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Am I my brother’s gatekeeper? Professional ethics and the prioritisation of healthcare
  1. David Hunter
  1. Correspondence to:
 David Hunter
 Lecturer in Bioethics, School of Biomedical Sciences, University of Ulster, Cromore Road, Coleraine, Co Londonderry, BT52 1SA, UK; d.hunter3{at}


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
  • prioritisation
  • healthcare resources
  • professional ethics
  • fiduciary relationships
  • scarcity

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  • 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.