Marginal effectiveness as a reason for rationing - conceptual clarification and preliminary ethical considerations

Buyx AM, Friedrich DR, Schöne-Seifert B

Abstract

Definition of the problem Rationing fairly remains a problem of great importance in most health care systems. While the scientific debate of this challenge is longstanding, few criteria of allocation have gained general approval within the literature and in policy making. In this article, we analyse the fairness and applicability of marginal effectiveness as a rationing criterion. Arguments In the so-called "futility-debate" of the 1990s, arguments for and against the concept of futile medical care were weighted against each other from the point of view of clinical medicine. At the time, the use of "futility" as a rationing criterion was strictly refused. In this article, we concentrate on a specific class of interventions which figured in this dispute, namely medical interventions with marginal effectiveness. We define two dimensions of marginal effectiveness and discuss several arguments in favour and against using these as rationing criteria. Arguments in favour are in particular: 1) the ethical advantages in comparison with cost-benefit-analyses, 2) the potential of transparent resource allocation, 3) the absence of discrimination, and 4) the compatibility with arguments from good clinical practice. However, we explore several problematic issues of definition and implementation which also have to be taken into account. Conclusion We argue that, barring pragmatic issues, marginal effectiveness is a fair and transparent rationing criterion which has many advantages when compared to other controversial criteria.