpose of assessing The Weak Non-Discrimination Claim, we assume that a rationing scheme discriminates against a certain set of individuals if, and only if, this set constitutes a socially salient group and the relevant scheme makes members of the relevant socially salient group worse off because of their membership of this group (Lippert-Rasmussen 2013, 2017). Second, we assess the moral justifiability of discrimination so construed from the perspective of the standard accounts of what makes discrimination wrong, e.g., the ideal of equality of opportunity (Segall 2013). We make no claims about what makes discrimination morally unjustified. Given these standard accounts we conjecture that rationing that discriminates against older patients is not morally unjustified, because it simply reduces the inequality of opportunity in favour of elderly patients who have already enjoyed more good life years than younger patients have (Harris 1985, 1987; Kappel & Sandøe 1992). The reasoning behind this is sometimes associated with the idea of fair innings, where those who have had their fair share of a good life can be given lower priority than those who have not enjoyed the same (Williams 1997; Bognar 2015). The case of disabled people (and most of the other groups mentioned above) is different, since while (if we are lucky) we all get old, not everyone becomes disabled (Daniels 1982; Brock 2009; cp. McKerlie 1989). The argument rejecting the Discrimination Claim underscores the need to discuss the merits of the Cost-Effectiveness Claim as well. This is where the second hypothesis enters the picture:
Hypothesis 2:
A morally justified scheme of health care rationing is not cost-effective, because sometimes the value of cost-effectiveness clashes with other values and in some of those cases these values should take priority over cost-effectiveness (Rejecting The CostEffectiveness Claim).
Hypothesis 2 can be affirmed only given certain assumptions; to wit, that a morally justified health care rationing system must satisfy widely accepted moral constraints other than cost-effectiveness, e.g. a) distributive concerns (Albertsen 2016); b) the humanitarian concern for patients with urgent medical needs (Nielsen 2013, 2015); c) considerations about rights, e.g. the right to informed consent (Childress 1997). We expect to show that Hypothesis 2 is generally true because although cost-effectiveness is a relevant moral concern, in some situations other shared moral considerations override this value. This project explores how the most widely shared values – in particular fairness, priority to the worst-off, and individual rights – constrain the demand for costeffectiveness. There is vast agreement within the state-of-art literature on health care rationing that these moral concerns do matter to health care priority setting (Cantor 1994; Ubel 2001; Nord et al. 1999; Bognar & Hirose 2014). But questions about how to understand these values and consequently how they constrain the demands of cost-effectiveness are yet to be answered. For instance, the appeal to fairness is often understood in terms of responsibility-sensitive distributions of access to health care services (Albertsen & Knight 2015), but occasionally it is operationalized as giving everyone a fair chance of access (regardless of irresponsible behaviour) (Ubel 2001). Similarly, giving priority to the worst-off is a widely recognized concern in health care rationing, but whether priority should mean absolute or weighted priority is still debated, and similarly whether to interpret the worst-off as the most severely ill or the most socially vulnerable is yet to be determined. The project investigates the most plausible ways to answer these questions in light of the health care trilemma. Together with Hypothesis 1, this motivates the third hypothesis:
Hypothesis 3:
The present rationing scheme in the Danish health care system does not cohere well with Hypotheses 1 and 2 and, given these, should be revised.
Generally, the project is tentatively non-committal in regard to the assessment of Hypothesis 3, because it depends largely on the outcome of the investigations of Hypotheses 1 and 2. However, we expect to show that Hypothesis 3 is true given several plausible assumptions. First, the health care trilemma is generally not recognized in the Danish health system and thus the moral reasoning necessary for identifying the right way of resolving it is lacking. In particular, no principled stance on permissible age discrimination and required deviations from cost-effectiveness has been articulated in Danish health care policies. The 2017 establishment of the Danish Medicines Council (DMC), which provides recommendations as to whether new medicines should be implemented at the public’s expense, takes the Danish healthcare system a step in the direction of more explicit priority setting. The DMC has expressed interest in being a partner to this project. Second, costeffectiveness and non-discrimination as well as other values such as basic needs and fairness are all considered important. However, by and large their relation and potential/inherent conflict remains unrecognized. Thus, the exploration of Hypothesis 3 will have significant political implications. Its focus will lie on current policy discussions and decisions about increased focus on explicit prioritization in the Danish healthcare system (Sundheds- og Ældreministeriet 2016), and we will conduct systematic analyses of the values pursued. The project group will collaborate closely with the secretariat of the DMC and invite it to all workshops. Moreover, the PI will have a two-week research stay at the council.
1 An extra life-year at perfect health has the value 1, while an extra life-year at a lower level of health has a value between 0 and 1 depending on the severity of the relevant health condition.