Rationing is reality


It is difficult to imagine being the parent of a premature baby
and not wanting to do everything you can to save its life. Medical
science is capable of so many miracles, adding almost daily to our
expectations. If there are strong links today between premature
birth and disability in later life, why shouldn’t we hope for new
advances that will sever the link or otherwise avert the problem?
You don’t need to be a crazed optimist to believe that what is
impossible today may be routinely possible tomorrow.

And if the child grows up to have a disability, do we need proof
that almost all parents love and care for their disabled children
as much if not more than their able-bodied ones? Technological
advances promise to make life easier for disabled people and their
carers. Public attitudes are gradually changing to accommodate and
even appreciate differences between human beings.

Equally, it is difficult to imagine a doctor or nurse not wanting
to do everything to save a baby’s life. The “rescue principle” lies
at the heart of their professional ethos and training: if a life is
in danger, they must do everything in their power to save it. Only
rarely does compassion overrule the rescue principle – for example,
where efforts to resuscitate would cause the child a great deal of
pain and distress, and where there is no hope of anything but brief
survival. And these cases are by no means straightforward – take
the recent, harrowing court battles over two severely ill babies,
Charlotte Wyatt and Luke Winston-Jones.

With parental love and heroic medicine lined up together for
“life”, are there really any reputable arguments on the other side?
Is there a case against rescue at all costs?

But costs, inevitably, are what it comes down to. Health resources
are shared and finite. And here is where it becomes complicated.
Rescuing lives that are in acute danger is an utterly compelling
idea – one that has achieved iconic status, powerfully affecting
the way we think about health services. But it is just as important
to prevent illness before it occurs, and to care for those who have
to live with chronic, though not life-threatening, conditions.
Money spent on saving lives cannot be spent, now or in the future,
on other functions that are no less essential although they may
seem less glamorous in the popular imagination.

However much taxpayers’ money is invested in the NHS, it will never
be enough to meet all the needs of all the population. This is
partly because people have rising health expectations, partly
because scientists and others keep coming up with new things to
spend money on, and partly because health and social care services
are labour-intensive, and labour costs continue to rise.

The problem of sharing out finite resources will not be solved by
trying to increase the size of the cake:however big the cake, it
still has to be shared out. So it is legitimate to ask whether
money spent on any health intervention, including saving the life
of a premature baby, is appropriately and fairly invested. In a
publicly funded system that aims to provide universal health care,
free at the point of use for all who need it, choices must be made
by negotiating between claims and interests. This is the
“rationing” debate which has dogged health policy for many

Health economists and others have worked hard to come up with
satisfactory criteria for allocating health resources. The QALY, or
quality-adjusted life year, estimates the number of years and
quality of life gained as a result of an intervention. The “fair
innings” argument is predicated on a “natural” lifespan for
everyone, and so favours spending more on prolonging younger than
older lives. Some judgements rely on public opinion about how tax
revenue should be spent; others on expert analysis of the likely
outcome of particular treatments. The National Institute for
Clinical Excellence was set up to generate authoritative judgements
about which interventions are worthy of public expenditure, drawing
on scientific appraisal as well as public opinion.

But it may be impossible to arrive at a definitive formula for
distributing health resources that satisfies everyone. So let’s at
least keep things in perspective. A universal health system is
about much more than saving lives. It is about giving everyone an
equal chance to live long and healthy lives – within the limits of
unavoidable risk and disadvantage, and of finite shared resources.
We cannot afford to let the rescue principle override less
glamorous claims on the public purse.

Anna Coote is Drector of Public Health, The King’s Fund.

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