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April 5, 1995

Rationing Resources While Improving Quality-Reply

Author Affiliations

Kaiser Permanente of Southern California Pasadena

JAMA. 1995;273(13):996-997. doi:10.1001/jama.1995.03520370035022

In Reply.  —Dr Fisher misunderstood the guideline for contrast agents. It was actually designed by physicians (not managers), and it recommended HOCAs only for intravenous administration in low-risk patients. But Fisher's main point is that, whereas transfers within diseases are ethical, transfers across diseases are not. I do not understand the distinction. Whether transfers are made within or across diseases, in both cases some individuals will lose while others will gain, and whether the losses or gains are within the same disease seems immaterial. For example, a policy that Fisher endorsed of "restricting mammography to more appropriate ages" will deprive a 38-year-old woman of coverage. Why should the ethics of that policy depend on whether the saved resources are used to screen other women for breast cancer (a within-disease transfer) or for cervical cancer (an across-disease transfer)? The example Fisher used to illustrate his point—stereotactic biopsies—was actually a within-patient transfer.

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