An egalitarian conception of rationing

It may be helpful to begin by presenting the general conception of ECR in outline before noting the significance of the moral position that it embodies. First, it relates to a distribution that includes the micro level, reflecting a concern with what is allocated to individual people. Second, it is not merely a process that restricts access to goods but a policy that is directly intended to allocate goods to needs in a specific way; in John Butler's terms, an explicit form of rationing by entitlement (p13).8 Third, in virtue of embodying an egalitarian principle of fairness, it aims to avoid abandoning anyone. To this end it will either adopt a policy of straightforward equality in distribution, or, if not this, it will aim to justify any variation by further considerations that are consistent with egalitarian objectives.9 Lastly, like any plausible egalitarian distributive principle, it aims not merely at equality10 but equality at a useful level, where this most obviously involves the provision of at least a basic minimum for all. It is then a further question what other needs, above that level, should be met on an egalitarian basis.

It is this conception of rationing that is at work when the small group of survivors struggle through the desert, eking out their water supplies, every so often passing the bottle round for one drink, and only one, per person. Or, as mentioned, there is the example of rationing in time of war. In the case of food this would involve the supply of at least enough calories for each person's survival at a reasonable level of health. Where there is any variation in a straightforward allocation of equal calories for all, the appropriate form of justification is one that refers to more complex considerations of equality. This might involve the unequal needs that result from such differences between persons as being very young or being involved in heavy labour, where these can be seen as falling directly under a principle of equality: that of supplying equal calories for equal needs. Of course, under conditions of severe scarcity, some demands on food (choosing to run marathons, perhaps) might be judged unacceptable as a basis for an unequal share, but once those activities are ruled out, the expectation will be that everyone's remaining needs will be met.

This brings us to the moral significance of ECR. The crucial point, I suggest, is that this rationing is distinct from prioritisation, where the latter comprises those mechanisms that restrict supply so as to leave (whether intentionally or just foreseeably) some of the population better off than others. This happens most obviously where it is directly intended, as where the young are given preference over the old. It can also happen indirectly, as where we distribute goods by market forces. By contrast, even where ECR leads to different amounts of food being provided in response to different ages or workload, it does not cross the moral boundary of giving any priority or higher status to anyone in the group, and nor does it depend on such a move for its rationale. It merely responds to the different needs that are relevant to having the same objective (survival, most basically) for each member of the group. It thereby preserves the idea of equal treatment for all, and thus an ideal of equal worth and equal respect. All are required to make a sacrifice, but no-one is asked to make one larger than another's, nor to make one in order that another's may be reduced.

Clearly, ECR embodies certain moral claims. I am not here referring to the nature of the overall aim of rationing, which perhaps has an uncertain status. That is, if we take the wartime example, it may be argued that the overall aim is that of increasing the chance of a nation surviving through difficult times and that this is not so much moral in nature as a matter of (group) self-interest. Whatever we think about this, though, it is clear that ECR modifies this goal by means of two moral constraints: a concern for the continuing survival of all current members of the group, and a concern that the policies promoting this survival are justified in terms of equal regard for all. Neither of these two requirements is essential to the survival of something like a national group, since, of course, such a group has a continuing identity independent of the survival of any given person among its current membership, and independent also of whether they are treated equally. Both, though, are vital to characterising ECR.

First, the concern for the survival of all current members marks a clear distinction between this concept of rationing and, for example, a policy that might be thought appropriate in very much more straightened circumstances, that of some severe kind of triage (Butler, p47),8 where some individuals might (in effect if not intent) be sacrificed to help secure the overall aim of group survival. Those already in a weakened condition might be selected. This kind of triage policy would not necessarily be ruled out by an appeal to equality alone. For example, it might be argued that, precisely in order to uphold fairness and the ideal of equal worth, a lottery should be held to decide who should be sacrificed. Such a policy, while arguably egalitarian in that it gives an equal chance of survival to all, nevertheless constitutes a decision that some must be sacrificed and thus falls foul of the requirement for a concern for the survival of all current members.

Second, there is reason to think that requiring the concern for all to be an equal concern is also a vital condition, since where there is either an unjustified departure from equality, or a departure justified by reference to some principle inconsistent with equality, we are, at least to a degree, sacrificing one or more members of the group. Thus, to make further savings, a sub-group might be selected to receive what was predictably sufficient for survival but only at a lower level of health than others, and therefore at a greater level of risk. By way of defence, it might be said that this did not represent the sacrifice of any current member, but rather that the survival of all remained a concern. Nevertheless, such a policy would not represent an equal concern for the survival of all current members, so that, even if we took this justification to have some weight, it could not be on grounds of an equality of respect for all. Even if it were thought justified by the extreme circumstances, it would amount to at least a degree of disregard of the interests of some current members of the group relative to the rest and thus be inconsistent with the concept of ECR.

As well as noting the moral elements that are partly constitutive of ECR, there is a further important point to be made here, which is that, under conditions of scarcity, rationing of this kind has a strong claim to be morally justified, perhaps even required, however regrettable may be the circumstances under which it becomes appropriate. That is, at least where it is agreed that the scarcity is not remediable and agreed that non-rationed access to the relevant goods constitutes a serious risk to the relevant group, we might well say that it is exactly the right policy. Rather more controversial, perhaps, is the situation where the scarcity results not from unavoidable circumstances but from a political decision about funding. Such a decision, though, would seem to be a separate moral issue, one that does not alter the moral rightness of the rationing, given a reasonable degree of certainty that, for whatever reason, the scarcity will persist.

Egalitarian and broad conceptions compared

How, then, does ECR compare with the other restrictions on supply, mentioned earlier, that are now also typically included in the general idea of ‘rationing’ and so help make up the BCR? One point to note immediately is how very varied are the practices and processes included. PA Ubel, who writes in favour of rationing, is another who supports a broad conception, seeing it as deriving from the usage favoured by economists: ‘To them, rationing includes any mechanisms that limit how many goods people receive, including ability to pay’.11 So, even if we set aside ECR from these, we are left with a very diverse range of proposals. However, what they crucially have in common, besides the imposition of limits to supply, is that they all constitute ways of sacrificing the welfare of some for the welfare of others. If we briefly revisit those mentioned at the outset, we can first note those that would come within Ubel's category of ‘explicit’ rationing, where the administrators consciously intend to withhold a service from certain people.

The idea of the lottery has already been mentioned, together with the fact that it does take some account of fairness. So, in different ways, do principles of distribution based on age12 or queueing. Most significantly, though, all three involve the assumption that it is legitimate to decide that some patients (whether unlucky, older or at the back of the queue) will be denied treatment. This is not to say that this could never be justified. Even where the treatment related to basic needs, really extreme circumstances might warrant such a policy. The proposal is rather that we should mark its moral significance by describing this as a point where rationing, understood as embodying a commitment to treating all, becomes impossible, and some more radical policy of prioritising has to be adopted instead.

Of all the explicit forms, though, it is probably the appeal to cost-effectiveness and the role of the National Institute for Health and Clinical Excellence (NICE) that is currently most prominent. Not surprisingly, its work in giving or withholding approval of treatments within the NHS has been highly controversial. However, more to the point here is that, whatever the original intention, NICE's efforts to prioritise on the basis of cost-effectiveness have come to be regarded by many, notably in the press, as part of the process of ‘rationing’ healthcare. To take one example from The Times, we can note the health editor referring to NICE as ‘the government's drug rationing body’.13 It is important to be clear, then, that while some assessments of effectiveness could obviously be relevant to ECR, there is nothing intrinsically egalitarian in the usual comparisons of cost-effectiveness in healthcare or in the maximising objectives that typically accompany them.

We can turn now to what Ubel refers to as ‘implicit’ rationing, where some mechanism restricts access to services but not through any intention that this occur. Here, perhaps, we reach the point furthest from the concept of ECR, since this involves the inclusion of market forces. These seem to meet barely any of the defining features of ECR that were described at the outset. To begin with the most straightforward difference, although free markets are obviously mechanisms that affect distribution at the micro-level, it is evident that they may leave some unable to afford any given product or service. Plainly, then, they do not aim to secure a basic minimum for all. More generally, they do not aim at any specified distribution. In fact, far from constituting a policy intended to produce a particular pattern of distribution the free market has been held by some, famously by Robert Nozick,14 to be the morally appropriate form of distribution precisely for abjuring those coercive interventions required to produce a preconceived pattern. The idea of a market is thus strikingly at variance with ECR, but also with what Beauchamp and Childress4 refer to as the original concept of rationing. This concept, they suggest, was not necessarily related to severe shortages, but was one that simply referred to the normal allocation of an allowance or portion (eg, rations of food in the army) to the relevant individuals. The workings of the free market seem to have no relation to this sort of planned and measured allocation, beyond, as mentioned earlier, the very general idea that access to the goods concerned is, like that to almost all goods, restricted rather than entirely open.

The broad conception: arguments and replies

Can a positive case be made for the adoption of BCR? Ubel11 is noteworthy in attempting this, though in doing so he focuses on the only aspect of it that he regards as conceptually contentious: the extension of the concept of rationing from solely explicit mechanisms to the inclusion of the workings of market forces as well. However, since his defence of the extension has a bearing on ECR, it is relevant here.

To begin, Ubel himself admits (p17) that the ‘implicit’ rationing of the market will be at variance with the ‘popular understanding’ of the meaning of rationing, but goes on to offer three responses to this discrepancy. First, simply in respect of linguistic usage, he suggests that, given the special place of healthcare in our lives, the popular understanding would change if healthcare was distributed purely on the basis of ability to pay the market price, and we saw more patients suffer from lack of the treatments they could not afford. By way of reply, I suggest that a prediction about a possible change in language does not warrant us in consciously assisting such a change at the expense of an important distinction.

Second, though, he argues that we should in fact choose to include implicit mechanisms in our conception of rationing because the ‘deprivation and hardship’ that results from a distribution according to ability to pay is something commonly associated with rationing. It is an argument that seems much more significant than the first. This claim, that it is desirable to bring under one broad conception all those distributive mechanisms which produce the hardship we associate with a narrower conception, is one that would undermine the distinction between ECR and other forms of explicit restriction, as much as that between the explicit and implicit. Yet it is an argument lacking a crucial rationale. Why should we organise our concepts to reflect the general outcomes of deprivation and hardship, conditions that unfortunately will result for some of us whatever policies are chosen? Is it not more important to mark those moral distinctions that we use in trying to justify the various mechanisms that partly determine where these outcomes occur and where they are avoided?

Ubel's third response is to claim that it would actually be dangerous to limit our conception of rationing to explicit mechanisms, since this would allow providers of healthcare to withhold services through implicit mechanisms while defending the practice by denying that any rationing was taking place. This response, we should note, involves the familiar but contestable assumption that rationing is always wrong. However, even if we accepted this for the sake of argument, there seems no reason to suppose that, having agreed that no rationing was occurring, we would thereby be rendered oblivious to other wrongs, such as the injustices of the free market. More important, though, is the way in which a reversion to ECR would alter the assumption behind Ubel's third claim. If we reverted to the traditional concept of rationing, where this is a procedure plausibly seen as morally right in the appropriate circumstances, then a claim that rationing was not occurring would of course constitute no defence of public policy at all. In fact, talk of rationing would be irrelevant. Instead (and surely better) the putative service suppliers would have to tackle the problem head on and provide an overt defence of their decision to do nothing regarding the failures of supply arising from implicit mechanisms such as market forces.