Any talk of considering costs in treatment decisions usually triggers an immediate outcry against “rationing” of care, experts say.

“It will always be challenging to obtain public buy-in for making cost of care a factor in medical decision-making,” says Nancy S. Jecker, PhD, a professor in the Department of Bioethics and Humanities at Seattle-based University of Washington. She offers the following approaches to make cost considerations more “palatable to the public”:

Separate medical and societal decision-making.

This takes physicians out of the role of rationing healthcare, she says. “Physicians are obligated to distribute limited treatments on the basis of potential medical benefits, without regard to nonmedical factors,” explains Jecker. This means not taking the patient’s social worth, ability to pay, or lifestyle choices into consideration.

“By contrast, society is responsible for establishing policies that allocate scarce healthcare resources based on both medical and nonmedical factors,” says Jecker.

Faced with limited resources, society may choose to invest more on lower-cost preventive care that benefits a large number of people, for instance, and less on high-cost care that benefits a relatively small number of individuals.

Make cost-effective analyses transparent and publicly accountable.

A life-year gained by a healthcare intervention might be assigned a value of $50,000. “This benchmark is then used to make comparative assessments of what represents a reasonable healthcare investment,” says Jecker.

This is one example of a transparent and systematic way of setting healthcare priorities. “It benefits everyone when there are fair and explicit procedures for allocating healthcare that are consistently applied and publicly accountable,” says Jecker.

Is it Reasonable?

“Rationing” of healthcare, referring to the denial of beneficial treatments under conditions of fiscal scarcity, raises justice considerations. The ethical issue is what constitutes a fair share of healthcare services when there is not enough to provide services to everyone who stands to benefit, she says.

“Even when interventions offer a reasonable likelihood and quality of benefit to the patient, patients may be denied treatment in order to ensure a just distribution of scarce healthcare resources for all,” says Jecker.

In Jecker’s view, the probability of medical success is a major factor that should be taken into account in patient care. She says that if care is of little value and there is not a reasonable prospect of benefitting the patient, interventions should not be used — even if they are inexpensive and readily available.

“What constitutes a ‘reasonable’ prospect of benefit can be determined by appealing to the idea of the ‘quantitative futility,’” says Jecker. This is the same threshold that is already used in the statistical evaluation of clinical trials. If an intervention produces its desired effect in only 1 in 100 cases, this is not considered significant, because it occurs so infrequently that it may be due to chance. “Likewise, if the likelihood of medical benefit from a particular intervention is just 1 in 100, that is not considered significant and qualifies as quantitatively futile,” says Jecker.

Aging Populations

One increasingly important trend is the aging of populations around the globe. “This will raise new questions about the fair allocation of healthcare, and what constitutes a just allocation of healthcare between young and old,” says Jecker.

People 65 and older are among the heaviest users of healthcare services. Also, diseases affecting older people tend to be chronic, progressive, and disabling. Thus, healthcare systems will need to place greater emphasis on out-of-hospital caregiving services. “This is necessary to ensure that people suffering from chronic progressive disease have the capability to perform basic activities of daily living,” says Jecker.


  • Nancy S. Jecker, PhD, Professor, Department of Bioethics and Humanities, University of Washington, Seattle. Phone: (206) 616-1865. Email: