Health care rationing: the public's debate.

OBJECTIVE--To elicit the views of a large nationally representative sample of adults on priorities for health services. DESIGN--An interview survey based on a random sample of people aged 16 and over in Great Britain taken by the Office of Population Censuses and Surveys. SUBJECTS--The response rate to the survey was 75%, and the total number of adults interviewed was 2005. MAIN OUTCOME MEASURES--A priority ranking exercise of health services supplemented with attitude questions about priorities, who should set priorities, and budget allocation. RESULTS--The results of the main priority ranking exercise of 12 health services showed that the highest priority (rank 1) was accorded to "treatments for children with life threatening illness," the next highest priority (rank 2) was accorded to "special care and pain relief for people who are dying." The lowest priorities (11 and 12) were given to "treatment for infertility" and "treatment for people aged 75 and over with life threatening illness." Most respondents thought that surveys like this one should be used in the planning of health services. CONCLUSIONS--The public prioritise treatments specifically for younger rather than older people. There is some public support for people with self inflicted conditions (for example, through tobacco smoking) receiving lower priority for care, which raises ethical issues.     

Inventory rationing for a system with heterogeneous customer classes

Many retailers find it useful to partition customers into multiple classes based on certain characteristics. We consider the case in which customers are primarily distinguished by whether they are willing to wait for backordered demand. A firm that faces demand from customers that are differentiated in this way may want to adopt an inventory management policy that takes advantage of this differentiation. We propose doing so by imposing a critical level (CL) policy: when inventory is at or below the critical level demand from those customers that are willing to wait is backordered, while demand from customers unwilling to wait will still be served as long as there is any inventory available. This policy reserves inventory for possible future demands from impatient customers by having other, patient, customers wait. We model a system that operates a continuous review replenishment policy, in which a base stock policy is used for replenishments. Demands as well as lead times are stochastic. We develop an exact and efficient procedure to determine the average infinite horizon performance of a given CL policy. Leveraging this procedure we develop an efficient algorithm to determine the optimal CL policy parameters. Then, in a numerical study we compare the cost of the optimal CL policy to the globally optimal state-dependent policy along with two alternative, more naïve, policies. The CL policy is slightly over 2 % from optimal, whereas the alternative policies are 7 and 27 % from optimal. We also study the sensitivity of our policy to the coefficient of variation of the lead time distribution, and find that the optimal CL policy is fairly insensitive, which is not the case for the globally optimal policy.     

Thoughts on rationing medical care

The use of wood stoves has increased greatly in the past decade, causing concern in many communities about the health effects of wood smoke. Wood smoke is known to contain such compounds as carbon monoxide, nitrogen oxides, sulfur oxides, aldehydes, polycyclic aromatic hydrocarbons, and fine respirable particulate matter. All of these have been shown to cause deleterious physiologic responses in laboratory studies in humans. Some compounds found in wood smoke--benzo[a]pyrene and formaldehyde--are possible human carcinogens. Fine particulate matter has been associated with decreased pulmonary function in children and with increased chronic lung disease in Nepal, where exposure to very high amounts of wood smoke occurs in residences. Wood smoke fumes, taken from both outdoor and indoor samples, have shown mutagenic activity in short-term bioassay tests. Because of the potential health effects of wood smoke, exposure to this source of air pollution should be minimal.     

Analysis of flexibility with rationing for a mix of manufacturing facilities

A major competitive advantage of a flexible manufacturing facility is its ability to cope with uncertainties in demand. At a strategic level, capacity-size decisions for a mix of flexible facilities (each not necessarily producing the same combination of products) are made based on aggregates of product types. Such an approach overlooks possible capacity-devouring by some products, arising at the operational level, when the aggregate demand for the period exceeds the available capacity. A rationing policy is required to ensure that the available aggregate capacity of the facilities is shared equitably. In this article, it is shown that such a rationing policy has an impact on the required capacity size and, therefore, must be integrated with the decisions at the strategic level. Several properties indicating the relative preferences of certain facility strategies are also established.     

Prior consent as a liberal theory of health care rationing: commments of Savulescu's constructive critique

[In his review essay in this issue of Bioethics,] Julian Savulescu lucidly summarizes and assesses each essay in Strong Medicine. I would like to clarify a few important general points about prior consent as a conceptual framework for the ethical rationing of health care, correct several specific misreadings, and defend my basic claim despite some acknowledged problems.     

Administrative gatekeeping - a third way between unrestricted patient advocacy and bedside rationing

The inevitable need for rationing of healthcare has apparently presented the medical profession with the dilemma of choosing the lesser of two evils. Physicians appear to be obliged to adopt either an implausible version of traditional professional ethics or an equally problematic ethics of bedside rationing. The former requires unrestricted advocacy of patients but prompts distrust, moral hazard and unfairness. The latter commits physicians to rationing at the bedside; but it is bound to introduce unfair inequalities among patients and lack of political accountability towards citizens. In this paper I shall argue that this dilemma is false, since a third intermediate alternative exists. This alternative, which I term 'administrative gatekeeping', makes it possible for physicians to be involved in rationing while at the same time being genuine advocates of their patients. According to this ideal, physicians are required to follow fair rules of rationing adopted at higher organizational levels within healthcare systems. At the same time, however, they are prohibited from including considerations of cost in their clinical decisions.