Critical care services represent a large and growing proportion of health care expenditures. Limiting the magnitude of these costs while maintaining a just allocation of these services will require rationing. We define rationing as “the allocation of healthcare resources in the face of limited availability, which necessarily means that beneficial interventions are withheld from some individuals.” Although some have maintained that rationing of health care is unethical, we argue that rationing is not only unavoidable but essential to ensuring the ethical distribution of medical goods and services.
Intensivists have little to guide them in the rationing of critical care services. We have developed a taxonomy of the rationing choices faced by intensivists as a framework for ethical analysis. This taxonomy divides rationing decisions into three categories. First are those rationing decisions that may be justified by external constraints (such as not prescribing a potentially beneficial medication because it is not available on the hospital formulary). Second are those that may be justified by reference to clinical guidelines (as, for example, not prescribing a potentially beneficial medication because a valid guideline recommends treatment with a less expensive alternative). Third are those that are justified by individual clinical judgment (such as choosing which of two patients should be admitted into the last ICU bed, in the absence of any evidence-based guidance). Judgments made on the basis of clinical judgment deserve particular scrutiny, since they may mask unethical prejudices or bias.
Although this taxonomy does not by itself determine which decisions are ethical, it does clarify the type of evidence that is appropriate to supporting the decision that is made. Additional work is needed to elucidate how both empirical evidence and ethical analysis can further inform the rationing decisions that arise in the taxonomy described here.
Professor of Medical Ethics and Anesthesia (Pediatrics, Harvard Medical School, Senior Associate in Critical Care Medicine, Children’s Hospital, Boston, MA (RDT); Professor of Medical Ethics, Harvard Medical School, Boston, MA (DWB); Professor of Medicine, Clinical Epidemiology and Biostatistics, McMaster Medical Center, Hamilton, ON, Canada (DJC); Head, Section on Ethics and Health Policy, Chief, Bioethics Consultation Service, Department of Clinical Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD (MD); Professor of Medicine and Anesthesia, University of California, San Francisco, CA (JML); Associate Professor of Medicine, Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA (GDR); Medical Director, Medical Intensive Care Unit, Rhode Island Hospital, Professor of Medicine, Brown Medical School, Providence, RI (MML).
The Task Force on Values, Ethics, and Rationing in Critical Care (VERICC) is an ad hoc working group, not affiliated with any institution or society, that was funded by an unrestricted grant from Eli Lilly and Company, which had no role in either the deliberations of the task force or the editorial content of the manuscript. The opinions expressed here are those of the authors and do not reflect the policies of the NIH or the Department of Health and Human Services.