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Pricing Life–Why It's Time for Health Care Rationing
  1. Søren Holm
  1. Institute of Medicine, Law and Bioethics, University of Manchester & Centre for Medical Ethics, University of Oslo

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    Peter A Ubel, Cambridge, MA, The MIT Press, 2000, 208 pages, £15.50.

    Pricing Life is an extremely timely and stimulating book. The debate about health care rationing has now been running for several decades but there are still people who publicly deny that rationing of health care has to take place, or that health care rationing could be ethically justifiable. In many countries we have also had politicians who have refused to allow the “R” word to pass their lips. In this well written, and very direct book Peter Ubel decisively shows that rationing is an inevitable feature of modern medicine and that it is not something that health care administrators and economists force doctors to perform against their better judgment. Deciding who should have access to treatment has always been a part of the doctor's work. Ubel's analysis of the phenomenon of bedside rationing is incisive and definitive. Anyone who will still deny that rationing does and must take place after having read this section can only be in bad faith.

    The book would have been a valuable contribution to the literature even if it had only contained the analysis of the necessity and ubiquity of rationing in health care. But it also contains a second part which reviews and discusses the current knowledge about how the public view health care rationing and how they would distribute health care resources. Ubel is well known for his own work in this field and the book gives a very comprehensive and useful critical overview. It is explained what the main findings are, but also that these findings are context-sensitive and sensitive to the framing of questions. For the health care ethicist this is perhaps the most important part of the book. In the literature one can at times find categorical statements about the attitudes of the public–of the type: “Everyone prefers to give resources to the young and not the very old”–but often these statements have no other basis than the philosopher's own musings in his or her armchair, or the views of his or her friends. Ubel's book shows that such categorical statements are most often wide of the mark and that the public's views are much more nuanced. In doing so he also shows why empirical studies in this area are important, as well as their limitations.

    In this part of the book he also discusses how various forms of preferences, for example concerning age groups or justice can be incorporated into QALY-type measures.

    Ubel does not present a new philosophical approach to justice, but he does show just how much work still has to be done before our well-known theories about justice can give determinate answers to the question of how scarce resources should be rationed in the health care system.

    I can recommend this book without reservation. It should be read not only by health care ethicists but by doctors, health care administrators and, perhaps especially, by health care politicians.

    It is written in an American context but there is an explicit recognition that there are many other health care systems than the American, and that some of them might even have features that are superior to the American system. Its conclusions are therefore easily transferable beyond the American context.