Rationing and Triage

Abstract

In the last few years, most industrialized countries have been examining methods of controlling health care expenditure. The need for cost containment has come about as a consequence of the recession, rapidly rising health service costs, and a progressive increase in the proportion of the population who are of pensionable age [1]. Despite the great variation in national expenditures on health care, it seems unlikely that cost containment can be achieved without restricting in some way the quantity, quality or range of services provided. However, few governments (Oregon in the USA [2], and Holland [3]) have had the courage to examine openly various options for rationing. In general, politicians tend to find the term emotive and inconvenient, preferring euphemisms like ‘clinical prioritization’. Perhaps they forget that rationing is not a new phenomenon: in various forms it has always been an inevitable and integral feature of health care. This implicit rationing usually required the cooperation of doctors, but the medical profession is less willing to act as gatekeeper now that it is losing authority and power to managers who do not have the same direct responsibility for individual patient care. Other factors have also stimulated the debate about explicit rationing, these include a greater respect for patient autonomy; the lack of evidence for the comparative efficacy of different treatments; recognition of the power of medical interventions to do harm; realization that individual patient decisions affect the medical commons; and acceptance of public consultation and consensus on matters of health policy.