The ethics of overt rationing. Pragmatic, and fair for repeated offenders. Politicians could begin the debate here…

Kristine Bærøe, and Cornelius Cappelen from Bergen, Norway, opine in the Journal of Medical Ethics 12th August 2015: Phase-dependent justification: the role of personal responsibility in fair healthcare.

With apologies for reproducing their work, this gets to the heart of the ethical issues surrounding a pragmatic approach to rationing health care. Their conclusion accepts that transparent political decision making is a necessary on when and how to limit interventions. NHSreality calls this overt rationing… and never claimed it would be entirely fair. If politicians want to stop the disenchantment with health systems this could be where they should begin the debate..


ABSTRACT The main aim of this paper is to examine the fairness of different ways of holding people responsible for healthcare-related choices. Our focus is on conceptualisations of responsibility that involve blame and sanctions, and our analytical approach is to provide a systematic discussion based on interrelated and successive health-related, lifestyle choices of an individual. We assess the already established risk sharing, backward-looking and forward-looking views on responsibility according to a variety of standard objections. In conclusion, all of the proposed views on holding people responsible for their lifestyle choices are subjected to reasonable critiques, although the risk sharing view fare considerably better than the others overall considered. With our analytical approach, we are able to identify how basic conditions for responsibility ascription alter along a time axis. Repeated relapses with respect to healthcare associated with persistent, unhealthy lifestyle choices, call for distinct attention. In such situations, contextualised reasoning and transparent policy-making, rather than opaque clinical judgements, are required as steps towards fair allocation of healthcare resources.


The INTERHEART study of 30 000 men and women in 52 countries showed that at least 90% of heart disease is lifestyle related. And according to a new report from the WHO, 63%, or 36 million, of the 57 million deaths worldwide in 2008 were caused by chronic, non communicable diseases. The WHO claims that this has much to do with lifestyle. Smoking, drinking, lack of exercise and unhealthy eating habits all contribute to chronic disease. A highly relevant question arises: Is it fair to hold people responsible – one way or another – for lifetime choices with a potential adverse health impact?

The overall goal of this paper is to examine different ways of holding people responsible for healthcare-related choices. We limit our discussion to recent specific conceptualisations of responsibility, namely those involving blame and sanctions……..


Unless the backward-looking and forward-looking views presented here can be shown to convincingly circumvent the objections to them, holding people responsible in either of these ways in the sense discussed in this paper cannot be recommended as fair policies. The fairness of ascribing responsibility according to the risk-sharing view occurs, on the other hand, more acceptable. In the case of repeated relapses due to unaltered unhealthy lifestyle, fairness calls for a distinct approach, that is, transparent, political decision-making on when and how to limit interventions.


This entry was posted in A Personal View, Professionals, Rationing on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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