PRESS RELEASE 3-1-2018: New in the Hastings Center Report: January-February 2018
Can Rationing through Inconvenience Be Ethical?
Nir Eyal, Paul L. Romain, and Christopher Robertson
“Rationing through inconvenience” refers to burdensome arrangements such as application forms, waiting periods, and other red tape that are intended to steer clinicians and patients to limit the use of health care resources. This strategy has been “roundly but uncritically condemned,” the authors write. But they argue that under some conditions it may be ethical, and even preferable to direct rationing, such as drug formularies or copayments. Nir Eyal is an associate professor at the Harvard T. H. Chan School of Public Health; Paul L. Romain is a faculty member at Harvard Medical School; and Christopher Robertson is a professor at Harvard Law School.
James E. Sabin, who directs the ethics program at Harvard Pilgrim Health Care and is co-author of Setting Limits Fairly, a book about rationing policies, agrees that rationing through inconvenience can be justified, but he identifies a significant downside to the practice: that it reduces the capacity of health systems to learn from experience.
Sugar is a deeply consequential pathway to obesity, and the single greatest dietary source is sugar-sweetened beverages. The copious amount of sugar in the American diet is no accident. Industry practices and regulatory failures have fueled this explosion. Yet there are sensible, effective interventions that would create the conditions for healthier behaviors. Gostin, of Georgetown University Law Center, writes that he is “kick-starting scholarly and policy conversation by systematically laying out the major legal tools.” He thinks that tobacco control offers a powerful model, suggesting that success requires a suite of interventions working in concert: labeling, warnings, taxation, portion sizes, product formulation, marketing restrictions, and bans in high-risk settings such as schools and hospitals.
In the struggle over the durability of the Affordable Care Act, defenders of the ACA stand guard at many fronts. A major contribution of the ACA to nondiscrimination law, however, appears increasingly vulnerable. The ACA established significant new nondiscrimination protections for patients. Several of these regulations–including protections on the basis of gender identity and pregnancy termination–are now under reconsideration at the Department of Health and Human Services. Nondiscrimination laws matter, of course, because they promote equal access to health care. But focusing on discriminatory behavior alone is a narrow view of the purpose and potential of nondiscrimination rules–and underestimates the stakes of softening them. Nondiscrimination laws may affect not only discriminatory behavior in health activities but also the attitudes, beliefs, and decisions of people who are legally protected.
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