The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

Two answers to the question ‘how can we allocate health care resources fairly?’ are introduced and discussed. Both utilitarian and egalitarian approaches are found relevant, but both exhibit considerable theoretical and practical difficulties. Neither seems capable of solving the problem on its own. It is suggested that, for practical purposes, a version of Rawls' famous thought experiment might provide at least some enlightenment about which theoretical approach should be used to address the question.

Rationing health care is not new. As governments world wide struggle to contain the costs of health care, health policy analysts debate how rationing should be done. However, they too often neglect how the mechanisms for funding and allocating health care resources are themselves vehicles for rationing treatment. In the UK, where health care rationing debates currently abound, there has been no formal evaluation of the role of the market in allocating scarce health care resources.The market in health care has (...) increased administration, fragmented services, eroded local accountability, and decreased choice.This fragmentation, and the associated competition between purchasers and providers, means that resource allocation can no longer be monitored and evaluated in a national context. The loss of a population focus has left a vacuum in planning. Services cannot be planned rationally, and so are not able consistently to avoid duplication or to respond cogently to estimates of need.The loss of accountability means that decisions about the allocation of health care resources are no longer open to scrutiny by local people. Increasingly, especially in social and long term care the cost of care is being transferred to the individual. The new mechanisms for resource allocation are distributing resources unfairly: away from the poor, the sick and the elderly.The great myth of the market is that it has enabled decision-making to become explicit. This is not the case. To make health care resource allocation appear rational and acceptable to the public, health authorities have resorted to exercises in consumer consultation, and value laden guidelines where clinical cloaks are used to disguise political decisions on funding. In the UK, until the true role of the internal market is acknowledged, myths and subterfuge will conceal the winners and losers in the new system of rationing health care. (shrink)

Many countries encourage immigration, yet almost without exception they impose medical conditions on the admissibility of prospective immigrants. This paper examines the ethical defensibility of this practice. It argues that the neighbourhood principle, which states that we owe a greater duty to neighbours than to strangers, when properly understood, extends to all human beings, that economic and safety considerations play only a limited role in ethically underwriting an exclusionary policy, and that medical immigration criteria should be harmonized with treatment eligibility (...) criteria for citizens of the relevant countries themselves. (shrink)

It is generally assumed that allocation problems in a socialized health care system result from limited resources and too much demand. Attempts at solutions have therefore centered in increasing efficiency, using evidence-based decision-making and on developing ways of balancing competing demands within the existing resource limitation. This article suggests that some of the difficulties in macro-allocation decision-making may result from the use of conflicting ethical perspectives by decision-makers. It presents evidence from a preliminary Canadian study to this effect.