Introduction to Micro-Allocation
Michael A. Gillette, Ph.D.

Imagine that one space in a group home is available, but three clients in an MR facility might succeed if moved to a less restrictive environment. Imagine that a costly but experimental procedure might relieve the symptoms of mental illness for one individual, but a known and inexpensive measure could help to treat five others, and there simply are not sufficient funds to purchase both. How should health care providers and health care administrators deal with these troubling, yet soon to be unavoidable problems?

The micro-allocation of scarce medical resources is a medical ethics topic that concerns itself with making choices as to how limited funds will be spent, or how scarce resources will be allocated, when there is an insufficient supply given the demand. Health care reform, the increased presence of managed care, and changes in reimbursement criteria have forced the American public to think carefully about how, and how much, we want to spend on healthcare. We can no longer avoid thinking about some tough issues regarding access to health care.

The most obvious example to use in introducing this topic is that of organ procurement. Currently, kidneys are the most popular organs for transplant, and since one person can donate two kidneys, this organ is also the most readily available. Even so, there is an unfortunate shortfall of available organs for transplant that amounts to several thousand per year nationally. In other words, even in an area where the donated organs are most plentiful, several thousand people per year who are in need of a transplant will not receive one.

The shortage of kidneys is very real. It is not the case that by making careful waiting-list prioritizations that the people who need the kidneys immediately will get them, and others who are forced to wait will get kidneys next year when their need increases. People die every year in this country because there are not enough kidneys available for transplant, and no amount of careful prioritization will change that fact. Until more organs are donated, or an artificial substitute is created (dialysis can extend the length of time that a person can live with impaired kidneys but it does not work indefinitely), people will continue to die. It is in this environment of real shortage that we can best identify and evaluate our intuitions regarding the question "who shall receive care when not all can?"

Once we have drawn conclusions about the basic strategy of making decisions in the face of kidney shortages, we can then extrapolate to a discussion of the allocation of scarce medical resources in general.

Historically, four positions have been offered regarding a fair approach to allocation decisions. In general, each position seeks to advance the particular value upon which it is based. Some models for allocation stress personal liberty. Other systems of allocation stress the value of fairness. Yet other systems place value on efficiency.

The debate between these values is intense. Some argue that the government should not intervene in how people obtain organs. Others argue that individuals have a right to health care that must be guaranteed. Still others maintain that no matter how attached one might be to the concepts of liberty and equity, it does not make sense to place a donated organ into a person of an incompatible blood and tissue match, or into a person who is very likely to die in the near future of some other medical condition. We generally believe that when a scarce resource of great importance is to be used, it ought to be used to the greatest possible benefit. Since we are investing a rare commodity, we want to insure a good return on our investment.

After delineating the basic values that have been of concern historically, it is possible to examine the four basic approaches to allocation. These approaches are:

• The Market Approach,
• The Lottery Approach,
• The Political Approach
• The Mixed Approach.
  

I will briefly outline these models this month, and continue next month by evaluating the ethical nature of each.

The Market Approach to allocation is based on the premise that health care, just like any other consumer item, should be allocated by the market system. Proponents of this view maintain that health care providers own their own skills, and are therefore free to sell those skills on the open market for whatever price they may bear.

The Lottery Approach to allocation begins by arguing that medicine is not like any other consumer good. People have a right to health care, according to this view's adherents, and it is not fair to discriminate against low income individuals by relying on ability to pay. According to this view, it is far better that resources be allocated randomly when it is impossible to serve everyone. People should be chosen either by lot or on a first-come first-served basis.

The Political Approach argues that selection by random lot will introduce an intolerable level of inefficiency into the system. Person A may win the kidney lottery, but his heart may be so bad that he will die on the operating table. Surely we should prefer a far healthier person B to receive the kidney. On the force of this reasoning, the political approach demands that a careful selection from among individuals be made by a committee, on the basis of very specific selection criteria.

Finally, the Mixed Approach to allocation takes aspects of all of these systems and brings them together in a cohesive way. People might be selected by a committee to participate in a lottery when true scarcity cannot be avoided.

Next month, we will begin the process of fully describing the advantages and disadvantages of each of these allocation models.