Making Medical Spending Decisions The Law, Ethics, and Economics of Rationing Mechanisms

A fresh and comprehensive exploration of how health care rationing decisions are made, this book offers not specific criteria for rationing--like age or quality of life--but a comparative analysis of three alternative decision makers: consumers paying out of pocket, government and insuranceofficials setting limits on treatments and coverage, and physicians making decisions at the bedside. Hall's analysis reveals that none of these alternatives is uniformly superior, and, therefore, a mix of all three is inevitable. The author develops his analysis along three lines of reasoning: political economics, ethics, and law. The economic dimension addresses the practical feasibility of each method for making spending decisions. The ethical dimension discusses several theories--principally classic liberalism, socialcontract theory, and communitarianism--as well as concepts like autonomy and coercion. The legal dimension follows recent developments in legal doctrine such as informed consent, insurance coverage disputes, and the emerging direction of federal regulation. Hall concludes that physician rationing atthe bedside is far more promising than medical ethicists and the medical profession have traditionally allowed.

Mark A. Hall is Professor of Law and Public Health at the Bowman Gray School of Medicine at Wake Forest University.

I. Introduction: Who Decides?The Inevitability of Medical Spending DecisionsAsking the Right QuestionsThe Plan of this BookII. Patient Spending DecisionsThe Case in Favor of Market ReformsIncreasing Patient Sensitivity to Medical CostsThe Case Against Patient Cost-SharingConclusionIII. Third-Party RulesBureaucratic and Legalistic MechanismsTechnocratic Resource Allocation and the Emerging Role of ScienceThe Flaws of Rule-Based RationingIdeal Democratic ProcessesPhysician OverseersIV. Physician Bedside DiscretionOpposition to Physician Bedside RationingThe Nature and Extent of Bedside RationingThe Moral and Political Status of Mainstream Medical EthicsBeneficence and AutonomyConclusion and Further InquiriesAppendixV. Motivating Physicians With Financial IncentivesFiduciary LawAgency Cost TheoryVI. Informed Consent to RationingDisclosing Rationing Mechanisms During Insurance EnrollmentDisclosure at the Time of TreatmentA Theory of Economic Informed ConsentConclusionVII. Conclusion: Deciding Who DecidesComparing Decision MakersChoosing Decision MakersThe Political Morality of Insurance SelectionBibliographyIndex