Rationing versus Rationality

Abstract

This commentary takes up A. David Paltiel’s invitation to reflect on how to promote the use of decision analysis and cost-effectiveness analysis in health. From the perspective of a health services researcher outside the U.S. system, I make 3 arguments. First, the unthinking use of the term rationing for all applications of cost-effectiveness analysis distorts research priorities and may jeopardize wider public support. Second, public skepticism about decision and cost-effectiveness analysis (and thus the skepticism of decision makers) is well founded when ethical dimensions of these methods are not considered. We must continue to refine our methods to take account of societal values. Third, the United States may have particular problems in adopting more rational decision making in health care. The dominance of for profit institutions in the U.S. health care system erodes the social legitimacy on which other systems depend to improve the rationality of health care decision making.