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59 Medico-Legal J. 3 (1991)

handle is hein.journals/medlgjr59 and id is 1 raw text is: MEDICO-LEGAL JOURNAL Founded 1901 1991 Vol. 59 Part One EDITORIAL RATIONING HEALTH CARE: Ethical and Legal Considerations and QALYs The Doctor's Dilemma remains as pertinent as ever; the British National Health Service provides for universal access to health care but resources are limited. The Government's NHS reforms and the creation of an internal competing market of purchasers/suppliers operating within fixed budgets will affect the ways in which resources and treatments are made available and arguably also the criteria for allocation in individual cases. Will medical decision making and clinical freedom be affected as a result? Will the doctor's duty to care for an individual patient be tempered implicitly or overtly by his duty to the NHS to allocate resources in a manner best designed to ensure that society receives value for its money? Should those who pay most taxes and provide the most money towards the NHS be entitled to extract more as they would in the marketplace of insurance coverage related to premiums paid? If this were to happen it would undermine the basic ethos of the NHS and is thus, at present at least, not likely. Will general practitioners continue to act as gate (or lock) keepers to the provision of specialist services and will they as purchasers wield a greatly increased power to influence the type of care that hospitals and specialist services provide? At the end of the day, will patients benefit: will the greatest good be provided for the greatest number at a lower cost - and should this be the main aim? Incoherent and Incomprehensible Allocation of Scarce Resources In his Upjohn lecture,Whither the National Health Service? Has it a Future? presented at the Royal Society on November 5, 1990, Professor Alan Maynard, (Professor of Economics and Director of the Centre for Health Economics at the University of York), was contemptuous of the fumbling efforts of doctors today to select patients for scarce treatments: Patients are denied care now in the NHS by clinical rationing decisions which are incoherent, incomprehensible and implicit. In its place Maynard proposes a more logical criterion for the allocation of scarce treatments among competing patients, namely, the ability to benefit from care. (As a lawyer and layman one might have hoped that this was always at the root of any clinical decision making).