Abstract
Rationing occurs whenever the demand for a good or service exceeds its supply. Therefore
rationing is an inevitable occurrence in medicine and in critical care where the potential
demand for effective medical care will exceed supply. Although there are many strategies
to allocate medical resources one that is often considered is based on cost-effectiveness.
Cost-effectiveness analysis attempts to estimate the value of individual medical treatments
in terms of dollars and outcomes. Allocation of medical treatments based on cost-effectiveness
analysis requires valid estimates of both the costs and the effectiveness of treatments
as well as some overarching body with the authority to enforce allocation based on
these analyses.
Limitations of allocation based on cost-effectiveness analysis in critical care include
difficulties in estimating marginal costs of critical care treatments, limited evidence
for any treatments with efficacy, and the ethical principle of rescuing identifiable
lives in imminent risk of death. The prospect of a pandemic influenza-like infection
has stimulated a lot of interest in hypothetical rationing strategies for the intensive
care unit, none of which has been tested in actual pandemic scenarios. Given the burden
of critical illness and the wide variation in resources a global approach to rationing
is untenable. The article concludes with a vision of the future of allocation in critical
care.
Keywords
cost containment - rationing - critical care - ethics - resources
