Can Rationing Through Inconvenience Be Ethical?
Total Page：16
File Type：pdf, Size：1020Kb
Boston University School of Law Scholarly Commons at Boston University School of Law Faculty Scholarship 1-2018 Can Rationing Through Inconvenience Be Ethical? Nir Eyal Paul Romain Christopher Robertson Boston University School of Law Follow this and additional works at: https://scholarship.law.bu.edu/faculty_scholarship Part of the Health Law and Policy Commons Recommended Citation Nir Eyal, Paul Romain & Christopher Robertson, Can Rationing Through Inconvenience Be Ethical?, 48 Hastings Center Report 10 (2018). Available at: https://scholarship.law.bu.edu/faculty_scholarship/964 This Article is brought to you for free and open access by Scholarly Commons at Boston University School of Law. It has been accepted for inclusion in Faculty Scholarship by an authorized administrator of Scholarly Commons at Boston University School of Law. For more information, please contact [email protected]. Arizona Legal Studies Discussion Paper No. 19-03 Can Rationing through Inconvenience Be Ethical? Nir Eyal Harvard T.H. Chan School of Public Health Harvard Medical School Paul L. Romain Beth Israel Deaconess Medical Center Christopher Robertson The University of Arizona James E. Rogers College of Law March 2019 Electronic copy available at: https://ssrn.com/abstract=3358604 Can Rationing through INCONVENIENCE Be Ethical? BY NIR EYAL, paul L. ROMAIN, AND CHRISTOPHER ROBertson Using burdensome arrangements—application processes, forms, waiting periods, and the like—as a strategy for limiting the use of health care resources has been roundly but uncritically condemned. Under some conditions, it may be legitimate. It may even be preferable to direct rationing. n an influential essay, Gerald Grumet charac- needed health care. Recent efforts, for example, by terized “rationing through inconvenience” as the American College of Physicians, have sought to a potent but secretive strategy for “slowing and mitigate or eliminate administrative tasks and their I 4 controlling the use of services and payment for ser- adverse effects. vices by impeding, inconveniencing, and confus- However, inconvenience of service use is also a ing providers and consumers alike.”1 Donald Light commonplace rationing mechanism for encourag- similarly decried “practices [that] include rejecting ing socially preferred choices. Consider the following claims in whole or in part for procedural or techni- examples: cal reasons, making the claims process and its rules extremely complex, and [ultimately] inducing claim- • Pascaline Dupas and colleagues found that, ants to give up.”2 For clinicians, the phrase “ration- in western Kenya, combining free provision of a ing through inconvenience” usually evokes wasted chlorine water treatment (a diarrhea prophylactic) time, unnecessary red tape, byzantine bureaucratic with a voucher system that imposes the inconve- systems, escalating administrative expenditures, and nience of having to redeem a coupon at a local even “ambiguity, deception, or harassment.”3 For store screened out 88 percent of those who would patients, inconveniences like paperwork and travel otherwise accept the product without using it.5 can stand as a barrier to using insurance or accessing Similarly, Xiaochen Ma and coauthors found that giving Chinese children a voucher redeemable for eyeglasses in a store “modestly improved targeting Nir Eyal, Paul L. Romain, and Christopher Robertson, “Can Ration- 6 ing through Inconvenience Be Ethical?,” Hastings Center Report 48, efficiency” compared to handing out eyeglasses. no. 1 (2018): 10-22. DOI: 10.1002/hast.806 10 HASTINGS CENTER REPORT January-February 2018 Electronic copy available at: https://ssrn.com/abstract=3358604 • Rationing through inconve- medical, religious, or philosophical to cause or has the effect of causing nience can also influence the par- grounds. Several authors have pro- patients or clinicians to choose an ticular health service consumed. posed “making [nonmedical] ex- option for health-related consump- Making a preferred treatment the emptions for immunizations more tion that is preferred by the health default, overridden only with ef- difficult to obtain.”15 Their idea system for its fairness, efficiency, or fort, has been proposed as a way of is to make the legal procedure for other distributive desiderata beyond curbing health expenditure.7 For obtaining exemptions more “ar- assisting the immediate patient. This example, a physician might be re- duous” by, for instance, requiring definition can be unbundled. quired to navigate to the bottom of “a notarized parental statement, First, rationing through incon- a computerized list to find the op- counseling, and health depart- venience is a form of rationing. We tion that would allow her to refuse ment approval,” as some states do. take it as a starting assumption that generic substitution.8 To the ex- They point out that arduous ex- rationing, understood as scarce- tent that a small inconvenience is emption procedures are inversely resource prioritization, is inevitable used to shape preferred consump- related to the rate of nonmedical and, in a society that has goals be- tion, such nudges (recently called exemptions.16 Parents who are yond optimizing health care for in- “effort taxes”9) arguably constitute deeply and genuinely opposed to dividual patients—such as improving rationing through inconvenience. vaccinations may select to undergo societal health care, education, or the inconvenience, while children overall welfare—prudent and fair.17 • An inconvenience, and its ab- of the remainder get vaccinated. Whether in public or private insur- sence, can also affect patients’ choice of provider. Americans rely For clinicians, the phrase “rationing through on expensive specialists much more than patients in other countries inconvenience” usually evokes wasted time and do, in part because waits are lon- unnecessary red tape. However, inconvenience of service ger in other countries.10 About one in five urgent care center users said use is also a commonplace rationing mechanism for they chose their provider because the location was “more conve- encouraging socially preferred choices. nient, compared to other facilities like hospitals, doctors’ offices and In this article, we provide a com- ance pools, health care resources are community health centers.”11 prehensive analysis and a norma- collective. The resulting collective ac- Locating primary care clinics in tive assessment of rationing through tion problems require some system of convenient sites might likewise inconvenience as a form of ration- allocation, whether direct (such as a lure patients with nonemergency ing. We argue that under certain committee decision) or indirect (such conditions away from expensive conditions, rationing through in- as a pricing mechanism or ration- and less convenient emergency convenience may turn out to serve ing through inconvenience). Indeed, departments.12 Ironically, however, as a legitimate and even a preferable the definition holds that rationing a study of pharmacy-based retail tool for rationing; we propose a re- through inconvenience comprises clinics “found that 58 percent of search agenda to identify more pre- only those inconveniences that lead, retail clinic visits for low-acuity cisely when that might be the case or are intended to lead, to otherwise conditions represented new utili- and when, alternatively, rationing appropriate distributions. Distribu- zation and that retail clinic use was through inconvenience remains ethi- tions can be appropriate for their associated with a modest increase cally undesirable. After defining and fairness, efficiency, contribution to in spending, of $14 per person illustrating rationing through incon- social equality, or other societal re- per year.”13 Accordingly, com- venience, we turn to its moral advan- sponsibilities in medical or economic mentators wonder whether other tages and disadvantages over other terms. By contrast, when inconve- convenient, lower-priced options rationing methods. niences lead, or are intended to lead, such as “telehealth” or kiosks of- only to private profit for an insurer fering testing in stores “could also Rationing through whose subscribers are dissuaded from end up leading to overall increases Inconvenience: A Working claiming their moral and legal rights, in health spending, despite being Definition for example, and the inconveniences touted as cost-savers.”14 advance no social good, then they do y “rationing through inconve- not count as rationing through in- • Every U.S. state has a vaccina- Bnience” in the health sphere, we convenience. The reason for thus lim- tion mandate but also has proce- refer to a nonfinancial burden (the in- iting the scope of our investigation is dures for exempting individuals on convenience) that is either intended that when inconveniences serve no January-February 2018 HASTINGS CENTER REPORT 11 Electronic copy available at: https://ssrn.com/abstract=3358604 good purpose, ethical investigation choice: the reduction in consump- For example, a form may be complex is unnecessary: such inconveniences tion is mediated by the impact on and inconvenient to fill, not inten- only add offense to injury and are ob- whether patients and clinicians tionally but simply because exclusion viously undesirable. choose a treatment and which treat- criteria are genuinely complex or be- Second, other policy uses of in- ment choices they make. This choice- cause the form writer is incompetent. convenience lie outside our ambit. based characteristic is shared by the