4. August 2009 18:07
In an essay in The Washington Post, an infectious disease specialist writes that "the unspoken truth among doctors is that we objectively or subjectively ration care, and often don't tell patients or their families."
Organs, for example, "are a precious commodity, their donation strictly regulated by national guidelines. … Because donors are scarce, it seems appropriate to ration their organs on the basis of need and other ethical and medical considerations." Medical care is also rationed through long wait times to see physicians (ranging from 11 to 50 days in major cities, according to a 2009 survey by Merritt Hawkins & Associates) or shortages of beds in a hospital.
"In its broad definition, rationing is... one of the strategies for cost containment. The paradox of rationing is that it seems fair, just and equitable, and it makes sense when applied to a population. But when it applies to my patient or my mother, it makes me uncomfortable. That said, rationing is necessary and inevitable." Allocation of the H1N1 vaccine this fall will provide a practical experience of rationing: "If the demand for the vaccine exceeds the supply, we will have to allot and prioritize, as we decide who will receive the first 100 million doses available for the first mid-October round of vaccinations. That is rationing, but we are better off calling it 'appropriate allocation of resources'" (Jain, 8/4).
In its "Informed Patient" feature,
The Wall Street Journal reports on a program that helps patients make difficult treatment decisions. For example, the Decision Services unit at the UCSF Breast Care Center gave Mary Bianchi information on different treatment options for breast cancer. It also "offered her a personal coach to help brainstorm questions and concerns, accompany her on doctor visits and make audio recordings of medical consultations. ... For patients like Ms. Bianchi, the current health-policy debate comes down to a very personal issue: how to make ever-more-complex decisions when faced with multiple options, each with no clear advantage and with risks and harms that patients may value differently."
"Though decision-aid programs cost money to deliver, they appear to save money in the long run. Studies show that when patients understand their choices and share in the decision-making process with their doctors, they tend to choose less-invasive and less-expensive treatments than they would have otherwise received. A number of states and policymakers in Washington are considering legislation that would provide funding to study the use of shared-decision-making programs and in some cases require such programs to be offered to patients as part of the informed-consent process" (Landro, 8/4).
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