is based on a myth [5]. It is argued that just as a doubling of public toilets or public
bus services would not automatically double the desire !or need) of the public to
make use of them, so too there is a finite amount of kidney disease, a limit to the
number of people who can benefit from coronary by-pass surgery, and so on.
Perhaps if more buses were supplied very cheaply, or even at no cost to the user at
all, their use would increase, but even so there will always be a natural limit on the
number of people who would like to travel from A to B at one time.
It is not easy to judge which one of these positions ± the official line' or that of therebel camp' ± is correct. Clearly, both are at least partly true. For instance,
where there are more potential recipients than donated organs there is an
undeniable scarcity of this particular resource. On the other hand, it is equally
incontrovertible that if money were to be taken from some expensive high-tech' or over-provided medical services, and spent instead on the provision of better and more comprehensivepreventive services', many health needs' now not met because of scarcity could be provided for. What is clearest of all, however, is that there are considerable philosophical and practical uncertainties underlying theresources debate', most of which are unli-
kely to be resolved in the foreseeable future. The nature of health care cost' and health care benefit' is not agreed in theory [6]. Nor is it yet physically possible to
collate even the simple financial costs of many modern health services [7]. And
even if credible classifications and calculations were to be developed, even if
someone were to invent a comprehensive `health service slide rule', the accuracy
and appropriateness of these taxonomies and methods of calculating would
inevitably be challenged. It would, for instance, remain the case that different
individuals would value even identical services !and identical results) in different
ways. For one person a few more days of life, even in great pain, might be of
immense value ± while for another there would be no point at all.
8.13 Nursing in scarcity
What can nurses do when faced with such intangibles? These days almost all
nurses work in environments where managers, and others, are openly concerned
about efficiency, avoiding waste, and reducing cost wherever possible.
What is the nurse, concerned about how best to use scarce resources, to do?
How can she be fair? How can she deal with perceived injustice? How can she
make any difference at all?
Whether or not any individual can make a difference within massive, complex
systems depends on two factors. Firstly, and obviously, what she can do depends
on whether or not she is in a position of any power and influence. Secondly, and
less obviously, what she can do depends upon the clarity with which she has
formulated her goals. Philosophy !or clear thinking) can do nothing about the first
factor, but it can help !albeit only a little) with the second. With practice a nurse
can improve her understanding of both general situations and her own circum-
stances, she can learn to define the meaning of key terms !such as resource', rationing' and `fairness'), and she can become better able to identify her role !and
the limits of her role).
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