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Drawing the Line: Healthcare Rationing and the Cutoff Problem

Monday, November 28, 2016
Drawing the Line book cover

Philip M. Rosoff, MD, MA, professor of pediatrics and medicine, resident scholar of the School of Medicine's Trent Center for Bioethics, Humanities & History of Medicine, and chair of Duke University Hospital's Ethics Committee, recently celebrated the publication of his book, Drawing the Line: Healthcare Rationing and the Cutoff Problem (Oxford University Press, 2016). Rosoff has had a long-standing interest in the intersection between clinical ethics and healthcare policy, especially in the setting of scarce resources.

In his first book, Rationing is Not a Four-Letter Word (MIT Press, 2014), Rosoff argued that the only way to control healthcare costs is to impose rationing, and the only way to do so fairly is to have it apply to all. “The kind of rationing I had in mind was generous, fair and would only prevent access to interventions that were of minimal-to-no efficacy or those that could be categorized as elective,” Rosoff said. “By eliminating inefficiencies/waste and relocating and reallocating the enormous profits in our current system, we could afford to be generous and offer healthcare to all.” Further, he outlined a general approach to making these rationing decisions and illustrated this with the real-life accepted system of solid organ allocation for transplantation.

In his latest book, Rosoff presents an expansion of the argument he presented in his first book and discusses how to decide what should and should not be covered in a generous benefits plan for all. According to Oxford University Press, he considers a variety of ways this might be done and concludes that the most just approach is to utilize a transparent process in which experts and lay people develop a consensus on what should be covered by focusing on both clinical evidence of need and the effective and appropriate means to address those needs.

“The problem was figuring out where to draw the line or establish cutoffs between what was effective or ineffective, what was appropriate or inappropriate and what was needed and not (really) needed,” said Rosoff. “I argue that the only way these decisions could be made would be within the confines of a universal system where the rules were created to apply to all (including those charged with making the rules) and that decisions about cutoffs would be made by iterative consensus, similar to how clinical care guidelines are created, but by a much more broadly representative group of people empowered to represent medical experts, patients, etc.”  

Rosoff also considers the various objections and impediments to this proposal and concludes that they are obstacles that can be successfully met.

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