From an ethics of rationing to an ethics of waste avoidance.

n engl j med 366;21 nejm.org may 24, 2012 1949 distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste. This little-noticed shift has important policy implications. Whereas the “R word” is a proverbial third rail in politics, ethicists rush in where politicians fear to tread. The ethics of rationing begins with two considerations. First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods. The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too. The ethical argument about rationing then shifts to the question of the fairest means for allocating scarce resources — whether through the use of a quasi-objective measure such as quality-adjusted life-years or through a procedural approach such as increased democratic engagement of the community.1 Ethicists arguing for fair rationing have had to contend with claims that the cost problem would be solved if we eliminated waste, fraud, and abuse. They have replied with statistics suggesting that waste, defined as the cost of deliberate fraud, accounts for less than 10% of health care costs. Moreover, eliminating all waste would result in one-time savings; the primary drivers of cost escalation — technological advances and the aging of the population — would proceed unchecked. The facts that have recently overtaken this ethical discussion show that waste in U.S. health care, defined more broadly as spending on interventions that do not benefit patients, actually amounts to a much larger sum — at least 30% of the budget — and that this waste is a major driver of cost increases.2 A case study for the shift in ethical focus is the treatment of advanced, metastatic breast cancer with high-dose chemotherapy followed by autologous bone marrow transplantation. This treatment was initially thought to ofFrom an Ethics of Rationing to an Ethics of Waste Avoidance