Physicians often ration care without realizing it
Individualized decisions are ethically troubling
Doctors can talk all they want about how they are patient advocates first and foremost and would never consider the cost of treatment when managing patient care. The stark reality is that physicians do ration care. They have been doing so since time immemorial, and they will undoubtedly continue, says Susan Goold, MD, assistant professor of internal medicine and associate director of ethics and health policy in the society and medicine program at the University of Michigan Medical School in Ann Arbor.
"We don’t order vital signs on each hospital patient every hour of the day," she explains. "Some patients are monitored every 24 hours, some every eight hours, and in the intensive care unit, every 10 minutes."
There is nothing intrinsically wrong with physicians deciding which treatments generally are appropriate for which patients, Goold contends, adding that physicians are much better judges of patients’ best interests than are government officials or managed care case managers.
Bedside rationing, or rationing done at the discretion of a health care provider such as a physician, is ethically troubling when it undermines the trust between an individual caregiver and a patient, contends Peter A. Ubel, MD, assistant professor of medicine and a faculty member of the Center for Bioethics at the University of Pennsylvania in Philadelphia.
The key to rationing is for physicians to know when and how it is justified, say Goold and Ubel, and to understand the fairness of their health care system. "If a hospital or other provider says, We are accountable for scarce resources,’ the individual professionals must have a forum to discuss their concerns," says Goold. "This is where the ethics committee is so important."
"Whatever position one holds about the inevitability or morality of bedside rationing, it is clearly important to clarify what counts as bedside rationing,’" write Ubel and Goold in a recent journal article.1
The authors hope that the distinctions will "start a frank and open discussion of care resources and the need to prioritize them," says Goold.
Benefits vs. costs
Ubel explains that bedside rationing is the withholding of a medically beneficial service because of its cost to someone other than the patient. All three of the following conditions together constitute bedside rationing:
1. The physician withholds service that is in the patient’s best medical interest. Take the case of a patient with mild hypertension. The physician prescribes an older, less expensive medication. But consideration of costs alone is not bedside rationing, says Ubel, because optional medications that are more expensive in treating hypertension have not been shown to be more effective or have fewer side effects. "Considering costs when services are of equal benefit is morally praiseworthy because it can provide other needed services in the context of limited resources without producing additional burdens," Ubel says.1
When the benefits are questionable, physicians should ask themselves, "Would I be willing to provide or authorize this service if it were free or if the patient were paying for it himself or herself?"
2. The physician acts primarily to promote the financial interests of someone other than the patient. The other party may be the hospital, society at large, or the physician. Not all patients meet the criteria for a heart transplant, says Goold, but deciding whether to place a patient’s name on a heart transplant waiting list is not bedside rationing. While limiting the surgery to those more likely to benefit medically, organ allocation is not bedside rationing because it does not involve the financial interests of the patient, she explains. Decisions that balance the nonmonetary benefits and harms to others, promote the public health, or accomplish other important objectives qualify as other forms of health care rationing.
Self-imposed rationing’
In bedside rationing, a physician makes the decision that a particular service is not worth the financial cost to that patient, explains Ubel.
For example, if a particular managed care plan only covers certain prescription drugs for allergies and not sensitization shots that are likely to be more beneficial to the patient, and the physician only offers the allergy drugs to the patient, this is bedside rationing. Ubel and Goold describe this situation as "self-imposed rationing" by a physician. If the patient chooses the same option after being given both, it is not rationing by the doctor.
3. Is the service in question under the physician’s control? "This is where the physician has to look at the fairness of the system he or she works in," argues Goold. "It is not enough to say it is not bedside rationing because the hospital or the health plan decides whether a surgical procedure is medically necessary. Make sure the rules you are working under apply equally to everyone," she urges doctors. "Know when you sign on to a managed care plan what you have agreed to. It’s not enough to say to a patient, You can have it if you can pay for it.’"
Overall, Goold and Ubel maintain that bedside rationing should occur under specific guidelines devised by physicians who have patients’ interests at heart. "Jump in at the organizational level and confront these choices that are being made every day," says Goold.
Reference
1. Ubel PA and Goold S. Recognizing bedside rationing: Clear cases and tough calls. Ann Intern Med 1996; 126:74-80.
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