Nuanced Public Support for Rationing Treatments by Withdrawing and Withholding Due to Negative Reimbursement Decisions

When treatments are deemed not to be cost-effective and face non-reimbursement, policymakers in publicly funded healthcare systems may decide to ration treatments by withholding it from future patients. However, they must also address a critical question: should they also ration treatments by withdrawing it from patients already having access to the treatment, or is there an ethical difference between withdrawing and withholding treatments? To explore this question, we conducted a behavioural experiment (n=1404), examining public support for withdrawing and withholding treatments in reimbursement decisions across eleven different circumstances. Overall, public support for rationing by withdrawing and withholding was low, with no general perceived difference between withdrawing and withholding treatments. However, when we analysed the different circumstances separately, there were multiple circumstances where withholding was deemed ethically more problematic than withdrawing. Moreover, there was an overall preference for allowing individual assessments compared to ensuring that treatments are equally rationed between different healthcare providers. This result may indicate a preference for procedural fairness compared to outcome fairness. In addition, it was deemed more important to allow for individual assessments and to ensure equal rationing when withdrawing treatments compared to withholding. Overall, these findings reveal nuances in public preferences regarding withdrawing and withholding treatments, challenging the prevailing beliefs that withholding treatments is psychologically easier and ethically less problematic than withdrawing. They also challenge assertions of ethical equivalence between these two rationing approaches. If policymakers want to align their policies with public attitudes, our results suggest adopting a nuanced approach towards withdrawing and withholding treatments, recognizing that public support for ethical equivalence between withdrawing and withholding treatments varies depending on the circumstances.