The government’s health budget is now almost seven times what it was in 2012 – and that excludes inflation. Your medical staff have an extraordinary array of technologies and drugs on hand to help patients. But these tools are very expensive. And despite your hospital’s comparatively large budget, it can’t keep pace with demand. It’s perpetually crammed; the emergency department turns many people away; and waiting lists for some procedures are measured in years, not months.

You are regularly called on to decide who will be treated and who won’t. Who do you discriminate against? The elderly? Those with a lower chance of surviving treatment? Smokers, drinkers and the obese? Perhaps public hospitals are now only subsidised hospitals, and you favour those who can pay their way?

This scenario is only partly hypothetical; I extracted it from data in the latest Intergenerational Report. For decades, Australia’s public healthcare system has been guided by the principal of universality: the ideal that every patient, regardless of age, means or health, should receive the best possible care. But universal healthcare will inevitably crumble; we can’t afford it. Indeed, it’s already eroding.

Our governments don’t like to discuss publicly how they intend to ration healthcare, because they know how divisive the issue can be. Yet rationing takes place in most hospitals every day, even though it sometimes violates the principle of universal healthcare. Smokers, for example, generally don’t receive organ donations, regardless of how long they’ve waited. Some surgeons won’t replace a broken hip if the patient is in their 90s, because theatre time is limited and they prefer to prioritise patients who will live longer.

Indeed, the only form of rationing that governments condone openly is waiting lists, which benefit the wealthy. After all, hospital queues, whether for emergency treatment or elective surgery, tend to affect patients who can’t afford to pay a GP or a private surgeon.

Are we comfortable with this? The future of public healthcare is crucial to all of us. Yet, extraordinarily, there is almost no public debate on how we will limit it. Surely it’s sensible to discuss now – before we reach a crisis – what types of rationing are ethical and acceptable to Australians. If we don’t formalise this process, two things will happen. First, our healthcare system will continue to drift gradually towards a model that prioritises patients who can afford to buy care. And second: rationing will increasingly take place ‘‘on the sly’’, with decisions made by individual doctors and even, on occasion, by patients themselves. This is an unfair burden to place on medical staff, and is a recipe for inconsistency, misunderstandings and lawsuits.

American philosopher Daniel Callihan has tried to raise these issues for more than 20 years. Callihan is now aged in his 80s, but he believes firmly that the fairest and most effective way to ration public healthcare is to discriminate against the elderly. In March this year, he wrote in the Journal of Law, Medicine and Politics about the reactions to his attempts to discuss rationing:

"The eminent late geriatrician Robert Butler yelled at me in a taxi after a TV program we had been together on that the very title of my book, Setting Limits, was harmful. ‘We are a rich country,' he said, 'and can afford whatever it takes to provide healthcare.’ I was picketed at some lectures, accused of ageism, of promoting social euthanasia of the burdensome elderly, of sexism (because women live longer than men and thus would suffer more than men from rationing), and of all-around hard-heartedness. ‘What is it like to live with a Nazi?’ my wife was once asked.’’

Yes, these discussions will be difficult.

Just over 20 years ago, a National Health and Medical Research Council committee hosted a workshop on ‘‘ethical considerations relating to healthcare resource-allocation decisions’’. Its findings warned that ‘‘we are now faced with hard choices about how we should allocate or distribute scarce health resources and services’’. We’ve heard not a peep from the government since. If we don’t start the debate soon, money – and doctors – will start making these ‘‘hard choices’’ for us.

Markus Mannheim edits The Public Sector Informant. Send your tips to aps6@canberratimes.com.au