Public views on health care rationing: a group discussion study
Introduction
What ethical principles should govern decisions about the distribution or ‘rationing’ of limited health care resources [1]? Academics and health care professionals have proposed a number of different and potentially conflicting principles, including distribution according to need [2], distribution so as to maximise the health of the community [3] and distribution so as to reduce health inequalities [4]. However, there is now an increasing interest in finding out which of these principles are supported by the general public, on whose behalf rationing decisions are being made [5].
Much of the existing evidence comes from questionnaire surveys and opinion polls [6]. This conventional way of consulting the public has its limitations, however, since respondents are not given time to consider their answers in any depth, and may be unduly influenced by the way that questions are framed. The study reported in this paper takes a more ‘deliberative’ approach to consulting the public, which gives respondents an opportunity to discuss the issues and to develop their views during the process of consultation.
The study was based on small group discussions about a hypothetical rationing exercise designed to raise a wide range of ethical issues. Respondents had to choose which of four identified patients should be treated, assuming there is only enough money to treat one of them. In order to focus discussion on general principles, rather than particular details of the case, respondents were deliberately not presented with detailed information about the four patients and their suggested treatments. The aim was to elicit generalisable principles that can be applied to a wide range of decisions.
In this respect, this study departs from the ‘citizen’s jury’ approach described by Lengahan [7], which typically presents respondents with detailed information about the particular case being discussed, including the opportunity to cross-examine expert witnesses. The study also departs somewhat from the usual ‘focus group’ approach used by market researchers and sociologists [8], since (1) discussion leaders took a more pro-active role to encourage debate about general rationing principles and (2) in the qualitative analysis, respondents’ views were translated into general principles identified from a review of the theoretical literature.
Section snippets
The sample
In this study, 60 members of the general public from the York area of England took part in two separate group discussions, involving questionnaires and discussions about a wide range of issues of fairness in health care. The aim was to recruit ten groups of six people who would meet for about 2 h on two separate occasions with a fortnight between each meeting. Letters of invitation were sent out to 1000 people who were randomly chosen from two general practitioners’ lists in York. They were
Results
Table 2 shows the rankings that respondents gave to the four patients. Five of the 60 respondents (8%) argued that it is unethical to make explicit rationing choices and hence gave all four patients the same priority. However, the vast majority (92%) were prepared to give priority to at least one of the patients. Daniel was the top or joint-top priority for 80% of respondents, followed by Marinder and then Steve, with Joanne receiving lowest priority on average. Although Daniel emerged as the
Discussion
On the basis of the study of considered public opinion reported in this paper, it would seem that the public accept three main principles of justice: (1) a broad ‘rule of rescue’, (2) maximising the health of the whole community and (3) reducing inequalities in people’s lifetime experience of health. The public do not appear to accept the view that improving population health is the primary goal of the health care system [3]. Nor does the public appear to accept the official view of the medical
Acknowledgements
We thank Northern and Yorkshire Regional Research and Development Office for funding this research, and Nottingham Health Authority for permission to use their ‘How would you choose?’ exercise. For input into the study of public views we are grateful to Sue Baughan, Brian Ferguson and Rachel Johns, and Alan Williams; and for helpful comments we would like to thank Tony Culyer, Paul Menzel, an anonymous referee, and participants at the many lively seminars where we have presented this material.
References (16)
- et al.
Equity and equality in health and health care
J Health Econ
(1993) Viagra and rationing
Br Med J
(1998)Philosophy and practice of medical ethics
(1988)The principal objective of the NHS should be to maximise health: the case for
Intergenerational equity: an exploration of the ‘fair innings’ argument
Health Econ
(1997)- et al.
Whose priorities? listening to users and the public
Br Med J
(1998) What does the public think about rationing? A review of the evidence
- Lengahan J. Involving the public in rationing decisions. The experience of citizens’ juries. Health Policy (in...