Rationing, inefficiency and the roleof cliniciansKristin Voigt

The need for rationing of clinical servicesand medical resources is a crucial issuefacing healthcare systems. On mostaccounts, the demand for medical servicesvastly exceeds what can be provided onlimited budgets, requiring difficult deci-sions about which services should andshould not be provided to patients,whether patients might have to bear someof the cost of the services they use, andon what basis rationing decisions shouldbe made. At the same time, we know thathealthcare systems are far from perfectlyefficient; some of the expenditures ofhealthcare systems are wasteful and bringno benefits at all to patients. In light ofthe evidence of such inefficiencies withinhealthcare systems, it may seem problem-atic to insist on the importance of ration-ing: can it really be appropriate to denypatients beneficial services while ineffi-ciencies remain within the system?1

This is the question Strech and Danistake on in their paper, ‘How can bedsiderationing be justified despite coexistinginefficiency? The need for “benchmarksof efficiency”’. As they highlight, the evi-dence about inefficiencies within thehealthcare system is sometimes taken toundermine the legitimacy of rationing.Their response focuses on the implica-tions of particular clinicians’ involvementin both inefficient decisions and bedsiderationing: if clinicians cause or contributeto inefficiencies in the system—forexample by prescribing more expensive‘brand name’ medication instead ofequally effective but cheaper genericdrugs—is it legitimate for them also tomake, or be involved in, rationing deci-sions? Strech and Danis argue that eventhough no healthcare system can be fullyefficient, clinicians must make ‘sufficient’efforts to reduce inefficiencies within theirown realm of decision-making if theirengagement in rationing decisions is to belegitimate. They offer a set of ‘bench-marks’ against which we can judgewhether or not such efforts should beconsidered sufficient. Adherence to thesebenchmarks, they argue, is a “necessary…

but clearly not sufficient requirement forjust bedside rationing”.2

Over the past few decades, a livelydebate about rationing has developed,addressing, for example, questions aboutfairness and the role of public deliberationin making rationing decisions.3 4 Butthere has been very little, if any, debateabout the relationship between rationingand inefficiency. Strech and Danis are, tomy knowledge, the first to tackle this issuehead-on. Their paper makes a valuablecontribution that helps us think throughthe relationship between the two anddelineate the proper scope for rationingwithin inefficient systems, particularlywhen individual clinicians who areexpected to engage in bedside rationingare also contributing to inefficiencies.However, I am concerned that Strech

and Danis’ account construes the relation-ship between clinical inefficiency andbedside rationing in a way that results inproblematic and counterproductiverecommendations for clinicians. First, anydiscussion about the relationship betweenrationing and inefficiency must be basedon a clear understanding of the two con-cepts and the difficulties involved indrawing the line between instances ofrationing and attempts to reduce ineffi-ciency. Strech and Danis discuss a numberof these difficulties; I highlight somefurther issues relevant to the question athand. Second, it is not clear that therecommendations Strech and Danis makefor the behaviour of clinicians are in factan appropriate response to the problemthey identify. It is, of course, the case that,ideally, we would address inefficiencieswithin the healthcare system before anyrationing decisions are made—it is clearlypreferable to remove expenditures thatprovide no benefit than to deny servicesthat promise at least some benefit topatients. However, it does not follow thatclinicians should not make rationing deci-sions as long as they are contributing toinefficiencies (or their efforts to reduceinefficiency do not meet the benchmarksof sufficiency). Refusing to ration on thegrounds that previous decisions have ledto inefficiency only compounds any exist-ing problem. Rather, I suggest, cliniciansshould treat the reduction of inefficiencyand the willingness to make or enforce

fair rationing decisions as separaterequirements.

RATIONING OR REDUCINGINEFFICIENCY?If we are to reason about the relationshipbetween rationing and inefficiency, wemust be clear about when the denial of aparticular service reduces inefficiency or,instead, constitutes an instance of ration-ing. While different definitions of ration-ing are in use,5 rationing often refers toany decision not to provide a beneficialhealth service. This is also the approachStrech and Danis adopt. They definerationing as “the withholding for reasonsof cost of medical interventions that areexpected to have net additional benefit forthe patient”.2 Cases of inefficiency, con-versely, are those where interventions areprovided even though they provide no netbenefit to patients. More precisely, Strechand Danis distinguish between two typesof inefficiencies: first, when interventionswith no net benefit to the individualpatient are provided; second, when inter-ventions are provided that are associatedwith higher costs but equal benefit com-pared with alternative interventions.2

I focus here on the first type of inefficiency,which I think raises important issues.

On the face of it, the distinctionbetween instances of rationing and reduc-tions of inefficiency seems clear enough:if we don’t provide a service that has atleast some net benefit to the patient, weare involved in rationing; if we don’tprovide a service that has no net benefit,we are simply avoiding an inefficiency.However, the distinction raises complex-ities. Several of these are mentioned byStrech and Danis. For example, theyexplain that we must rely on value judge-ments in determining the net benefit of aparticular intervention, and that healthprofessionals’ judgement about whetheran intervention provides a possible benefitto the patient may differ from thepatient’s judgement.2

One important difficulty that is touchedupon only briefly by Strech and Danis isthat of uncertainty and probabilities.Screening and, in some instances, medicaltreatment involve uncertain outcomes:often, we do not know whether a treat-ment will benefit a particular patient. Inthe case of screening, a large number ofperfectly healthy individuals are screenedfor each abnormality detected. Thus, thechances of benefit to each individualpatient are often very small and we donot expect any one particular patient tobenefit from being screened. However, weexpect that for some patients, there will

Correspondence to Dr Kristin Voigt, McGillUniversity, Institute for Health and Social Policy, 1130Pine Avenue West, Montreal, Quebec H3A 1A3,Canada; kristin.voigt@mcgill.ca

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be very considerable net benefit. Changesto screening policies that we can expect toresult in fewer patients being diagnosedwith particular conditions are plausiblyconsidered rationing. However, it is notclear that they would fall within the scopeof Strech and Danis’ definition of ration-ing because it is often not the case thatthe screening service would be ‘expected’to have net additional benefit for eachpatient: given the probabilities in play, thechances that any one patient will benefitfrom undergoing screening are very small.

Strech and Danis’ treatment of the dis-tinction does not address this complexityin much detail. In the cases they cite asexamples of reductions of inefficiency, itis not clear whether it would not be moreappropriate to describe them as instancesof rationing. Strech and Danis cite twoexamples of expenditures that provide nonet benefit to patients: cancer screeningamong patients with advanced cancer andcardiac screening for low-risk, asymptom-atic patients. The concern about cancerscreening in patients with already existing,advanced cancers is that, given that thesepatients have significantly reduced lifeexpectancies, such screening would haveno ‘meaningful likelihood’ of benefitingthem. The authors of the study cited byStrech and Danis note that, for patientswith advanced cancer, this conclusionholds for ‘virtually all cases when a newmalignancy is found’.6 However, that thechance of net benefit is exceedingly smalldoes not establish there is no chance ofnet benefit.

Similar concerns arise with respect tocardiac screening in low-risk, asymptom-atic patients. Presumably, even though theprobability is small, there is some possibil-ity that a heart condition will be detectedeven in an asymptomatic, low-risk patient.The expected benefit for each individualpatient may be exceedingly small becausethe number of abnormalities in thispatient group is so low. Furthermore, thisexpected benefit must be weighed againstthe possibility of harms to the patient,such as false positives and the subsequentfurther, potentially risky, testing to whichpatients may be subjected. However, eventhough the probability is small, as long asthere is some net benefit to detection,then it does not seem accurate to describethis as a case where screening provides nonet benefit: a benefit that must be dis-counted by its extremely low probabilityis not the same as no benefit.

In specific cases, of course, screeningmay indeed have no net benefit forpatients. For example, if a patient’s condi-tion is so poor that it would be impossible

to treat whatever illness the screeningwould detect, then it is plausible to saythat such treatment would provide no netbenefit to the patient. For the most part,however, equating ‘extremely low prob-ability of benefit’ with ‘no net benefit’strikes me as problematic.This is not to say, of course, that ration-

ing of screening in the scenarios Strech andDanis describe is necessarily unfair.Screening may be so expensive and theprobability of detecting a case of heartdisease or cancer so small that the cost-benefit ratio is far less attractive than that ofother interventions to detect these or otherconditions. Reductions in screening areoften easy candidates for rationing becausethey are often very costly and the expectedbenefits very small. But this should notdetract from the fact that such decisions canplausibly be described as instances of ration-ing. It is puzzling, therefore, that Strech andDanis include these interventions as exam-ples of inefficiencies without further discus-sion of questions of uncertainty.Of course, Strech and Danis’ argument

does not hinge on whether denying theseparticular interventions should bedescribed as instances of rationing or asreductions in inefficiency. However, thisdistinction is important to the topic, notleast because it is likely to matter todoctors and other health professionalswho are in charge of deciding ‘on theground’ whether or not a particular inter-vention is offered to patients. Asking clini-cians not to provide an intervention thathas some likelihood of benefiting thepatient—even if that likelihood is exceed-ingly low—is different from askingdoctors not to provide an interventionthat has no chance whatsoever of benefit-ing the patient. Especially in light ofStrech and Danis’ focus on the role ofclinicians in inefficiency and rationing,this seems like a crucial aspect of theproblem they are discussing.

RATIONING AND INEFFICIENCYAs Strech and Danis highlight, there is abroad consensus that rationing is neces-sary in any healthcare system. Given therange of diagnostic, preventive and cura-tive technologies now available to us, notall such services can be provided to allpatients who might benefit from them.There is, however, no consensus on theextent to which, if at all, any of thisrationing should happen at the bedside.While some commentators have been con-cerned about requiring clinicians to makerationing decisions with respect to theirpatients,7 8 others have argued thatbedside rationing may be necessary.9

Strech and Danis do not seem to objectto bedside rationing in principle. However,they argue, clinicians’ involvement inbedside rationing becomes problematicwhen the clinician is also involved in ineffi-ciency: “sufficient efforts to improve effi-ciency are warranted before rationing canbe justly carried out”.2 Only when clini-cians have made sufficient efforts at redu-cing inefficiency (they propose a set ofbenchmarks to determine whether or notthe sufficiency requirement has been met),can their involvement in bedside rationingbe just. What I suggest in this section isthat, whatever amount of fair bedsiderationing we expect clinicians to engage in,this requirement should not vary in rela-tion to clinicians’ involvement in ineffi-cient decisions.

Inefficiencies in the healthcare systemmean that we are using more resourcesthan necessary to achieve a particularresult; inefficiencies reduce the availablebudget and thus make additional rationingnecessary. Arguments about the fairness ofrationing focus on determining how a par-ticular budget should be allocated, givendifferent health needs, the costs of differ-ent treatments, patients’ ability to benefit,etc. Such arguments are usually under-stood as independent from questionsabout the size of the budget.i Once theprinciples that should guide the allocationof resources have been settled upon(leaving aside for now the significant com-plexities surrounding the determination ofthese principles), we should be able toidentify which interventions to provideand which ones it is fair to ration, given aparticular budget.

What this means is that, at least at theconceptual level, we can distinguishbetween two kinds of fair rationing: someinstances of rationing would be requiredand fair even in a perfectly efficientsystem, whereas some instances of ration-ing only become necessary because ofinefficiencies; the latter would not berequired in a perfectly efficient system.Does a clinician’s involvement in ineffi-cient healthcare decisions reduce the needto engage in rationing of either kind?

iThe notion of ‘fairness’ that is at work in thecontext of ‘fair rationing’ is usually understoodmore narrowly than it is in other contexts.Questions of fairness, more broadly conceived,will also arise in connection with the size of thebudget allocated to healthcare: for example,concerns of fairness are likely to be relevantwhen deciding how much to allocate tohealthcare relative to, for instance, education. Ileave these issues aside for the purposes of thepresent discussion.

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If a clinician has been involved in deci-sions that are inefficient and has notengaged in attempts to reduce these ineffi-ciencies to an extent that would be suffi-cient (according to Strech and Danis’benchmarks), why would it not be legit-imate for her to make rationing decisionsthat would be fair and required even in aperfectly efficient system? I cannot seewhy, as Strech and Danis suggest, simul-taneous attempts to reduce the inefficien-cies resulting from her decisions wouldmake it ‘more legitimate’ for her to makethese kinds of rationing decisions. Whenit comes to situations where rationing isfair and necessary even in an efficienthealthcare system, the clinician’s record ofclinical efficiency does not seem relevant.Were she not to ration in these instances,this would only heighten resource scarcity.Thus, irrespective of their previousengagement in inefficient decision-making, it seems illegitimate for cliniciansnot to ration in these kinds of cases.

What about rationing decisions that onlybecome necessary because of inefficiencies?Here we must draw another distinction:that between inefficiencies that were theresult of the clinician’s previous actions andthose that resulted from the (inefficient)actions of other agents. Taking the lattercase first, it seems that clinicians should notrespond to inefficient decisions made byother clinicians by refusing to engage inrationing that is fair and necessary, givenavailable resources—even if the rationingbecomes ‘necessary’ only because of theinefficient decision. Once the inefficiencyhas led to the need for additional rationing,refusing to engage in bedside rationing onlyadds to the problem of resource scarcity.

Consider finally a clinician whose waste-ful choices have contributed to a resourceconstraint. Imagine this clinician now facesa situation where she knows that rationinghas become necessary because of a previ-ous, inefficient decision she has made. Thisis the scenario that Strech and Danis con-sider the most problematic: the personmaking inefficient clinical decisions alsobeing the one making bedside rationingdecisions. “Bedside rationing on the part of

this doctor”, they suggest, “cannot be fullyjustified because the specific doctor has con-sciously contributed to the need to ration,which would otherwise have been lessnecessary.”2

Again, however, it is not clear why a clin-ician should decide not to ration in thesekinds of cases. Once an inefficient decisionhas been made and additional rationing hasbecome necessary, nothing is gained by aclinician refusing to engage in bedsiderationing, as long as the rationing is fair.Refusing to engage in these rationing deci-sions, after the resources have been wasted,would only make things worse.ii Morebroadly, then, it seems that whateverrequirement falls on clinicians to engage infair rationing decisions—this may includesome degree of bedside rationing but alsoadherence to rationing decisions made byother agents—should be treated as entirelyindependent of the requirement to reduceinefficiency. Both of these are importantimperatives that clinicians should seek tomeet in their practice.

CONCLUSIONDebates about rationing seem problematicin the context of continuing inefficiency inthe healthcare system: as long as we couldsave resources by cutting services that bringno benefit to patients, why are we consider-ing withdrawing interventions that maybenefit patients? Clearly, reducing ineffi-ciency is an urgent imperative: unnecessaryexpenditures heighten resource scarcity anddeprive patients of beneficial services.Clinicians should seek to reduce inefficien-cies within their realm of decision-making—and Strech and Danis’ benchmarks mayhelp clinicians identify reasonable and

achievable goals with respect to efficiency.But whether or not clinicians succeed intheir attempts to reduce waste of resources,this should not affect whatever obligationthey have to engage in fair rationingdecisions.

Acknowledgements The author would like to thankthe editors and two anonymous reviewers for theirhelpful comments on an earlier version of this paper.

Competing interests None.

Provenance and peer review Commissioned;externally peer reviewed.

To cite Voigt K. J Med Ethics 2014;40:94–96.

Received 12 February 2013Revised 8 October 2013Accepted 28 October 2013Published Online First 29 November 2013

▸ http://dx.doi.org/10.1136/medethics-2012-100769

J Med Ethics 2014;40:94–96.doi:10.1136/medethics-2012-101236

REFERENCES1 Marckmann G. Rationalisierung und Rationierung:

Allokation im Gesundheitswesen zwischen Effizienzund Gerechtigkeit. In: Kick HA, Taupitz J. eds.Gesundheitswesen zwischen Wirtschaftlichkeit undMenschlichkeit. Münster: LIT Verlag, 2005:179–99.

2 Strech D, Danis M. How can bedside rationing bejustified despite coexisting inefficiency? The need for‘benchmarks of efficiency’. J Med Ethics 2014;40:89–93.

3 Daniels N, Sabin J. Setting limits fairly: learning toshare resources for health. 2nd edn. New York: OxfordUniversity Press, 2008.

4 Daniels N. Four Unsolved Rationing Problems: aChallenge. Hastings Center Report; 1994:27–9.

5 Ubel PA, Goold SD. ‘Rationing’ health care: not alldefinitions are created equal. Arch Intern Med1998;158:209–14.

6 Sima CS, Panageas KS, Schrag D. Cancer screeningamong patients with advanced cancer. JAMA2010;304:1584–91.

7 Weinstein MC. Should physicians be gatekeepersof medical resources? J Med Ethics 2001;27:268–74.

8 Lauridsen S. Administrative gatekeeping–a third waybetween unrestricted patient advocacy and bedsiderationing. Bioethics 2009;23:311–20.

9 Ubel PA. Physicians, thou shalt ration: the necessaryrole of bedside rationing in controlling healthcarecosts. Healthc Pap 2001;2:10–21.

iiThere may be instances where clinicians canredress the resource shortages their previous,inefficient decisions have created, for exampleby working unpaid overtime or providingprivate funds. In such cases, clinicians arguablyhave a duty to provide such redress (althoughof course whether or not we would want toenforce such a duty as a matter of policy is aseparate question). I thank an anonymousreviewer for raising this point.

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cliniciansRationing, inefficiency and the role of

Kristin Voigt

doi: 10.1136/medethics-2012-1012362013

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