Resource Allocation and the Right to Refuse to Treat

For many years, policy analysts, researchers, and ethicists have raised questions about whether the health care system distributes resources such as drugs, medi- cal care, and surgical care in a just and ethical way. This debate takes two forms: deciding which individuals should get care and deciding which procedures should be funded regardless of individual patient.

In the United States, decisions about who should get care mostly occur through implicit rationing: Anyone who can afford health care gets it, anyone who can’t afford it doesn’t. In contrast, and as we saw in Chapter 9, access to health care is considered a right in other developed nations. The Affordable Care Act (ACA) is an important step in that direction.

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But even when individuals can afford health care, decisions still sometimes need to be made about whether they should have access to that care. This situation occurs whenever doctors or others consider a treatment to be futile. For example, imagine an 80-year-old woman with a life-threatening infection and heart condition that have left her too ill to speak for herself. Now imagine that her husband demands heart surgery even though her doctors believe her odds of surviving the surgery and regaining a decent quality of life are slim. In cases like this one, the individual’s right to autonomy (in this case, with the husband legally speaking for his wife) must be balanced with doctors’ ethical responsibilities both to this patient (whom they believe will be harmed by continuing her suffering) and to other patients (given that any resources devoted to futile care for one patient will not be available to patients who might benefit more).

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