The “R” Word: Ethical Allocation of Medicine’s Resources

Fears about denial of needed medical care have consigned the “R” word to the unmentionable list. Yet unsustainable levels of expenditure for health care in the U.S. have forced us to consider, not whether we make resource allocation decisions, but how we make them justly and compassionately. And if we make them through a transparent, democratic process, how do we manage those single, bedside cases in which a loved one is ineligible to receive a needed treatment? This month’s contributors shed light on that question by struggling with it rigorously and honestly.

Volume 13, Number 3: 207-267 Full Issue PDF
  • From the Editor
    Apr 2011

    Confronting the “R” Word

    Melanie Mund, MBE
    Health care rationing—the controlled distribution of resources, goods, or services in short supply—has elicited extreme rhetoric and aroused much fear.
    Virtual Mentor. 2011;13(3):209-210. doi: 10.1001/virtualmentor.2011.13.4.fred1-1104.
  • Case and Commentary
    Apr 2011

    Cost Effectiveness in Clinical Screening

    Robert J. Karp, MD and Yuriy Shepelyak
    An evidence-based, patient-centered approach is the best way to convince colleagues accustomed to older practice methods of the value of instituting cost-effective screening practices.
    Virtual Mentor. 2011;13(3):211-216. doi: 10.1001/virtualmentor.2011.13.4.ccas1-1104.
  • Case and Commentary
    Apr 2011

    Patient Requests for Nonindicated Care

    Zachary Ginsberg, MD, MPP and Erica Kreismann, MD
    Though conservative management can be perceived as withholding care, sometimes it is in the patient's, not just the hospital's or clinic's, best interest.
    Virtual Mentor. 2011;13(3):217-219. doi: 10.1001/virtualmentor.2011.13.4.ccas2-1104.
  • Case and Commentary
    Apr 2011

    Rationing Treatments Based on Their Cost per QALY

    David A. Wong, MD, MSc, FRCS(C)
    In cost-effectiveness research, the cost of a medical intervention is reported as a dollar amount per quality-adjusted life year gained—the quality of health and the length of time over which the health state exists.
    Virtual Mentor. 2011;13(3):220-223. doi: 10.1001/virtualmentor.2011.13.4.ccas3-1104.
  • Medical Education
    Apr 2011

    Teaching Resource Allocation: And Why It Matters

    Meina Lee, LLB and Elizabeth Geelhoed, PhD
    By studying both basic economic theory and the social and philosophical values that underpin medical decision making, medical students will be prepared to make better resource allocation decisions.
    Virtual Mentor. 2011;13(3):224-227. doi: 10.1001/virtualmentor.2011.13.4.medu1-1104.
  • In the Literature
    Apr 2011

    Identifying Bedside Rationing

    Taeho Rhee
    The author reviews an article detailing a 3-question method for identifying bedside rationing as it occurs and discusses 2 cases of bedside rationing.
    Virtual Mentor. 2011;13(3):230-232. doi: 10.1001/virtualmentor.2011.13.4.jdsc1-1104
  • State of the Art and Science
    Apr 2011

    Diagnosing Acute Low Back Pain

    Robin Polansky, MD, MPH
    Etiology, diagnosis, and treatment of acute lower back pain.
    Virtual Mentor. 2011;13(3):233-236. doi: 10.1001/virtualmentor.2011.13.4.cprl1-1104.
  • Health Law
    Apr 2011

    ERISA’s Effect on Claims of Injury due to Denial of Coverage

    Ilene C. Albala, MBe, JD
    The Employee Retirement Income and Security Act (ERISA) has created a loophole through which managed care organizations can escape liability for full compensatory damages solely because the patient is insured by his or her employer.
    Virtual Mentor. 2011;13(3):237-240. doi: 10.1001/virtualmentor.2011.13.4.hlaw1-1104.
  • Policy Forum
    Apr 2011

    Oregon’s Experiment with Prioritizing Public Health Care Services

    Philip A. Perry, MSJ and Timothy Hotze
    The importance of the Oregon experiment is that the state developed a public process for prioritizing medical services rather than relying on undisclosed private decisions by individuals or insurers.
    Virtual Mentor. 2011;13(3):241-247. doi: 10.1001/virtualmentor.2011.13.4.pfor1-1104.
  • Policy Forum
    Apr 2011

    How Comparative Effectiveness Research Feeds into Cost-Benefit Analyses

    Kevin D. Frick, PhD
    Despite exclusion of cost from the definition of comparative effectiveness research from the recent health care reform legislation, it will feed into cost-benefit analyses.
    Virtual Mentor. 2011;13(3):248-250. doi: 10.1001/virtualmentor.2011.13.4.pfor2-1104.
  • Medicine and Society
    Apr 2011

    What Is a Life Worth?

    Leonard M. Fleck, PhD
    If I am unwilling to pay more taxes so an 85-year-old stranger can have a left-ventricular assist device, then I am morally obligated to say the same holds true for a future version of me in those same circumstances.
    Virtual Mentor. 2011;13(3):251-255. doi: 10.1001/virtualmentor.2011.13.4.msoc1-1104
  • Personal Narrative
    Apr 2011

    The Other Limited Resource: Time with Patients

    Douglas Jay Mund, MD
    In addition to rationing money and services, the structure of contemporary health care forces the limitation of an intangible resource crucial to both physician and patient satisfaction, time spent on patient visits.
    Virtual Mentor. 2011;13(3):256-257. doi: 10.1001/virtualmentor.2011.13.4.mnar1-1104.