Book Review

Current Dilemmas in Medical-Care Rationing: A pragmatic approach

N Engl J Med 1996; 335:1539November 14, 1996

Article

Current Dilemmas in Medical-Care Rationing: A pragmatic approach
By Henry A. Shenkin. 109 pp. Lanham, Md., University Press of America, 1996. $29.50. ISBN: 0-7618-0238-X

The debate about the organization, financing, and delivery of medical care in the United States has been the theme of the 1990s, and the cost of medical care is its driving force. Access, equity, and quality are touted as the rationale for the restructuring of the medical care system, but they have contributed only marginally to the real decision-making process. Who pays and by what means have been the dominant considerations in the restructuring and the positing of solutions to the financial crisis in medical care.

Current Dilemmas in Medical-Care Rationing: A Pragmatic Approach is a well-organized synthesis of the issues and methods now used and under consideration by policy makers, providers, payers, and consumers as they seek to understand and control the growth of the medical care industry through rationing. The premise of this book is that medical care should be and is being rationed. It undertakes to define the economic, philosophical, and political methods available to accomplish rationing.

Organized in six short chapters, spanning 109 pages, the book is an excellent and readable fusion of the definitions and interpretations of the methods used in Western civilizations to provide and control the use of medical services. There is a well-developed historical overview of medical coverage in the United States, as influenced by western European values and buttressed by capitalism. This history provides grounding for the author's choice of rationing options. Less concise are the series of abstract arguments on how rationing of medical care could be carried out, with examples of which groups gain or lose. For example, the author contrasts the medical needs of the elderly and the disabled with those of the young to demonstrate the framing effects of various forms of utilitarianism and alternative theories such as Rawlsian theory and moral transcendentalism. Shenkin then outlines the pros and cons of each of the philosophies and their methods within the context of a capitalistic democracy.

This approach is intellectually stimulating, but it fails to embrace other issues, such as the fact that the values of minorities and people of color differ from those considered traditionally western European; these people are not players in the policy-making arena. These groups are affected by policy without the benefit of helping to formulate programs, much less define problems. This book fails to address the needs and philosophical views of these other social communities, and hence shortchanges any discussion of the ramifications of rationing in their lives. This failing limits the definition of cost containment and rationing.

Nonetheless, the author does a credible job of expressing the elements of the debate on rationing of health care in an imperfect market-like system. But the reader should understand that Shenkin omits the voices of a large segment of a vulnerable population and the voices of political thinkers such as Michael Walzer and, particularly, Iris Young, who have questioned our usual terms of thought and debate.

Martha A. Hargraves, Ph.D., M.P.H.
University of Texas Medical Branch at Galveston, Galveston, TX 77555