Rational Choices Theory and Its
Application to Physicians and
Health Care Worker
dr. Nur Azid Mahardinata
Personal Choice?
Personal choice?
Personal choice?
Personal choice
• In seeking an answer to the question,
"Why do people engage in deviant
and/or criminal acts?", many
researchers have begun to focus on
the element of personal choice
• An understanding of personal choice
is commonly based in a conception
of rationality or rational choice
• These conceptions are rooted in the
early classical theorists, Cesare
Beccaria and Jeremy Bentham.
The central points of this theory are:
1. The human being is a rational actor
2. Rationality involves an end/means calculation
3. People (freely) choose all behaviors, both
conforming and deviant, based on their rational
calculations
4. The central element of calculation involves a
cost benefit analysis: Pleasure versus Pain,
5. Choice, with all other conditions equal, will be
directed towards the maximization of individual
pleasure
Should I commit a robbery?
(cost/benefit analysis)
Costs
• Risk (victim might
have a weapon)
• Arrested
• Public humiliation
• Incarceration
• Abusive
treatment in
prison
• Be away from
family for
uncertain time
Benefits
• Fast cash
• Easy to do
• Masculinity Status
• Can buy
drugs/alcohol
• Excitement and
thrill
• Public/Media
attention
Main Assumptions of Rational Choice
Theory
• Individuals are seen as motivated by the
wants or goals that express their
'preferences‘
• They act on the basis of the information that
they have about the conditions under which
they are acting
• Rational choice theories hold that individuals
must anticipate the outcomes of alternative
courses of action and calculate that which
will be best for them
• Rational individuals choose the alternative
that is likely to give them the greatest
satisfaction
The model
Stealing
Earn
Actor
Illegal
Business
Borrow
Money
Prison
DEBT
Limited Rationality
• Accurate assessment of situation and
anticipation of all possible outcomes
is impossible
• Limited rationality refers to the best
possible decision under the
circumstance
• Burglar cannot calculate the value of
property he/she expects to take
away
• Most of them do not know the extent
of the punishment
Background of the Problems
• The increase of health care expenditure
– Growing more rapidly compare to the
economic growth
– Increasing demand and the high cost of new
medical technologies  health care inflation
– Threat to the national budgets
• The fee for service and out of pocket money
payment in Indonesia lead to the free
market health care system
• No standards of payment for physicians
• Health care cost is a serious and growing
problems, for which we must find a solution
that is both economically sound and
ethically just
What is Rationing?
• To ration generally means to give
equal portions of a scarce good to
every body
– Is it applicable to health care?
• Aaron and Schwartz:
– rationing occurs when “not all care
expected to be beneficial is provided
to all patients
– Denying any potentially beneficial
care means that “the value of care is
being weighed against its costs,
explicitly or implicitly”
The Actions Resemble Rationing
Rationing
Distribution of
scarce good
Organ
Transplant
Prioritization of
services
Practice of
Triage
Allocation of
financial
resources
Social Safety
Net
Is Rationing Ethically Justifiable?
• The community need not only health, but also
other needs, e.g. education and cultural
enrichment is needed to make life full of
possessions
• There are important considerations in deciding
whether a given proposal to ration health care
are justifiable:
– There are other equally important needs
competing for scarce resources
– There are no alternative ways to produce
equivalent savings
– Savings from denied services will benefit other
patients or be invested in equally important social
needs
– Policies and procedures for limiting access to
treatment are applied equitably to all
– Limits are self-imposed through democratic
processes
The equally important needs
Education
Housing
Military budget
etc
Health care cost
No alternative ways to produce
equivalent savings
• Before rationing is implemented, every
reasonable effort should be made to
reduce waste and inefficiency within the
system, e.g. eliminate and minimized
unnecessary services and duplication of
resources
– The possession of expensive equipment which
is not effectively used
• The challenge is the decentralized and
fragmented system of health care
Cross subsidy
• Allocate un-used money for
another post of health care
cost
Equitable application of
rationing policies
• If one person sacrifices a
beneficial and desired
treatment, then others in the
same situation should make
the same sacrifice
Democratic process
• Limits to health care are freely
adopted rather than imposed
• The ways which limits can be
self-imposed:
– Participating in the formation of
policies
– Accepting the results of the
process
Who will make the rationing
decision?
• Open procedures that are broadly inclusive
are the best
• Rousseau’s view of democracy demanding
that policy should be formulated by the
people through systematic process
• Guido Calabressi and Philip Bobit argue that
public involvement in rationing decisions
would be unwise. Rationing decisions are
among the most dangerous of tragic
choices because they expose our willingness
to make trade-offs with human life and in
some sense to set a price on it, thus
compromising our commitment to the
Kantian principle that human life does not
have a price but rather, a dignity that gives it
inestimable value and incomparable worth
WHAT THE PHYSICIAN CAN
DO?
Rational is
• Attempt to achieve a goal
through a feasible means
• Not rational
– if someone smoke while he does
not have the goal to enjoy it
Goals to become a Physician
• Steady income
– professional – enjoy the job
• get more money
• Additional goals: humanitarian
• Self satisfaction
What physician can do?
• Morally obligatory gate-keeping: the
traditional role
– Practicing competence and scientifically
rational
– The guidelines should be diagnostic
elegance and therapeutic parsimony
• The negative gate-keeping role
– Constrain of self interest to restrict the use
of medical services of all kinds, but
particularly those that are most expensive
• The positive gate-keeping role
– To increase rather than decrease access
to services
Thank You