Skip to main content
SpringerLink
Log in

Prevalence and determinants of physician bedside rationing

Data from europe

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND: Bedside rationing by physicians is controversial. The debate, however, is clouded by lack of information regarding the extent and character of bedside rationing.

DESIGN, SETTING, AND PARTICIPANTS: We developed a survey instrument to examine the frequency, criteria, and strategies used for bedside rationing. Content validity was assessed through expert assessment and scales were tested for internal consistency. The questionnaire was translated and administered to General Internists in Norway, Switzerland, Italy, and the United Kingdom. Logistic regression was used to identify the variables associated with reported rationing.

RESULTS: Survey respondents (N=656, response rate 43%) ranged in age from 28 to 82, and averaged 25 years in practice. Most respondents (82.3%) showed some degree of agreement with rationing, and 56.3% reported that they did ration interventions. The most frequently mentioned criteria for rationing were a small expected benefit (82.3%), low chances of success (79.8%), an intervention intended to prolong life when quality of life is low (70.6%), and a patient over 85 years of age (70%). The frequency of rationing by clinicians was positively correlated with perceived scarcity of resources (odds ratio [OR]=1.11, 95% confidence interval [CI] 1.06 to 1.16), perceived pressure to ration (OR=2.14, 95% CI 1.52 to 3.01), and agreement with rationing (OR=1.13, 95% CI 1.05 to 1.23).

CONCLUSION: Bedside rationing is prevalent in all surveyed European countries and varies with physician attitudes and resource availability. The prevalence of physician bedside rationing, which presents physicians with difficult moral dilemmas, highlights the importance of discussions regarding how to ration care in the most ethically justifiable manner.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Asch DA, Ubel PA. Rationing by any other name. N Engl J Med. 1997;336:1668–71.

    Article  PubMed  CAS  Google Scholar 

  2. Relman A. Use of medical resources—overview. Prev Med. 1990;19:688–92.

    Article  PubMed  CAS  Google Scholar 

  3. Bloche MG, Jungman ER. The “R” word. J Contemp Health Law Policy. 2002;18:633–9.

    PubMed  Google Scholar 

  4. Coulter A, Ham C. The Global Challenge of Health Care Rationing. Buckingham: Open University Press; 2000.

    Google Scholar 

  5. Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med. 1992;116:920–6.

    PubMed  CAS  Google Scholar 

  6. Hiatt HH. Protecting the medical commons: who is responsible? N Engl J Med. 1975;293:235–41.

    Article  PubMed  CAS  Google Scholar 

  7. Loewy EH. Cost should not be a factor in medical care. N Engl J Med. 1980;302:697.

    PubMed  CAS  Google Scholar 

  8. Levinski N. The doctor’s master. N Engl J Med. 1983;311:1573–5.

    Article  Google Scholar 

  9. Pellgrino ED. Managed care at the bedside: how do we look in the moral mirror? Kennedy Inst Ethics J. 1997;7:321–30.

    Article  Google Scholar 

  10. Askin WJ. Bedside rationing. CMAJ. 2002;166:711.

    PubMed  Google Scholar 

  11. Weinstein MC. Should physicians be gatekeepers of medical resources? J Med Ethics. 2001;27:268–74.

    Article  PubMed  CAS  Google Scholar 

  12. Veatch RM. Who should manage care? The case for patients. Kennedy Inst Ethics J. 1997;7:391–401.

    Article  PubMed  Google Scholar 

  13. Morreim E. Balancing Act; The New Medical Ethics of Medicine’s New Economics. Dordrecht: Kluwer Academic Publishers; 1991.

    Google Scholar 

  14. Pearson SD. Caring and cost: the challenge for physician advocacy. Ann Intern Med. 2000;133:148–53.

    PubMed  CAS  Google Scholar 

  15. Ubel P. Pricing Life: Why It’s Time for Health Care Rationing. Cambridge, MA: The MIT Press; 2001:(McGee G, Caplan A, eds. Basic Bioethics).

    Google Scholar 

  16. Daniels N. What is the obligation of the medical profession in the distribution of health care? Soc Sci Med [F]. 1981;15F:129–33.

    Google Scholar 

  17. Baines DL, Tolley KH, Whynes DK. The ethics of resource allocation: the views of general practitioners in Lincolnshire, U.K. Soc Sci Med. 1998;47:1555–64.

    Article  PubMed  CAS  Google Scholar 

  18. Cooke L, Hutchinson M. Doctors’ professional values: results from a cohort study of United Kingdom medical graduates. Med Educ. 2001;35:735–42.

    Article  PubMed  CAS  Google Scholar 

  19. Rosen P, Karlberg I. Opinions of Swedish citizens, health-care politicians, administrators and doctors on rationing and health-care financing. Health Expect. 2002;5:148–55.

    Article  PubMed  Google Scholar 

  20. van Delden JJ, Vrakking AM, van der Heide A, van der Maas PJ. Medical decision making in scarcity situations. J Med Ethics. 2004;30:207–11.

    Article  PubMed  Google Scholar 

  21. Ubel PA, Baron J, Nash B, Asch DA. Are preferences for equity over efficiency in health care allocation “all or nothing”? Med Care. 2000;38:366–73.

    Article  PubMed  CAS  Google Scholar 

  22. Perneger TV, Martin DP, Bovier PA. Physicians’ attitudes toward health care rationing. Med Decis Making. 2002;22:65–70.

    Article  PubMed  Google Scholar 

  23. Ryynanen OP, Myllykangas M, Kinnunen J, Takala J. Doctors’ willingness to refer elderly patients for elective surgery. Fam Pract. 1997;14:216–9.

    Article  PubMed  CAS  Google Scholar 

  24. Escher M, Perneger TV, Chevrolet JC. National questionnaire survey on what influences doctors’ decisions about admission to intensive care. BMJ. 2004;329:425.

    Article  PubMed  Google Scholar 

  25. Mendelssohn DC, Kua BT, Singer PA. Referral for dialysis in Ontario. Arch Intern Med. 1995;155:2473–8.

    Article  PubMed  CAS  Google Scholar 

  26. Wilson R, Godwin M, Seguin R, et al. End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain. Am J Kidney Dis. 2001;38:42–8.

    PubMed  CAS  Google Scholar 

  27. Arnesen T, Fredriksen S. Coping with obligations towards patients and society: an empirical study of attitudes and practice among Norwegian physicians. J Med Ethics. 1995;21:158–61.

    Article  PubMed  CAS  Google Scholar 

  28. WHO. Countries: selected indicators. Vol. 2005; 2003. Available at: http://www.who.int/countries/en/.

  29. Ubel PA, Goold SD. ‘Rationing’ health care. Not all definitions are created equal. Arch Intern Med. 1998;158:209–14.

    Article  PubMed  CAS  Google Scholar 

  30. Sulmasy DP, Bloche MG, Mitchell JM, Hadley J. Physicians’ ethical beliefs about cost-control arrangements. Arch Intern Med. 2000;160:649–57.

    Article  PubMed  CAS  Google Scholar 

  31. Ryynanen OP, Myllykangas M, Kinnunen J, Takala J. Attitudes to health care prioritisation methods and criteria among nurses, doctors, politicians and the general public. Soc Sci Med. 1999;49:1529–39.

    Article  PubMed  CAS  Google Scholar 

  32. DuVal G, Clarridge B, Gensler G, Danis M. A national survey of U.S. internists’ experiences with ethical dilemmas and ethics consultation. J Gen Intern Med. 2004;19:251–8.

    Article  PubMed  Google Scholar 

  33. Hurst SA, Hull SC, DuVal G, Danis M. Physicians’ responses to resource constraints. Arch Intern Med. 2005;165:639–44.

    Article  PubMed  Google Scholar 

  34. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ. 2002;324:1183.

    Article  PubMed  Google Scholar 

  35. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50:1129–36.

    Article  PubMed  CAS  Google Scholar 

  36. Alexander GC, Werner RM, Ubel PA. The costs of denying scarcity. Arch Intern Med. 2004;164:593–6.

    Article  PubMed  Google Scholar 

  37. Wennberg JE, MacAndrew Cooper M. The Quality of Medical Care in the United States: a Report on the Medicare Program; the Dartmouth Atlas of Health Care 1999. Chicago, IL: AHA Press; 1999.

    Google Scholar 

  38. OECD. Health Data 2005. 2005.

  39. Herzlinger RE, Parsa-Parsi R. Consumer-driven health care: lessons from Switzerland. JAMA. 2004;292:1213–20.

    Article  PubMed  CAS  Google Scholar 

  40. Committee on Consequences of Uninsurance. Insuring Health: Care Without Coverage: Too Little Too Late. Washington, DC: National Academy Press; 2002:(Institute of Medicine, ed).

    Google Scholar 

  41. Wynia MK, VanGeest JB, Cummins DS, Wilson IB. Do physicians not offer useful services because of coverage restrictions? Health Aff (Millwood). 2003;22:190–7.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Bioethics Institute, University of Geneva Medical School, Geneva, Switzerland

    Samia A. Hurst

  2. The Ethox Centre, University of Oxford, Oxford, UK

    Anne-Marie Slowther

  3. The Research Institute, Norwegian Medical Association and University of Oslo, Oslo, Norway

    Reidun Forde

  4. Fondazione Lanza, Padova, Italy

    Renzo Pegoraro

  5. Institute for Applied Ethics and Medical Ethics, University of Basel, Basel, Switzerland

    Stella Reiter-Theil

  6. General Internal Medicine Service, Geneva University Hospital, Geneva, Switzerland

    Arnaud Perrier

  7. Johns Hopkins Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, USA

    Elizabeth Garrett-Mayer

  8. Department of Clinical Bioethics, National Institutes of Health, Building 10, Room 1C118, 20892, Bethesda, MD

    Marion Danis

Authors
  1. Samia A. Hurst
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anne-Marie Slowther
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Reidun Forde
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Renzo Pegoraro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stella Reiter-Theil
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Arnaud Perrier
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Elizabeth Garrett-Mayer
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Marion Danis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marion Danis.

Additional information

The views expressed here are the authors’ own and do not reflect the position of the National Institutes of Health, of the Public Health Service, or of the Department of Health and Human Services.

Conflict of interest statement for authors: none

This work was funded by the Department of Clinical Bioethics at the National Institutes of Health, and was conducted while S.A.H. was a fellow at this Department. S.A.H. was funded in part by the University Hospitals of Geneva, by the Oltramare Foundation, and by the Centre Lémanique d’Ethique. The views expressed here are the authors’ own, and not necessarily those of the University Hospitals of Geneva, the Oltramare Foundation, or the Centre Lémanique d’Ethique.

The funding sources were not involved in the study design, the collection, analysis, or interpretation of data, in the writing of the report, or in the decision to submit the paper for publication.

S.A.H. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hurst, S.A., Slowther, AM., Forde, R. et al. Prevalence and determinants of physician bedside rationing. J Gen Intern Med 21, 1138–1143 (2006). https://doi.org/10.1111/j.1525-1497.2006.00551.x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2006.00551.x

Key Words

Search

Navigation