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The need for rationing of clinical services and medical resources is a crucial issue facing healthcare systems. On most accounts, the demand for medical services vastly exceeds what can be provided on limited budgets, requiring difficult decisions about which services should and should not be provided to patients, whether patients might have to bear some of the cost of the services they use, and on what basis rationing decisions should be made. At the same time, we know that healthcare systems are far from perfectly efficient; some of the expenditures of healthcare systems are wasteful and bring no benefits at all to patients. In light of the evidence of such inefficiencies within healthcare systems, it may seem problematic to insist on the importance of rationing: can it really be appropriate to deny patients beneficial services while inefficiencies remain within the system?1
This is the question Strech and Danis take on in their paper, ‘How can bedside rationing be justified despite coexisting inefficiency? The need for “benchmarks of efficiency”’. As they highlight, the evidence about inefficiencies within the healthcare system is sometimes taken to undermine the legitimacy of rationing. Their response focuses on the implications of particular clinicians’ involvement in both inefficient decisions and bedside rationing: if clinicians cause or contribute to inefficiencies in the system—for example by prescribing more expensive ‘brand name’ medication instead of equally effective but cheaper generic drugs—is it legitimate for them also to make, or be involved in, rationing decisions? Strech and Danis argue that even though no healthcare system can be fully efficient, clinicians must make ‘sufficient’ efforts to reduce inefficiencies within their own realm of decision-making if their engagement in rationing decisions is to be legitimate. They offer a set of ‘benchmarks’ against which we can judge whether or not such efforts should …
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
↵i The notion of ‘fairness’ that is at work in the context of ‘fair rationing’ is usually understood more narrowly than it is in other contexts. Questions of fairness, more broadly conceived, will also arise in connection with the size of the budget allocated to healthcare: for example, concerns of fairness are likely to be relevant when deciding how much to allocate to healthcare relative to, for instance, education. I leave these issues aside for the purposes of the present discussion.
↵ii There may be instances where clinicians can redress the resource shortages their previous, inefficient decisions have created, for example by working unpaid overtime or providing private funds. In such cases, clinicians arguably have a duty to provide such redress (although of course whether or not we would want to enforce such a duty as a matter of policy is a separate question). I thank an anonymous reviewer for raising this point.
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