Ethics of Resource Allocation and Rationing Medical Care in a Time of Fiscal Restraint - US and Europe

Background: All resources are scarce. The ethical dilemma in health care is how to balance the precepts of autonomy, beneficence, and distributive justice. Rationing may affect three dimensions of coverage: the share of the population covered, the services covered, and the extent to which services are covered.

United States: The US spends 50 percent more per capita on health care than any other country while achieving worse health than many. Poorly coordinated insurance mechanisms leave 19 percent of the population uninsured. Until passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, health care was effectively a privilege, not a right. While PPACA seeks to rectify this, by 2019 five percent of non-elderly US residents will likely remain uninsured.

Europe: Most European countries provide universal or near-universal population coverage to people resident in the respective country. Central and Eastern European countries inherited the Soviet-era commitment to universal coverage free at the point of use. Faced with a decline in government spending on health, almost all of them reduced the scope of services and introduced official user fees. In contrast, other European countries expanded entitlement to publicly funded health care, resulting in greater equity. A number of countries have attempted to depoliticize decisions on rationing by using health technology assessments and dedicated agencies.

Discussion: Resource allocation and rationing differ considerably between the US and Europe. In the US, where social welfare remains controversial, there are few restrictions on the use of health care technology regardless of cost or clinical effectiveness. European countries engage in more explicit debates about these limits, though these are complicated by media and lobby power.

Conclusion: The ethical issues in the US largely revolve around rationing care by eligibility for insurance coverage, whereas in Europe they are more concerned with the scope of publicly funded services to all. On both sides of the Atlantic, public debates are needed about the financial sustainability of health systems, the tradeoffs between cost-containment and broader societal and health system goals, the role of the welfare state, and the limits of publicly financed health care.