Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis

Abstract

R ationing continues to be a hotly debated and controversial issue, with great disagreement over not only whether rationing is acceptable, but what it means to ration care. In this issue of JGIM, Sheeler et al. present findings of a crosssectional study that aims to describe physician rationing behaviors and characteristics of rationing in the United States. 1 Surveys mailed to physicians randomly selected from the American Medical Association master file asked about frequency with which they Bpersonally refrained, because of cost to the health care system,^from using ten different interventions, including laboratory tests, magnetic resonance imaging (MRI), referral, or prescription drugs. They found overall that 53 % of respondents reported refraining from using services in the past 6 months. 1 Prescription drugs and MRI were most frequently reported at 48 % and 45 %, respectively. 1 Surgical and procedural specialists, medical school settings, and physicians who self-identified as very or somewhat politically conservative reported higher frequency of refraining from using at least one of the ten services than primary care, small or solo practice, and those identifying as very or somewhat liberal. 1 In addition, the survey asked respondents one of three randomly assigned questions to gauge perceived responsibility for containing costs, phrasing questions either as responsibility to Bexercise wise financial resource stewardship,^Bpromote cost consciousness^or Bration in my daily care of patients.Ĉ ompared to 88 % agreeing with the Bwise-stewardship^and 81 % agreeing with the Bcost-conscious^statements, only 22 % agreed with the Brationing^statement. 1

Balancing Patient and Societal Interests in Decisions About Potentially Life-Sustaining Treatment

“…From the viewpoint of the person seeking treatment, who perceives some benefit or chance of a benefit, denying such treatment could not be justified on a "best interests" basis so could be regarded as rationing. However, from the doctor's viewpoint, denying the treatment amounts to a decision to forgo "inappropriate" or "futile" treatment 1 While a detailed conceptual discussion is beyond the scope of this article, we note that definitions of rationing, like definitions of futility, are contested (Walker and Egede 2016 [22] "The exercise of the parens patriae jurisdiction should not be for the benefit of others (Re Eve (1987) 31 DLR (4th) 1 at 34), including a health care system that is intent on saving on costs." Similarly, in Messiha v South East Health [2004] NSWSC 1061 at [9] Howie J noted that a reference made by the treating doctor about the availability of the intensive care unit resources was "… arguably … an irrelevant matter, at least so far as the welfare of the patient was concerned … and might have been taken as a form of pressure on the family to agree with the hospital's decision."…”