When the need or demand for healthcare resources exceeds the available supply, resources must be distributed on some basis. The more explicit the criteria, the more likely it will be that the term rationing will be applied, although the meaning of the term varies considerably in the bioethical, healthcare, economic, and public-policy literature. Rationing often refers to general limitations placed on the availability of certain types of healthcare, but it may also encompass specific treatment decisions for particular patients. Distribution of healthcare at a broad institutional or societal level is referred to as macroallocation. Macroallocation includes the way a hospital budgets its spending, as well as the amount of resources a nation devotes to primary and preventive care compared with high-technology curative medicine and nonmedical activities such as education and defense.
Microallocation, on the other hand, focuses on treatment decisions regarding particular persons. It may entail deciding which of several potentially beneficial treatments to provide an individual patient, particularly when only a limited time is available for treatment. Caregivers most commonly employ various medical criteria in order to make such decisions. These decisions, however, take place in institutional and societal contexts of limited resources. Accordingly, the relative merits of devoting particular resources to one patient rather than to others may exert at least an unconscious influence on treatment decisions, and nonmedical considerations may become involved. Patients' values and beliefs often play a role here as well.
Other microallocation decisions, sometimes referred to as patient selection decisions, more explicitly involve choices among patients. In the less developed countries of the world, large numbers of people continue to die for lack of vaccines to prevent disease, antibiotics to cure infections, oral rehydration therapy to replenish fluids lost through severe diarrhea, and healthcare personnel to administer such interventions (UNICEF, 1993, 2003). Microallocation decisions constantly determine who will receive the limited care that is available. Some countries not only continue to wrestle with these low-technology scarcities but also face the high-technology microallocation dilemmas commonly encountered in the more developed countries, where expensive medical technologies have proliferated.
Organ transplantation and hospital intensive care are two primary examples of such technologies. The expense of heart, liver, and other types of organ transplantation keep some patients from even considering such operations. Of those seeking transplantation, more than 6,000 patients in the United States alone die each year while waiting for a suitable organ to be donated (Organ Procurement and Transplant Network [OPTN]). Microallocation of hospital intensive care, meanwhile, must occur whenever more patients could benefit medically from access to it than the available space can accommodate—a persistent occurrence even in the more developed countries (Truog; Lantos, Mokalla, and Meadow).
Scarcities of vital healthcare resources are not likely to disappear in the future. The degree of scarcity in the less developed countries will likely decrease through worldwide cooperative efforts. Nevertheless, social, political, and economic constraints will continue to hamper such efforts. Even in the more developed countries, the need for microallocation will persist (and probably grow) for at least three reasons. First, many emerging technologies such as artificial organs and imaging techniques are so expensive that the cost of making them available to all who could benefit from them is prohibitive. Second, the scarcity of some treatments (e.g., organ transplantation) is not simply a matter of funding but reflects the limited supply of the critical resource itself (e.g., the donated organ). Third, technological development will continue to yield new resources that only a limited number of patients can obtain until the capacity to produce those resources expands sufficiently. The history of healthcare is filled with examples of such scarcity, including the early years of the polio vaccine, the antibiotic streptomycin, the hormone insulin to treat diabetes, the iron lung to enable patients with polio to breathe, and the dialysis machine to filter people's blood when their kidneys fail (Mehlman).
Those responsible for microallocation decisions have adopted a wide range of criteria for determining which patients receive available resources. Sometimes a triage model has been used, drawing on the experience of prioritizing the treatment of casualties on the battlefield or patients in the emergency room (Rhodes, Miller, and Schwartz; Bell). At other times these criteria have only been implicit, as was common during the early years of kidney dialysis in the
United States, prior to universal funding by the federal government in 1972. Many dialysis centers employed an ad hoc approach, in which particular patients were selected from eligible pools without any set of guidelines developed in advance. The resulting decisions were widely criticized as arbitrary. Of greater concern is the tendency of ad hoc decision making to reflect the biases and preferences of the decision makers (Fox and Swazey).
Ad hoc decision making continues to take place when individual caregivers, ethics committees, or healthcare institutions make microallocation decisions without first developing an explicit set of allocation criteria to guide them. Nevertheless, significant attention in practice and theory has been devoted to formulating a more ethically acceptable decision-making approach. Overall approaches are discussed in the closing section of this entry.
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