4 - Rationing and the Problem of Legitimacy

Summary

The instability of explicit forms of rationing: tragic choices

In their well-known work on ‘tragic choices’, Guido Calabresi and Philip Bobbit provide a means by which we may better understand the instability which is generated by strategies of explicit rationing of the type outlined in the preceding chapter. While the authors of this text eschew simple distinctions between those choices which are ‘tragic’ and those which are merely ‘difficult’, it is notable that they consider the provision of haemodialysis machines to represent the ‘paradigmatic’ example of the tragic choice, and that the book makes frequent reference elsewhere to scarce medical resources. It therefore seems justifiable to regard the rationing of healthcare as a form of tragic choice, and it is certainly the case that works in this field make liberal use both of Calabresi and Bobbit's terminology and of their analysis.

Calabresi and Bobbit are concerned with those scarce goods whose distribution ‘entails great suffering or death’. It has been argued that their scope of enquiry may best be defined as ‘life and death cases’, but as this statement makes apparent, it is more accurate to view the authors' focus as being upon those choices where no outcome is without significant human cost in terms of suffering, albeit that life itself may not necessarily be at stake. What is key, however, is not the subject-matter of the choice (thus, in addition to examples drawn from healthcare, Calabresi and Bobbit discuss, inter alia, conscription and the right to have children), but rather the fact that the choice in question gives rise to irreconcilable conflicts of values.