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Priority setting: learning to make tough decisions
  1. S R Benatar
  1. Department of Medicine, University of Cape Town, Observatory, 7925, Cape, South Africa;

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    The costs of trying to provide modern medical care for all who could potentially benefit exceed the capacity of most countries

    Priority setting (also termed resource allocation) for healthcare expenditure is inevitable in all societies, even the most affluent.1 New technologies are the dominant driving forces.2 Although these advances have been successful both in saving lives and in improving quality of life, the costs of trying to provide such modern medical care for all who could potentially benefit exceed the capacity of most countries.

    A very considerable proportion of medical expenditure is generated on treating patients during what turns out to be the last year of life.3 It is now increasingly recognised that there are inadequate health returns from such expenditure (both in terms of duration and quality of life) and that there are limits to what medicine should be attempting to achieve.4 Consequently there has been a subtle, but largely unacknowledged, shift from a “sanctity of life” approach (in which medical care is continued relentlessly, even when death seems imminent) to “quality of life” considerations.5 This is reflected in the wishes of many patients to be spared ongoing heroic measures and to be allowed to die peacefully. Increasingly healthcare professionals are also willing to withdraw treatment when the prognosis seems very poor, or when other goals of health care are considered to be higher priorities.6

    Additional reasons for interest in priority setting, beyond the appropriateness of aggressive medical care, include the need for more equitable access to care and the desirability of reducing arbitrariness in medical practice through use of practice guidelines informed by the best evidence.

    As many values are at stake and there are differing rankings given to these, the debate about priority setting has been heated and acrimonious. In the …

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