Most of the decisions doctors are called upon to take seem to be concerned with individual patients but there is often an underlying problem of resource allocation determining the nature of the dilemma. In the example above of the two patients requiring an ICU bed, the dilemma would not have arisen if there had been no limit on the provision of ICU beds. Clearly, it is unrealistic to expect that all possible health care needs will always be met and decisions on the allocation of resources must be taken. These decisions have an ethical component and should be analysed with regard to the justice of the alternative lines of action. This is a larger question than just the distribution of resources within the health services and includes how national governments partition their resources among health, education, welfare, defence, etc.
So far, no satisfactory approach has been found. In free market economies, the distribution is based on what the individual can afford so that the wealthy have the latest and best technology while the poor have nothing. In government-financed systems, what is available to a given patient may depend on the idiosyncrasies of the local medical personnel. In both systems rationing occurs without any explicit public debate as to who should be treated and which services should be provided. When debate does occur it is often centred on specific cases and driven by emotion rather than careful analysis.
A just allocation of resources can take place only when the costs and consequences of various alternative interventions are accurately known and can be overtly compared with one another. A difficulty arises in attempting to define outcomes. Improvement in survival can be accurately quantified, but how is an improvement in quality of life to be quantified and how is an improvement in quality of life to be compared with an improvement in survival? This is a difficult enough decision when it concerns one individual, but is even more difficult when the comparison is between the survival of one patient and the improvement in quality of life of another. Attempts have been made to overcome these problems using quality-adjusted life years (QALYs) but this is only partly successful. While the QALY gives a figure which can be manipulated by the health economists, it is not as objective as it at first appears since the value of the QALY is dependent on the assessment of quality of life which is still, despite great efforts, a subjective judgement. The QALY is concerned with the 'average' patient and does not take account of individual differences between cases. It is very sensitive to minor changes in the estimates of the duration of benefit and the outcome.
An attempt was made in Oregon State in the USA to produce explicit criteria for resource allocation based on a prioritised list derived from modified QALYs. The weightings for quality of life were derived from a telephone survey of local citizens. This experiment has not proved to be effective in practice. Some of the results were distinctly odd, with cosmetic breast surgery being rated as more important than the treatment of a compound fracture of the femur. The attempt was shelved when the Federal Government intervened.
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