At the 5th International Conference on Priorities in Health Care in Wellington, New Zealand, 2004, one resonating theme was that for priority setting to be effective, it has to include clinicians in both decision making and the enforcement of those decisions. There was, however, a disturbing undertone to this theme, namely that doctors, in particular, were unjustifiably thwarting good systems of prioritising scarce healthcare resources. This undertone seems unfair precisely because doctors may, and in some cases do, feel obligated by their professional ethics to remain uninvolved either in deciding priorities and in some cases in enforcing them. I will argue that the professional role of a doctor ought not be considered inconsistent with the role of a priority setter or enforcer, as long as one crucial element is in place, a rationally coherent and broadly justifiable regime for prioritising healthcare. Given this I conclude both that prioritisation and doctoring are not incompatible under certain conditions, and that the education of healthcare professionals ought to include material on distributive justice in healthcare.
- A4R, accountability for reasonableness
- healthcare resources
- professional ethics
- fiduciary relationships
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
↵i Of course, this is only one way to conceptualise the relationship between the various levels involved in the provision of healthcare, and alternative models have been proposed—for example, attempting to remove government from having a steering role. Nonetheless, in the UK and other countries with public healthcare systems, this model seems to accurately reflect how they operate.
↵ii A nocebo effect is the opposite of a placebo effect, that is, a negative response to an inactive substance or procedure; this could come about because the patient believes their condition is worse than it actually is, as the result of a clinician’s gaming.
↵iii A strong duty is one which may be seen as binding in a way that trumps or over-rules other concerns. It can be contrasted with a weak duty, which is merely a prima facie obligation to do something, easily over-ruled by other concerns.
↵iv Here I am treating the patient as simply anyone who has a medical problem of some sort which requires intervention or assistance. It should be noted, though, that one means of prioritisation that is used is to define people who are in genuine medical need as not being patients at all, through the use of screening criteria; that, in effect, stops them at the door. This has the politically useful effect of keeping patient numbers down—for example, on waiting lists for particular operations. Similar definitional tricks are used by governments to lower unemployment figures, for example. This hidden sort of prioritisation practice ought to be resisted. It is better to know the actual size and scope of particular healthcare problems, so that we can best deal with them, than to have artificially lower figures.
↵v A fiduciary relationship is one based on trust; it can be contrasted with the typical, arm’s-length marketplace relationship, which is based instead on mutual advantage.
↵vi While this is a utilitarian priority, I do not intend to suggest that this is the only appropriate prioritisation scheme in the situation described, but just that priorisation is not inappropriate.
Competing interests: None.
Read the full text or download the PDF:
Other content recommended for you
- Clinical governance development: learning from the New Zealand experience
- Ethics and opportunity costs: have NICE grasped the ethics of priority setting?
- Priority setting in cardiac surgery: a survey of decision making and ethical issues
- Conscientious commitment, professional obligations and abortion provision after the reversal of Roe v Wade
- Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy
- Imperfect by design: the problematic ethics of surgical training
- Access to intensive care unit beds for neurosurgery patients: a qualitative case study
- Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand
- Medical ethics
- Clinical outcomes after percutaneous or surgical revascularisation of unprotected left main coronary artery-related acute myocardial infarction: a single-centre experience