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Cancer Care, Money, and the Value of Life: Whose Justice? Which Rationality?

Daniel P. Sulmasy

From the St Vincent's Hospital—Manhattan and New York Medical College, New York, NY

Address reprint requests to Daniel P. Sulmasy, OFM, MD, PhD, The John J. Conley Department of Ethics, St Vincent's Hospital—Manhattan, 153 W 11th St, New York, NY 10011; e-mail: daniel_sulmasy{at}nymc.edu

Cost-containment in oncology is a moral issue. While economists use the word "rationing" to describe all limitations on resource utilization that result from human choice, the ordinary language distinction between allocation and rationing is morally meaningful and can help oncologists to determine their proper moral role in cost-containment. It is argued that oncologists should not be required to ration at the bedside, nor should they be given financial incentives to practice frugally, nor should they be subjected to a variety of bureaucratic mechanisms to control costs indirectly. In addition, it is argued that the fact that treatments have a price does not logically imply that patients have a price. Cost-effectiveness analysis is often suggested as a means of deciding how best to allocate resources, but some of its many ethical limitations are discussed. The alternative is an open, public, participatory process about how to ration care, abandoning the formulaic pretenses of cost-effectiveness analysis, but with a commitment to reason, good will, and common sense. Oncologists would then be free to advocate for their patients within the constraints imposed by this public process.

Author's disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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