Rationing and the Health Care System (PHIL 292)

Fall 2011

Trent Center for Bioethics

Mondays 3:05 – 5:35

Seeley Mudd 108


Reading Schedule

Week 1 (8/29)                   Introduction:  Health systems basics & Seattle dialysis case  McKinney

Week 2 (9/5)                     Organ transplantation  Rosoff

                * UNOS, Liver Allocation Policy

                * UNOS, Liver Patient Information

                * UNOS, Lung Allocation Policy pamphlet

                * UNOS, Alien Transplant Policy

                * UNOS, Statement regarding Convicted Criminals


Week 3 (9/12)                    The moral case for rationing  Ubel

                *Ubel, Pricing Life (MIT, 2000), Intro and chh. 1-3

Week 4 (9/19)                    Ventilator rationing  Rosoff

                * White et al., “Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions,” Ann. Intern. Med. 150 (2009): 132-38

                * Rosoff, “Should Palliative Care Be a Necessity or a Luxury During an Overwhelming Health Catastrophe?,”  Journal of Clinical Ethics 21(4) (2010):  312-20

                * Rosoff, “Unpredictable Drug Shortages:  An Ethical Framework for Short-Term Rationing in Hospitals,” American Journal of Bioethics (2011), in press


Week 5 (9/26)                    Bedside rationing  Ubel

                *Ubel, Pricing Life (MIT, 2000), chh. 6-9

Week 6 (10/3)                   Cost-effectiveness analysis:  how it works  (e.g., Oregon  experience)  Ubel

                *Ubel, Pricing Life (MIT, 2000), chh. 4-5 & 10-11

Week 7 (10/17)                                Cost-effectiveness analysis:  ethical objections  Sreenivasan

* Brock, “Ethical Issues in the Use of Cost Effectiveness Analysis for the Prioritization of Health Care Resources” in Anand et al. (eds.) Public Health, Equity, and Ethics (Oxford, 2004), ch. 10.  

Week 8 (10/24)                 Accountability for Reasonableness (and its critics)  Sreenivasan

                * Daniels and Sabin, Setting limits fairly, 2 ed. (Oxford, 2008), chh. 1-4.

                *  Lauridsen and Lippert-Rasmussen, “Legitimate Allocation of Public Healthcare: Beyond Accountability for Reasonableness,” Public Health Ethics 2 (2009): 59-69

                * Friedman, “Beyond Accountability for Reasonableness, “ Bioethics 22 (2008): 101-12

                * Rid, “Justice and procedure: how does ‘accountability for reasonableness’ result in fair limit-setting decisions?,”  J Med Ethics 35 (2009): 12-16


Week 9 (10/31)                 Rationing at the end of life  Tulsky

                * Gawande, “Letting Go,” New Yorker (August 2, 2010): 36-49.

                * Zhang et al., “Health Care Costs in the Last Week of Life,” Arch. Intern. Med. 169 (2009):480-88

                * Morrison et al., “Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries,” Health Affairs 30(3) (2011):  454-63

                * Morrison et al., “Cost Savings Associated with US Hospital Palliative Care Consultation Programs,”  Arch. Intern. Med. 168 (2008): 1783-90


Week 10 (11/7)                 Research exercise:  how are various states curtailing Medicaid expenditures? McKinney

Week 11 (11/14)               Provenge case  Kevin Schulman

Week 12 (11/21)               Rationing by age  Sreenivasan

* Daniels, “The prudential life-span account of justice across generations,” in his Justice and Justification (1996), ch. 12

* A. Williams, “Intergenerational equity: An exploration of the ‘fair innings’ argument,” Health Economics (1997):  117-32.


Week 13 (11/28)               Concluding exercise:  how should we ration?   (student presentations)



Please buy a copy of Ubel’s Pricing Life.  Other readings will be made available inside the course Blackboard site, either as PDFs or links to them.



Students will be required to write a 600 word paper every other week.  These assignments are due by noon on seminar day in Blackboard’s digital dropbox.  Topics for the assignments will be posted weekly.  The assignments will be graded and returned with comments.

Students will also be required to do a group research exercise (on state Medicaid budgets) and to make one presentation in class.  Finally, there will be a ten page paper due at the end of term (students will select their own topics with guidance).


Grading weights

Twenty percent of the final grade will be based on each of:  (i) the four highest grades on the weekly papers (out of the six written), (ii) the group research exercise, and (iii) the class presentation.  The final paper will be worth forty percent of the course grade.

The grading will be done by Professors McKinney and Sreenivasan.



September 12, 2011