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Semin Respir Crit Care Med 2012; 33(04): 421-426
DOI: 10.1055/s-0032-1322412
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Physician as Rationer: Uncertainty about the Physician's Role Obligations

Leslie P. Scheunemann
1   Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
2   Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
,
Douglas B. White
2   Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
3   Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania
› Author Affiliations
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Publication History

Publication Date:
08 August 2012 (online)

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Abstract

Although the need to ration health care is increasingly accepted, the need for bedside physicians to participate in it is not. There are three common perspectives on physicians' roles in rationing: one is that bedside physicians should advocate fully for their patients and eschew rationing; another is that some rationing is permissible but should be imposed from outside the patient–physician relationship; the third is that bedside physicians should simultaneously advocate for their individual patients and make bedside rationing decisions that incorporate societal interests. The first two conceptualizations are at odds with empirical evidence that physicians do ration at the bedside and the idea that doing so may be a necessary part of efforts to control costs, whereas the third raises difficult ethical questions about the extent of physicians' obligations to advocate maximally for their individual patients.

Keywords

intensive care unit - resource allocation - rationing - ethics
 

  • References

  • 1 Veatch RM. The Basics of Bioethics. Upper Saddle River, NJ: Prentice-Hall; 2003
    Google Scholar
  • 2 The Hippocratic Oath. Classical Version. NOVA Online. 2009. http://www.pbs.org/wgbh/nova/doctors/oath_classical.html . Accessed February 11, 2011
    PubMedGoogle Scholar
  • 3 Strech D, Synofzik M, Marckmann G. How physicians allocate scarce resources at the bedside: a systematic review of qualitative studies. J Med Philos 2008; 33 (1) 80-99
    CrossrefPubMedGoogle Scholar
  • 4 Hurst SA, Slowther AM, Forde R , et al. Prevalence and determinants of physician bedside rationing: data from Europe. J Gen Intern Med 2006; 21 (11) 1138-1143
    CrossrefPubMedGoogle Scholar
  • 5 Ward NS, Teno JM, Curtis JR, Rubenfeld GD, Levy MM. Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units: results of a national survey. Crit Care Med 2008; 36 (2) 471-476
    CrossrefPubMedGoogle Scholar
  • 6 White DB, Katz MH, Luce JM, Lo B. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med 2009; 150 (2) 132-138
    CrossrefPubMedGoogle Scholar
  • 7 Kahn JM. Understanding economic outcomes in critical care. Curr Opin Crit Care 2006; 12 (5) 399-404
    CrossrefPubMedGoogle Scholar
  • 8 Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38 (1) 65-71
    CrossrefPubMedGoogle Scholar
  • 9 Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM ; Values Ethics and Rationing in Critical Care Task Force. Rationing critical care beds: a systematic review. Crit Care Med 2004; 32 (7) 1588-1597
    CrossrefPubMedGoogle Scholar
  • 10 Carr BG, Addyson DK, Kahn JM. Variation in critical care beds per capita in the United States: implications for pandemic and disaster planning. JAMA 2010; 303 (14) 1371-1372
    CrossrefPubMedGoogle Scholar
  • 11 Kohn R, Rubenfeld GD, Levy MM, Ubel PA, Halpern SD. Rule of rescue or the good of the many? An analysis of physicians' and nurses' preferences for allocating ICU beds. Intensive Care Med 2011; 37 (7) 1210-1217
    CrossrefPubMedGoogle Scholar
  • 12 Angell M. The doctor as double agent. Kennedy Inst Ethics J 1993; 3 (3) 279-286
    CrossrefPubMedGoogle Scholar
  • 13 Calabresi G, Bobbitt P. Tragic Choices: The Conflicts Society Confronts in the Allocation of Tragically Scarce Resources. New York/London: WW Norton; 1978
    Google Scholar
  • 14 Scheunemann LP, White DB. The ethics and reality of rationing in medicine. Chest 2011; 140 (6) 1625-1632
    CrossrefPubMedGoogle Scholar
  • 15 Truog RD, Brock DW, Cook DJ , et al; for the Task Force on Values, Ethics, and Rationing in Critical Care (VERICC). Rationing in the intensive care unit. Crit Care Med 2006; 34 (4) 958-963 , quiz 971
    CrossrefPubMedGoogle Scholar
  • 16 Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009; 122 (8) 741-746
    CrossrefPubMedGoogle Scholar
  • 17 Kennedy J, Morgan S. A cross-national study of prescription nonadherence due to cost: data from the Joint Canada-United States Survey of Health. Clin Ther 2006; 28 (8) 1217-1224
    CrossrefPubMedGoogle Scholar
  • 18 Kennedy J, Morgan S. Cost-related prescription nonadherence in the United States and Canada: a system-level comparison using the 2007 International Health Policy Survey in Seven Countries. Clin Ther 2009; 31 (1) 213-219
    CrossrefPubMedGoogle Scholar
  • 19 Iapichino G, Corbella D, Minelli C , et al. Reasons for refusal of admission to intensive care and impact on mortality. Intensive Care Med 2010; 36 (10) 1772-1779
    CrossrefPubMedGoogle Scholar
  • 20 Opinion 2.03 - Allocation of Limited Medical Resources. AMA Code of Medical Ethics 1994; http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion203.shtml . Accessed February 5, 2011
    PubMedGoogle Scholar
  • 21 Childress J, Beauchamp T. Principles of biomedical ethics. New York: Oxford University; 2009
    Google Scholar
  • 22 Snyder L ; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med 2012; 156 (1 Pt 2) 73-104
    CrossrefPubMedGoogle Scholar
  • 23 Wendler D. Are physicians obligated always to act in the patient's best interests?. J Med Ethics 2010; 36 (2) 66-70
    CrossrefPubMedGoogle Scholar
  • 24 Rodwin MA. Strains in the fiduciary metaphor: divided physician loyalties and obligations in a changing health care system. Am J Law Med 1995; 21 (2–3) 241-257
    PubMedGoogle Scholar
  • 25 Rie MA, Kofke WA. Nontherapeutic quality improvement: The conflict of organizational ethics and societal rule of law. Crit Care Med 2007; 35 (2, Suppl) S66-S84
    CrossrefPubMedGoogle Scholar
  • 26 McCullough LB. The legacy of modern Anglo-American medical ethics: correcting some misperceptions. In: Shelp EE, , ed. The Clinical Encounter: The Moral Fabric of the Patient-Physician Relationship. Dordrecht, The Netherlands: D Reidel; 1983: 47-64
    Google Scholar
  • 27 Amundsen DW, Ferngren GB. Evolution of the patient-physician relationship: antiquity through the Renaissance. In: Shelp EE, , ed. The Clinical Encounter: The Moral Fabric of the Patient-Physician Relationship. Dordrecht, The Netherlands: D Reidel; 1983: 3-46
    Google Scholar
  • 28 Bloche MG. Clinical loyalties and the social purposes of medicine. JAMA 1999; 281 (3) 268-274
    CrossrefPubMedGoogle Scholar
  • 29 Shelp EE , ed. The Clinical Encounter: The Moral Fabric of the Patient-Physician Relationship. Dordrecht, The Netherlands: D Reidel; 1983
    Google Scholar
  • 30 Ubel PA, Arnold RM. The unbearable rightness of bedside rationing. Physician duties in a climate of cost containment. Arch Intern Med 1995; 155 (17) 1837-1842
    CrossrefPubMedGoogle Scholar
  • 31 Benatar SR, Upshur REG. Dual loyalty of physicians in the military and in civilian life. Am J Public Health 2008; 98 (12) 2161-2167
    CrossrefPubMedGoogle Scholar
  • 32 Zawacki BE. ICU physician's ethical role in distributing scarce resources. Crit Care Med 1985; 13 (1) 57-60
    CrossrefPubMedGoogle Scholar
  • 33 Woolf SH. Potential health and economic consequences of misplaced priorities. JAMA 2007; 297 (5) 523-526
    CrossrefPubMedGoogle Scholar
  • 34 Daniels N. Accountability for reasonableness. BMJ 2000; 321 (7272) 1300-1301
    CrossrefPubMedGoogle Scholar
  • 35 Daniels N, Sabin J. Limits to health care: fair procedures, democratic deliberation, and the legitimacy problem for insurers. Philos Public Aff 1997; 26 (4) 303-350
    CrossrefPubMedGoogle Scholar
  • 36 Danis M, Ginsburg M, Goold S. Experience in the United States with public deliberation about health insurance benefits using the small group decision exercise, CHAT. J Ambul Care Manage 2010; 33 (3) 205-214
    PubMedGoogle Scholar
  • 37 Baum NM, Jacobson PD, Goold SD. “Listen to the people”: public deliberation about social distancing measures in a pandemic. Am J Bioeth 2009; 9 (11) 4-14
    PubMedGoogle Scholar
  • 38 Cook DJ, Guyatt GH, Jaeschke R , et al; Canadian Critical Care Trials Group. Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. JAMA 1995; 273 (9) 703-708
    CrossrefPubMedGoogle Scholar
  • 39 Schenker Y, White DB, Asch DA, Kahn JM. Health-care system distrust in the intensive care unit. J Crit Care 2012; 27 (1) 3-10
    CrossrefPubMedGoogle Scholar
  • 40 Mechanic D. Dilemmas in rationing health care services: the case for implicit rationing. BMJ 1995; 310 (6995) 1655-1659
    CrossrefPubMedGoogle Scholar
  • 41 World Health Organization Statistical Information System. 2008. http://www.who.int/whosis/whostat/2008/en/index.html . Accessed December 1, 2011
    PubMedGoogle Scholar
  • 42 Emanuel EJ. Where civic republicanism and deliberative democracy meet. Hastings Cent Rep 1996; 26 (6) 12-14
    PubMedGoogle Scholar
  • 43 Truog RD. Screening mammography and the “r” word. N Engl J Med 2009; 361 (26) 2501-2503
    CrossrefPubMedGoogle Scholar