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Three pitfalls of accountable healthcare rationing
  1. Marleen Eijkholt1,
  2. Marike Broekman2,
  3. Naci Balak3,
  4. Tiit Mathiesen4,5
  5. EANS Ethico-legal committee
  1. 1Unit Ethics and Health Care, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
  2. 2Department of neurosurgery, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
  3. 3Istanbul Medeniyet University, Istanbul, İstanbul, Turkey
  4. 4Department of Neurosurgery and Dept of Clinical Medicine, University of Copenhagen, Copenhagen University Hospital, Kobenhavn, Denmark
  5. 5Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Stockholm, Sweden
  1. Correspondence to Professor Tiit Mathiesen, Department of Neurosurgery and Dept of Clinical Medicine, University of Copenhagen, Copenhagen University Hospital, 2200 Kobenhavn, Denmark; tiit.illimar.mathiesen{at}


A pandemic may cause a sudden imbalance between available medical resources and medical needs where fundamental care to a patient cannot be delivered. Inability to fulfil a professional commitment to deliver care as needed can lead to distress among caregivers and patients. This distress is sometimes alleviated through mechanisms that hide the facts that care is rationed and not all medical needs are met. We have identified three mechanisms that jeopardise accountable and optimal allocation of resources: (1) hidden value judgements that allow rationing under the disguise of triage or prioritisation, (2) disguised conflict of interest between societal and individual patient’s needs and (3) concealed biases in the application of medical tools. Under these three pitfalls decisions of resource allocation and who gets treated are handled as medical decisions: normative decisions are concealed and perceived as falling with the realm of medical judgement. Value judgements and moral agency are hidden to offer a ‘false sense of medical judgement’, while in fact there are several ethical judgements and biases at stake. The three pitfalls entail hidden normative deliberation and are inappropriate for sustainable healthcare delivery and resource allocation. We believe it is necessary to maintain transparency in decision making under conditions of insufficient resources to maintain trust in professional care givers and secure fair treatment allocation. Recognition of the pitfalls, by applying our recommendations, may help to ensure transparent and accountable distribution of care and contribute to public acceptance of the ethics behind rationing.

  • end-of-life
  • health care economics
  • right to healthcare
  • resource allocation
  • moral psychology

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  • ME and TM are joint first authors.

  • ME and TM contributed equally.

  • Contributors Conception and design of this work was done by ME and TM with assistance by MB and NB. All authors have revised this work critically for important intellectual content, conducted the literature search, drafted this work and revised it based on critical feedback provided by all coauthors. This manuscript has been read and approved by all authors.

  • Funding This study was supported by a grant from The Swedish Medical Association.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.