Fair Resource Allocation and Rationing at the Bedside

Health systems need to set priorities fairly. In one way or another, part of this important task will fall to physicians. How do they make judgments about resource stewardship, and how should they do so? How can they make such decisions in a manner that is compatible with their clinical duties to patients? In this book, philosophers, bioethicists, physicians, lawyers and health policy experts make the case that priority setting and rationing contribute significantly to the possibility of affordable and fair healthcare and that clinicians play an indispensable role in that process. The book depicts the results of a survey of European physicians about their experiences with rationing and other cost containment strategies, and their perception of scarcity and fairness in their health care systems. Responding to and complementing these findings, commentators discuss why resource allocation and bedside rationing is necessary and justifiable. The book explores how bedside rationing relates to clinical judgments about medical necessity and medical indications, marginal benefits, weak evidence based medicine, off-label use. The book highlights how comparative studies of health care systems can advance more effective and fair bedside rationing through learning from one another. From a practical standpoint, the book offers a number of strategies for health care systems and clinicians to work in tandem to allocate and ration resources as fairly as possible: how to foster more attention to fairness when rationing at the bedside, how to avoid exacerbating health disparities when allocating resources, how to teach about bedside rationing to students, how to discuss rationing more explicitly in the public arena and in the doctor's office.

Table of Contents:
Introduction Marion Danis, Reidun Forde, Leonard M. Fleck, Samia A. Hurst, Anne Slowther Part I. A European Survey of Bedside Rationing Chapter 1. The Values at the Bedside Study: Bedside rationing by physicians Samia A. Hurst, Anne Slowther, Reidun Forde, and Marion Danis Chapter 2. The interaction of bedside rationing and the fairness of healthcare systems: Physicians' views Samia A. Hurst, Reidun Forde, Anne Slowther, and Marion Danis Part II The Societal Context Chapter 3. The Swiss Context. Samia A. Hurst Chapter 4. The UK Context. Anne Slowther Chapter 5. The Norwegian Context. Reidun Forde Chapter 6. The Italian Context Renzo Pegoraro and Alessandra Bernardi Part III Analysis of Bedside Rationing Chapter 7. How Do Economic Incentive Schemes Influence Rationing Decisions by Primary Care Physicians? Tommy Allen, Matt Sutton, and Richard Cookson Chapter 8. The legal context of bedside rationing. Keith Syrett Chapter 9. Bedside Rationing or Rational Planning: In Search of Perspective on Medical Benefit and Safety Michael Barilan Chapter 10. Just Caring: The Ethics Challenges of Bedside Rationing Leonard M. Fleck Chapter 11. Overdiagnosis and Overtreatment: Implications for Bedside Rationing Howard Brody Chapter 12. How can bedside rationing be justified despite coexisting inefficiency? The need for "benchmarks of efficiency" Daniel Strech and Marion Danis Chapter 13. The Collective Action Problem Bob Goodin Chapter 14. Statistical vs. Identifiable Lives: Why Not to Use the R Word. Paul Menzel Chapter 15. Give to The Doctor What is Due to The Doctor! Why 'Fair Rationing at The Bedside' is Impossible Vegard Bruun Wyller Part IV. Strategies for Promoting Fair Bedside Rationing Chapter 16. Priority Setting in Hospital Care: Implementing National Legislation and Guidelines in a Hospital Trust Odd Søreide, Stener Kvinnsland, and Torhild Heggestad Chapter 17. Rationing by Clinical Judgment Samia A. Hurst and Marion Danis Chapter 18. Fairness and Transparency in Bedside Micro-allocation: Improving the Ethical Competence of Clinical Staff Jan Schürmann, Barbara Meyer-Zehnder, Marcel Mertz, Heidi Albisser Schleger, Mathias Schlögl, Reto Kressig, Hans Pargger, and Stella Reiter-Theil Chapter 19. Fair Resource Allocation in Clinical Care for Socially Disadvantaged Groups and Health Disparity Populations: Issues and Strategies Irene Dankwa-Mullan, Paula Goodwin, and Matthew Wynia Chapter 20. Bedside Rationing After Health Care Reform in the United States: The Emergence of Accountable Care Organizations Steven D. Pearson Chapter 21. Priority Setting Through Clinical Practice Guidelines: Lessons Learned Ole Norheim Chapter 22. Physicians as Bellwethers. Susan Dorr Goold Chapter 23. Moving Away from Silent Trepidation: Changing the Discussion of Rationing and Resource Allocation Marion Danis, Greer Donley and Reidun Forde Chapter 24. Priority Setting As a Clinical Skill: How Do We Educate Physicians? Anne Slowther and Benjamin P Bennett Afterword