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PubMed2001

Sociology and the public understanding of science: from rationalization to rhetoric.

This paper contributes to the reappraisal of sociological theories of modernity inspired by the sociology of scientific knowledge (SSK). As much as these theories rely on received ideas about the nature of science that SSK has called into doubt, so do they rely on ideas about the public understanding of science. Public understanding of science has been assumed to conform to the monolithic logic and perception of science associated with rationalization, leading to an impoverished view of the cognitive outlook of the modern individual. Rationalization has become the basis for the construction of theoretical critique of science divorced from any clear reference to public understanding, with the result that theory has encountered considerable problems in accounting for public scepticism towards science. However, rather than question rationalization, the more typical strategy has been to propose radical changes in the modernization process, such as postmodernism and the risk society. Against this, an alternative view of public understanding is advanced drawn from SSK and rhetorical psychology. The existence of the sociological critique of science, and SSK in particular, suggests that the meaning of science in modernity is not monolithic but multiple, arising out of a central dilemma over the universal form of knowledge-claims and their necessarily particular, human and social grounding. This dilemma plays out not only in intellectual discourses about science, but also in the public's understanding of science. This argument is used to call for further sociological research into public understanding and to encourage sociologists to recognize the central importance of the topic to a proper understanding of modernity.

Humans↗
PubMed1982

Anxiety reduction through group instruction in rational therapy.

This study investigated the effects of group Rational Therapy in promoting rational thinking and self-enhancing emotions among 24 college students. Each subject was administered the Sixteen Personality Factor Questionnaire as a pre- and post-test measurement. Results reveal that some aspects of personality are affected by Rational Therapy group programs while others are not.

Adolescent↗
PubMed1994

Rationing and the Clinton health plan.

President Clinton, already facing formidable obstacles in reforming the health care system, denies that it will involve any rationing. This is politically understandable, but wrong. Infinite needs are rapidly overtaking finite resources. Most health providers recognize that the genius of modern medicine has outpaced our ability to pay. But the public still has unlimited expectations and a blind faith that everything can be provided to everyone by simply eliminating "waste, fraud, and abuse." Rationing is inherent in any health care system. As government undertakes to define what is "medically necessary or appropriate," it will unavoidably undertake a series of rationing decisions. Health care is being transformed from a private good to a public good. Government, when it reforms the health care system, must inevitably ask: How do we buy the most health for the public?

Delivery of Health Care↗
PubMed1995

The ethics of rationing.

Rationing can occur at three levels of health care choice: the individual, the institutional and the social, with each level posing its own ethical problems. The institutional level is the focus of this paper. The principle of effectiveness may seem attractive, since it promises to ease the institutional dilemmas of rationing, but it is not straightforward to implement in the face of uncertainty. Greater efficiency also promises much, but concepts of benefit are contested and improving contractual performance has complications. Fairness can be a powerful criterion, but there are contested cases, for example age, where its meaning is unclear. Democratic responsiveness, for all its difficulties, is important to maintain in whatever process of rationing is chosen and this can be done by adopting some procedural devices.

Decision Making↗
PubMed1995

Help or hindrance? The role of economics in rationing health care.

The economic evaluation of alternative diagnostic and therapeutic interventions is not merely a help to the processes by which decision makers allocate scarce economic resources, it is an essential ingredient into those rationing processes. Clinicians and other decision makers who advocate the use of effectiveness data alone to determine who will be treated and who will be left in pain and discomfort may perpetuate the inefficient use of resources. Rationing, or resource allocation, in health care must be informed by knowledge of the costs and consequences (effects) or alternative interventions. To ignore the economic element in clinical choices, generates inefficiency, and therefore unethical practice. The great advantage of the economic approach to rationing is that it requires an explicit framework which identifies the costs and benefits of alternative actions in all domains of human action. The combination of explicitness and precision inherent in good economic evaluation can only help in the difficult task of producing further health benefits for patients from the limited resources of the NHS.

Health Care Rationing↗
PubMedDate not supplied

Healthcare rationing: issues and implications.

What methods, if any, should be used to practice healthcare rationing? This article looks at healthcare rationing in the United States, identifies ethical issues associated with implementing healthcare rationing, and addresses legal implications. The author utilizes sources from published literature and her own experience. Society must recognize that it does not have the resources available to fulfill all healthcare needs of all its members. Resolution will bring conflict and compromise.

Delivery of Health Care↗
PubMed1990

Rationing health care: the choice before us.

Rapid technological advances and upward pressure on wages of hospital personnel are leading to a steady increase in health care spending that is absorbing an ever-larger fraction of gross national product. Eliminating inefficiencies in the system can provide brief fiscal relief, but rationing of beneficial services, even to the well-insured, offers the only prospect for sustained reduction in the growth of health care spending. The United States, which has negligible direct experience with rationing, can learn about choices it will face from the experience of Great Britain where health care has been rationed explicitly for many years.

Cost Control↗
PubMed2002

The problem with rational approaches to reforming the NHS.

Several papers with a common theme published between May and August 2002 are drawn together to present a research-informed critique of economic logic present within recent NHS reform. They attempt to persuade the reader that excessive faith in predictive systems of thought that are underpinned by theories of rational behaviour is misplaced within the NHS. They suggest rational economic theory makes some problematic assumptions about human and individual behaviour. The problem is that there are many modes of thought at work within the NHS, and not all of these cogs are turned by economic rationality. Increasingly, over the last 10 years or so, economic concepts have become more and more prominent in the NHS. Their influence has gone beyond finance becoming a dominant issue. In addition to budgets, contracts and cost itemisation, theoretical relationships of supply and demand are now called upon to change professional behaviour. A new framework for the NHS has been built which is developing market forces. The papers provide some insight into whether the systems set in place to produce a patient-centred service do so in a meaningful way. The first paper examines an emerging primary care group (PCG). Now part of primary care trusts, PCGs were a lynchpin of new economic relationships in the new NHS. Community based, in theory PCGs take decisions made about healthcare resources closer to the patient for whom they are a proxy demander and shaper of services. To what extent do PCGs fulfil this role? The first paper is based on data collected during an in-depth 2 year observation study to test the applicability of health economics to healthcare organisations. It examines the early experience of commissioning services for coronary heart disease (CHD).

Aged↗
PubMed1997

Health care rationing: can we afford to ignore euthanasia?

Explicit rationing decisions are being made to encompass a wide range of health care issues. Voluntary euthanasia has largely been excluded from this debate due to, in my view, the emotive nature of the issue. Euthanasia is an issue in which economists have been largely excluded and in which ethicists and philosophers dominate. It is the purpose of this paper to review the economic and ethical literature on euthanasia and to discuss their compatibility within the debate on euthanasia. The potential cost savings by the use of advance directives, do-not-resuscitate orders, and futile care withdrawal are then reviewed, as are the potential cost savings created by hospice care. As a conclusion, the ethical and economic arguments are then balanced to assess their compatibility. It is the contention of this paper that reducing medical care costs near the end of life should not be a taboo subject, and that rationing decisions could focus on an exploration of this area and the approaches to it, which are ethically justifiable and economically worthwhile. The introduction of a policy of voluntary euthanasia could have a large impact on the rationing of health care resources whilst also promoting patient choice and an arena for a more dignified death.

Advance Directives↗
PubMed2000

US neurologists: attitudes on rationing.

OBJECTIVE: To assess neurologists' attitudes on rationing health care and to determine whether neurologists would set healthcare priorities in ways that are consistent with cost-effectiveness research. BACKGROUND: Cost-effectiveness research can suggest ways to maximize health benefits within fixed budgets but is currently being underused in resource allocation decisions. METHODS: The authors surveyed a random sample of neurologists practicing in the United States (response rate, 44.4%) with three hypothetical scenarios. Two scenarios were designed to address general attitudes on allocating finite resources with emphasis on formulary decisions for costly drugs. The third scenario was designed to assess whether neurologists would optimize the allocation of a fixed budget as recommended by cost-effectiveness analysis. RESULTS: Three-quarters of respondents thought that neurologists make daily decisions that effectively ration healthcare resources, and 60% felt a professional responsibility to consider the financial impact of individualized treatment decisions on other patients. Only 25% of respondents thought that there should be no restrictions placed on any of the five newer antiepileptic agents. In a 1995 survey, 75% of similarly sampled neurologists agreed that no restrictions should be placed on the availability of FDA-approved medications. Nearly half (46%) of respondents favored a less effective test and would be willing to let patients die to ensure the offering of a more equitable alternative. CONCLUSIONS: Most neurologists recognize the need to ration health care, and although they think cost-effectiveness research is one method to achieve efficient distribution of resources, many think that considerable attention should also be given to equity.

Attitude of Health Personnel↗
PubMed1998

Managed care: rationing without justice, but not unjustly.

Three ethical criticisms of managed care are often voiced: (1) by "skimming the cream" of the patient population, managed care organizations fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that each of these criticisms is misconceived. The first rests on the false assumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning access to managed care organizations. The second and third criticisms wrongly assume that we in the United States have taken the first step toward assuring equitable access to care for all, articulating a standard for what counts as an "adequate level of care" to which all are entitled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institutional setting within which no connection can be made between the activity of rationing and the basic requirements of justice.

Contracts↗
PubMed1999

The which-hunt: assembling health technologies for assessment and rationing.

To rationalize and restrict health care spending, policy, makers in many jurisdictions have withdrawn insurance or funding for selected health care technologies. Numerous analytic frameworks and applied exercises have emerged to guide decisions about "which" services to cut. But in their focus on choice-making processes, these efforts have paid little attention to the problem of defining and dividing the set of technologies to choose among. If technology assessment refers to methods for weighing services for their relative value, the term technology assembly might be used to refer to methods for framing the technological trade-offs to enroll in such contests. This article examines technology assemblies found in several types of theoretical and applied rationing exercises (including Oregon's Medicaid rationing process, economic evaluation literature, citizen "values" surveys, and Canadian provincial deinsurance policies). Based on this review, some key conceptual conventions and problems in technology assembly can be identified. The boundaries between health technologies are fuzzy, interlocked, layered, and continuously moving. Consequently, the defining features of technological trade-offs are inevitably socially constructed and negotiated. Trade-offs can be arranged along numerous dimensions, and the divisions typically correspond to broader political, administrative, and ethical dilemmas in health policy. Examples include equity among demographic classes, concepts of need, legitimacy of therapeutic goals, and so forth. Insights into the process of constructing technological trade-offs may help policy makers better question what technologies they are looking at and why, before moving on to the task of determining which ones to cover.

Adult↗
PubMed2001

Rationing healthcare: the appeal of muddling through elegantly.

There is no denying the existence of rationing in healthcare. It is an example par excellence of a "wicked issue." Faced with the reality of rationing, the issues are: who should ration, and how rule-bound and explicit should it be? Clinicians are ambivalent on these matters. Many would prefer governments and politicians to make these decisions openly in publicly funded healthcare systems, since they decide how much to spend on healthcare. Others believe it to be the responsibility of clinicians to decide how finite resources should best be used in individual cases.

Decision Making↗
PubMed2004

Rationing health care in the welfare state: three policies.

Three policies of health care rationing are discussed. The premise underlying their analysis is that all welfare systems must ration health care. This raises the question as to how the problem ought best to be resolved. But before thinking about normatively appealing answers it might be helpful to study how the problem is dealt with in the real world. For such a study brings to light several advantages and drawbacks of various rationing schemes which would be hard to consider in the abstract alone, but whose knowledge may be highly relevant for any designation of adequate solutions.

Delivery of Health Care↗
PubMed1993

The Oregon Health Plan: a rational approach to care for the underserved.

The Oregon Health Plan addresses the needs of 450,000 Oregonians presently without health insurance, among them 120,000 living in poverty who are not now Medicaid-eligible. This is accomplished by expanding eligibility for Medicaid to individuals and families with incomes at 100 percent of the federal poverty level. T0 help expand access within the limitations of the state budget, certain services, determined to be of limited value or effectiveness, are not covered for payment. This concept of rationing health care reimbursement stands in contrast to existing mechanisms of rationing employed by every state and the nation. The Oregon Health Plan introduces a rational plan for expanding services to the entire population of the state, while acknowledging the limitations of funding resources.

Cost Control↗
PubMed2003

A philosophical approach to rationing.

Rationing, the equitable allocation of medical resources, is both an economic and moral challenge--economic, because the various components of healthcare must be budgeted; moral, because the prioritisation of these resources is a value-laden decision. The moral debate about rationing pits individual choice against communal interests. The advocacy of equitable distribution of healthcare resources originates in arguments for distributive justice and a revised version of individual autonomy. If autonomy is defined strictly in terms of atomistic individuality, then the social obligations and duties of persons are subordinated to their individual rights. Alternatively, when people are defined by their relationships, "relational autonomy" balances responsibilities against the claims of individual rights to maximise distributive justice. The concept of relational autonomy provides medicine with a philosophical basis for communal rationing of healthcare resources.

Ethics, Medical↗
PubMed1993

Desperately seeking solutions: rationing dilemmas in health care.

Rationing health care is high on the policy agenda in many countries as the demand for care apparently outstrips supply. There are calls for the public to become more actively involved in determining priorities along the lines of the Oregon experiment in the United States. In Britain rationing has always been a feature of the National Health Service (NHS) although it has become implicit rather than explicit. The NHS reforms, principally the purchaser-provider separation, is making rationing much more explicit. The paper reviews the debate in Britain and concludes that there are no quick fixes or simple panaceas to a complex issue. It questions the extent to which the public can or should be involved in deciding who should or who should not get treated and argues that doctors have a central role to play in finding a better way of allocating resources effectively.

Community Participation↗
PubMed2001

Rationing medical care: rhetoric and reality in the Oregon Health Plan.

The Oregon Health Plan (OHP) has been widely heralded as an important innovation in medical care policy and rationing. Oregon's pioneering method of prioritizing funding for health care through systematic and public ranking of medical services has drawn substantial international interest. This paper reviews the experience of the Oregon plan since it began operation in 1994. We argue that widespread misconceptions persist about the significance of the OHP. In particular, there is little evidence that the OHP has operated as a model of explicit rationing. In reality, Oregon has not rationed services, nor has its policy of cutting public coverage for services produced substantial savings. These findings have important implications regarding the desirability and feasibility of adopting a policy of removing items from the list of insured medicare services in Canada. Oregon's experience suggests that drawing the line on medicare coverage would be more difficult and less financially rewarding than advocates claim.

Health Care Rationing↗