Let’s see if I can state the problem correctly. A typical guideline for medical staff when faced with the need to ethically allocate scarce resources is
- Justice, which is the primary ethical consideration in the area of health care is concerned with ‘fairness’ or the equity of distribution of resources
- There is no necessary connection between justice and efficiency. A program that is efficient in achieving a given health outcome (low cost) may nevertheless be unjust or inequitable
- An ethical decision should, therefore, subordinate considerations of cost-efficiency to considerations of justice and equity
- A decision in which cost-effectiveness outweighs considerations of justice and fairness is not ethically sound
But is this a practical guideline? Or does it just avoid the dilemma facing the medical decision-maker?
The decision-maker probably does not question that justice-as-fairness is important or has primary weight. But, in the absence of universal rules-of-thumb about (theories of) justice, a reasonable person may first try to find a trivial solution to conundrums of justice where equity is reduced to actually equal—or nearly equal—proportionment of resources or goods that are proportionable. Of course, not all goods/resources are proportionable—as the story of the judgment of Solomon illustrates. In health care, decisions must be taken about the allocation of resources where cost, which is the index of scarcity, is the principal barrier to an actually equal distribution. Saying that a resource has a high cost means that the decision-maker must allocate the resource unequally among the needy because each portion of the good is scarce (costly). The higher the cost of each portion of resources, the less likely that the decision-maker will be able to meet all needs within a given budget and must therefore choose to distribute fewer portions to some than to others. Conversely, the lower the cost of meeting the sum of needs, the nearer the decision-maker can come to making a distribution among needs that is equitable in the sense of equal. I suspect that it does not help the decision-maker, therefore, to warn them that (apart from avoiding waste), economic considerations are not to be a primary concern. It will be apparent to any decision-maker that greater cost efficiency would be one means of approaching the trivial solution to the problem of a fair distribution. But many decision-makers must also realize that they don’t have an opportunity to achieve more efficient use of resources because, in the short-run, costs are likely to be fixed. This is what the short run means: the sum of proportionable resources and the sum of needs stand in a fixed relationship to each other. There’s not the time to devise cost-saving strategies or to develop cost-saving technologies. In the short-run, they have to have a theory of just but unequal distribution in order to get on with it. The degree of inquality they need to accept is actually a reflection of cost in the first instance (although it may ultimately also reflect other optimizing distribution strategies)