Explicit reasoning in allocating healthcare resources
Explicit reasoning means sharing out limited healthcare resources by rules set out in advance, with the reasons stated openly so others can challenge them.
Remember
When sharing out limited healthcare resources, explicit reasoning states its rules and reasons openly, so decisions can be questioned and the people who make them held to account, whereas implicit reasoning leaves the reasons unclear. A main cost is that rigid general rules may overlook individual circumstances.
Memory aid
explicit means explained
Use it to recall that explicit reasoning explains why a decision was made.
Healthcare demand outstrips supply, so someone has to decide who gets treatment. Explicit reasoning is one way of doing it. The rules of entitlement (the rules about who gets treatment) are written down in advance, and the decision makers explain their choices against those rules.
Because the rules are visible, the process is transparent, meaning anyone can see the reasons. Decisions can be questioned, debated and checked, which makes them accountable: those making them can be asked to explain and defend them. The people who draw up guidelines are held accountable for them, so evidence-based decisions are championed.
There are costs. General rules applied rigidly may miss individual circumstances, preferences and differences in likely benefit or harm. Explicit reasoning can include those differences, but it does not require identical outcomes for everyone. A patient who is refused can also be distressed if they think the rules have judged them undeserving.
Implicit reasoning is the contrast: decisions are made without being clear about why. It is quicker, because no time is spent justifying choices, but its closed nature can lead to inequality, favouritism, discrimination and abuse. Explaining a decision usually takes longer, so speed is the advantage of implicit reasoning, whereas the key advantage of explicit reasoning is that decisions can be debated and held to account.
Key facts
- Definition
- predetermined rules of entitlement (rules about who gets treatment, written down in advance) and transparency.
- Strengths
- decisions can easily be questioned (debatable), those responsible must answer for them (accountable), and the approach champions evidence-based decisions.
- Main weakness
- general rules applied rigidly may overlook individual circumstances.
- Patient distress
- a refused patient can be distressed if they think the rules have judged them undeserving of treatment.
- Speed
- explaining a decision usually takes longer, so speed is the advantage claimed for implicit reasoning.
- Example
- NICE justifies which treatments the NHS should fund using cost per QALY (quality-adjusted life year, a unit of health gain combining length and quality of life).
Exam traps
- Explicit reasoning does not hide the values behind a decision. It makes the values and assumptions open to challenge, and hiding them is a feature of implicit reasoning.
- Explicit reasoning does not remove uncertainty from complex decisions. It shows where the uncertainty lies, so people can discuss it.
- Visible rules do not spare patients distress. Stated rules make the judgement visible, so patient distress at being judged undeserving is a drawback of explicit reasoning, not an advantage.
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