Governments with universal healthcare systems are increasingly bemoaning the costs of their systems and the need to contain these costs if affordable healthcare services are to be sustained into the future. In a bid to reduce the costs of healthcare, politicians and bureaucrats have championed the need for reform. Although avoiding the language of rationing, the kinds of ‘reforms’ being championed (eg. greater government regulation of universal health coverage, reducing reimbursement for medical costs, cutting funding to public hospitals) seem however, to be more concerned with restricting universal healthcare coverage, rather than reforming it.


The rhetoric of healthcare reforms has also had a political ideological objective shifting the provision of and accountability for public healthcare services to private sector providers. This objective has been pursued despite experts warning that such a shift will ultimately lead (and in some cases has already led) to inequities and unjust disparities in access to healthcare and related health outcomes, especially in vulnerable populations who cannot afford private health insurance.


Australia has not been immune from ideologically driven machinations about the sustainability of its universal healthcare scheme, ie. Medicare. Despite health expenditure in Australia reportedly reaching a record low for the period 2012-2013, there has been a political campaign of spreading false and misleading information about Medicare’s sustainability (Keast 2015).This misinformation has included ‘blaming’ vulnerable populations (eg. an ageing demographic, the ‘undeserving poor’) for their allegedly disproportionate over-utilisation of public healthcare services and the need to curb this costly ‘wanton’ demand. What has been overlooked in this situation, however, is that a key driver of the spiraling costs of healthcare is not the over-utilisation of services by people in need, but rather ‘the use of wasteful tests and treatments’ prescribed by doctors (Tilburt & Cassel, 2013) together with the rising costs of drugs (driven by the business behaviours of the pharmaceutical industry) and medical technology, particularly in hospitals. Also overlooked is the problem of language and the tendency to treat the terms ‘healthcare’, ‘hospital care’, and ‘medical care’ as being synonymous, when they are not. Failure to distinguish what each of these terms refers to unnecessarily muddles debate about what healthcare reforms are needed as well as where and how these should occur.


Question of nursing ethics


The ethics of healthcare rationing has been the subject of debate for decades. This debate has primarily rested on the issue of whether it is ever acceptable to ration healthcare and, if so, on what grounds. It has also prompted unresolved controversies about the interests of individuals versus the collective interests of society in accessing limited healthcare resources and how best to balance these competing interests. Meanwhile, those working at the intersection of health policy and ethics have attempted to persuade pundits that the issue should not be about rationing and compromise, but about justification and appropriateness (Asch & Ubel 1997). In other words, it should be about rationalising (justifying) healthcare, not rationing (arbitrarily restricting) it. Here the question arises: What stance should the nursing profession take in response to this vexed issue?


Taking a stance


In 2015, the theme Nurses: A force for change – care effective, cost effective has been adopted for International Nurses Day. In a media release announcing this theme, David Benton, ICN Chief Executive Officer, contends that because nurses are the single largest group of health professionals they ‘can have an enormous impact on reducing health costs and increasing quality of care’ (www.icn.ch/). In light of this, the ICN urges all nurses and policy makers to ‘focus on the nursing role as a key priority and determinant for achieving equity, delivering universal health coverage and ultimately improving health outcomes globally.’ To aid in this task, the ICN has prepared a toolkit for examining ‘the current issues around health system financing and the value of nursing’ (available at: www.icn.ch/).


Rationalising healthcare


Achieving equity, delivering universal health coverage and ultimately improving health outcomes is going to require a collective effort on the part of a range of stakeholders, not just nurses. It is also going to require much more than a ‘Choosing Wisely’ campaign (soon to be launched in Australia – see O’Callaghan et al. 2015), the aim of which is to encourage doctors to engage in ‘parsimonious medicine’ and to make better treatment choices, reduce risks and, where able through prudent decision making, reduce costs (Tilburt & Cassel, 2013). As argued previously in this column (ANJ 2010, April & August issues) what is also required is a cultural revolution in thinking about: the values of health and healthcare, ageing and death, the kind of reform that is required to ensure a healthcare system that is responsive and well-coordinated to meet the needs of current and future generations, and whether the solutions being proposed by authorities will be effective and just.


The nursing profession needs to think deeply about these issues. Meanwhile, it is incumbent on nurses in Australia to campaign to promote, protect and preserve Australia’s Medicare scheme. This includes taking collective action to: affirm the value of Medicare, expose the misinformation that is being spread about its sustainability, interpret attacks on it as unfair, and to discredit official channels that are distorting the issues at stake in favour of progressing an ideologically driven agenda for dismantling universal health coverage in Australia and dismissing its humanitarian objectives.


Asch DA & Übel PA. 1997. Rationing by any other name. New England Journal of Medicine, 336(23): 1668-1671.

Keast K. 2015. Medicare under threat: the Americanisation of Australia’s health system. Australian Nursing and Midwifery Journal, 22(9): 25-29.

O’Callaghan G., Meyer H., & Elshaug A. 2015. Choosing wisely: the message, messenger and method. Medical Journal of Australia, 202(4): 175-178.

Tilburt JC & Cassel CK. 2013. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA, 309(8): 773-74.


Megan-Jane Johnstone is Professor of Nursing in the School of Nursing and Midwifery at Deakin University in Victoria. Professor Johnstone has extensive interest and expertise in the area of professional ethics in nursing.

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Copyright Australian Nursing and Midwifery Federation Jul 2015

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Based on this Article i have an assignment that is due tomorrow


Rationing Issues in Healthcare


The concept of rationing healthcare is dealt with on a daily basis. Healthcare rationing in the United States exists in various forms. Access to private health insurance is rationed based on price and ability to pay. Those not able to afford a health insurance policy are unable to acquire one, and sometimes, insurance companies prescreen applicants for pre-existing medical conditions and either decline to cover the applicant or apply additional price and medical coverage conditions. Access to state Medicaid programs is restricted by income and asset limits through a means test and to other federal and state eligibility regulations. Health maintenance organizations (HMOs) that commonly cover the bulk of the population restrict access to treatment via financial and clinical access limits.

After reading your article, summarize its contents and the main theme discussed. Then, answer the following questions:

 How is rationing defined and what criteria are offered to ration care?Discuss and apply at least one of the major ethical theories to the issue and the ethical decision-making process to the issue.What do you feel the impact of the issue in the article will be on the healthcare industry? What can be done to ensure rationing is done fairly?Discuss the major codes of ethics of the stakeholders involved in the issue and how these codes will affect the decision-making process and the final decision.Examine and discuss the impact that the issue and the final decision will have on the stakeholders involved.Discuss any potential policy implications for the issue and the final decision.


Compile the summary and answers to the above questions in a 4 pages Microsoft Word document.


Support your responses with examples.


Cite any sources in APA format.

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