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American Geriatrics Society (AGS) Position Statement Rational Allocation of Medical Care: A Position Statement from the AGS Ethics Commitee* *Last Updated in 2002* Background: The word "rationing," given its etymological root, should suggest a rational allocation of scarce resources, but instead it carries a connotation of painful limitation or withholding of necessary care. In this paper, we will use the term "rationing" to refer to methods of allocation of medical care resources. In the United States, medical care resources, even for basic medical care, are not made routinely available to all, but are "rationed" on the basis of financial, cultural, or geographic access to health care and to health care insurance through employment, self-purchased health insurance, or ability to pay out of pocket. Both market forces and government initiatives are now drastically re-shaping the organization of health care delivery in the U.S. Every health care plan developed has or will have some means, either implicit or explicit, of allocating its medical care resources to individuals in the plan. As a society, we cannot do all the socially desirable things that can be imagined. We are not currently providing all the medical care that would improve health or relieve suffering. The current distribution of benefits of health care, and of its costs, results from a combination of accidents of history, habits, and deliberate choices. It is preferable to ensure that the benefits and costs of health care be allocated fairly, or justly. Defining what is fair and just is difficult. We must seek ways to improve the fairness of resource allocation for health care. The present functioning of the health care system allocates too much to the insured, and too little to the underinsured; too much to high-technology procedures and too little to supportive care. We present here our position on the ethical basis of several rationing methods. Medical care can be conceptualized as falling into three categories: (1) the clearly medically necessary, where most practitioners would have no disagreement about the need for and the benefit of the care; (2) the clearly inappropriate or unnecessary, where most practitioners would agree (but a few might continue to provide such care); (3) a large, indeterminate middle group for which there is disagreement about the necessity of the care. POSITIONS 1. A decent minimum of health care should be made available to all, and should include all clearly medically necessary care. Rationale: We believe that U.S. society should provide basic medical care services to all without restriction to access based on financial status. Moreover, priority should be given to improving access and quality of care to the most underserved. 2. Eliminating inappropriate or unnecessary medical treatment serves patients’ best interests and is ethically sound. Rationale: It is unethical to expose patients to the risk of treatment that is not medically indicated. It is unethical to subject persons to costs, either financial or emotional, for treatment that is not medically indicated. 3. Rationing plans that seek to limit treatment in the indeterminate category may be ethically acceptable under some circumstances. Rationale: There are societal goods other than health care that compete for the same financial resources, e.g., education and food programs. In the process of determining where societal resources should be directed, it is appropriate to weigh the comparative anticipated benefits of different allocations. If competing efforts are more clearly destined to improve the welfare of the recipients, it is appropriate to redirect efforts in that direction. Health care that is of indeterminate value to the patient may thus be placed lower in priority than some non-health-care good that is more certain to benefit recipients. 4. System wide allocation is an ethically acceptable approach to limitation of the use of resources. Rationale: For many HMO’s and government providers, the health care system administration determines the global needs of the health care plan enrollees for major services, e.g., the number of intensive care unit (ICU) beds, the number of operating rooms, the number of neurosurgeons. These estimates are based on past utilization coupled with review of appropriateness of previous referrals, and customary practice in the community. The level of resources made available should be set to meet the needs of medically necessary care. The availability of ICU beds, operating room time, and so forth, then places a constraint on utilization that forces individual practitioners to limit referrals to those that are the most clearly necessary. Such systems should make available an "escape valve," e.g., by contracting outside the health plan for additional services, that allows for access to additional services at peak flow times. Our society routinely makes decisions that a hypothetical statistical life is worth a certain amount of money—for example, when a community decides that the frequency of automobile accidents at particular intersections does or does not warrant installation of traffic lights, or when safety standards are set for air traffic. Our society is more reluctant to accept the practice of placing a monetary value on an identified life. System wide allocation involves decision-making about statistical lives, and is thus more acceptable to our society than bedside rationing in which a practitioner denies a patient access to a readily available treatment. 5. Health care delivery systems have a responsibility to ensure that practitioners are rewarded for optimal medical care, not for over or under utilization. Rationale: All health care financing methods involve some degree of conflict of interest for the health care professionals. Under fee for service methods for payment of professionals, the professionals are subject to a financial incentive to over-utilize resources. Under capitated systems, professionals are subject to an incentive to under-utilize resources. These financial incentives are counter-balanced by other factors, including professional training and integrity, customary practice in the community, and the threat of malpractice liability. Financing methods for health care professionals should seek to keep financial incentives within a reasonable balance with the other forces. We believe that a financial incentive by which a health care professional shares in the overall savings of a health care plan if the plan performs efficiently is acceptable. In contrast, we believe that a plan that directly reimburses a physician for a decision to limit treatment for an identified patient presents too great a weight of incentive to avoid serious conflict of interest. Prepared by Mary K. Goldstein, MD; reviewed and
approved by the AGS Ethics Committee and the AGS Board of Directors,
November, 1996. This position statement is a revision of an early
version, titled, Equitable Distribution of United Medical Resources.
Copies of this position statement may be obtained from the American
Geriatrics Society: The Empire State Building
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