Author Affiliations: Department of Clinical Bioethics, National Institutes of Health, Bethesda, Md (Drs Hurst, Hull, and Danis); and University of Toronto Joint Centre for Bioethics, Toronto, Ontario (Dr DuVal). This work was conducted while Drs Hurst and DuVal were fellows in the Department of Clinical Bioethics at the National Institutes of Health.
A common dilemma that confronts physicians in clinical practice is the allocation of scarce resources. Yet the strategies used by physicians in actual situations of resource constraint have not been studied. This study explores the strategies and rationales reported by physicians in situations of resource constraints encountered in practice.
A national survey of US internists, oncologists, and intensive care specialists was performed by computer-assisted telephone interviews. As part of this survey, we asked physicians to tell us about a recent ethical dilemma encountered in practice. A subset of respondents reported difficulties regarding resource allocation. Transcripts of open-ended responses were coded for content based on consensus.
Of the 600 physicians originally identified, 537 were eligible and 344 participated (response rate, 64%). Internists do not make allocation decisions alone but rather engage in negotiation in their resolution. Furthermore, these decisions are not made as dichotomous choices. Rather they often involve alternative solutions in the face of complexities of both the health care system and situations where limited resources must be allocated. Justice is not commonly the justification for rationing.
Physicians’ experiences in situations of resource constraints appear to be more complex than the normative literature on health care rationing assumes. In addition, reasoning about justice in health care seems to play only a small part in clinical decision making. Bridging this gap could be an important step in fostering fair allocation of resources in difficult cases.
The ceaseless rise of health care costs is driving concerns about the best way to contain expenditure. Inevitably, cost containment efforts require changes in physician practices.1- 3 The role that physicians should play in the allocation of resources is a matter of debate. On the one hand, it has been argued that cost should never enter into physicians’ decision making at the bedside.4- 7 On the other hand, it has also been pointed out that their responsibility toward society requires physicians to become stewards of scarce resources.3,8,9 This debate reflects what is, in effect, a deep role conflict that physicians face when they are in a situation where they must allocate resources in clinical practice.10 Thus, a key question is how do physicians confront and resolve the ethical challenges posed by resource constraints and cost containment efforts?
Despite the importance and the intensity of this debate, the strategies used by physicians in actual situations of resource constraint have not been studied. Studies to date have been limited to physicians’ attitudes regarding resource allocation11- 17 and surveys of their intended practices using hypothetical scenarios.18- 20 We report on an analysis of cases in which US physicians reported difficulties with resource allocation in clinical practice. Our aim is to describe the type of ethical difficulties reported regarding resource allocation, the strategies used by responding physicians to resolve them, and their rationales.
Our participants were general internists, oncologists, and intensive care physicians identified by random sampling from the American Medical Association Master List of Physicians and Medical Students for Mailing Purposes, which provides a comprehensive list of physicians not limited to members of the American Medical Association.21 These specialties were chosen to capture physicians active in the primary care setting, as well as those providing highly technological care. Since our purpose was to explore an aspect of clinical experience, physicians were eligible to participate if they reported practicing medicine for at least 1 year before the survey and spending at least 20% of their time in direct patient care.
Development of the survey instrument involved cognitive interviewing with a small group of general internists, oncologists, and intensive care specialists, followed by field pretesting of a completely revised instrument with another group of board-certified internists.22 The domains of the questionnaire included the following: type and frequency of ethical dilemmas, type of guidance sought by responding physicians in situations of ethical difficulty, report of a specific ethically difficult situation, strategies used to resolve this specific case, and type of help that would have been useful in this specific case. Other data from this survey have been reported elsewhere.21,23
Computer-assisted telephone interviews were used with both close-ended and open-ended questions.24 Interviews were conducted between October 1999 and March 2000 by trained interviewers from the Center for Survey Research at the University of Massachusetts in Boston. The interviews took an average of 26 minutes to complete. Physicians were not paid to participate. Responses to open-ended questions were entered into a database by the telephone interviewers.
The following open-ended questions were asked to elicit the specific example of an ethically difficult case and the strategies used to resolve it: (1) Can you describe a recent ethical dilemma you experienced at your main practice site? (2) What do you consider to be the primary ethical issue or dilemma raised by the situation? (3) Please briefly describe the decisions that were made as the situation played itself out. A series of closed-ended follow-up questions were asked regarding the strategies used by responding physicians in facing the situation, as well as the kind of help they would have considered useful. The questionnaire is available on request from the authors.
Participants were contacted by telephone and told about the study purpose and interview process. Participation was voluntary. Because no personally identifiable information was collected, this study was exempted from review by an institutional review board by the Office of Human Subjects Research at the National Institutes of Health, Bethesda, Md.
Transcripts of cases in which one of the central issues raised by the responding physician was resource allocation were identified, and this list was finalized based on review of all cases by consensus of the authors (S.A.H., S.C.H., M.D.). Responses to closed-ended questions were entered into a statistical software program (SPSS 11.0 for Windows; SPSS Inc, Chicago, Ill) for analysis. Along with descriptive statistics, we used Pearson χ2 and Mann-Whitney U tests as appropriate to compare allocation cases to other cases given as examples by responding physicians. Responses to open-ended questions were imported into QSR NUD*IST, version N6 (QSR International, Victoria, Australia), qualitative research software to facilitate data analysis. Codes for the type of allocation cases, the strategies reported, the resource in question, the rationale offered for the strategies, and the outcome and success of the strategies were developed and refined. Cases identified as resource allocation difficulties were then coded for content by 2 authors (S.A.H. and M.D.). For purposes of reading ease, quotations presented inthis article have been completed from the telegraphic style in which transcripts were taken. Additions are identified by braces () and deletions by ellipses ( . . . ).
Of the 600 physicians originally identified, 537 were eligible and 344 participated (response rate, 64%). Study respondents were predominantly male, white, and born in the United States (Table 1). Of our respondents, 310 (89%) could recall a recent ethical dilemma. Of these, 55 (18%) reported a recent case that involved resource allocation. Responding physicians who gave a resource allocation example were significantly less likely than other responding physicians to have access to an ethics consultation process and less confident about their knowledge of ethical standards. They were more likely to have been born in Europe but not more likely to be trained outside the United States. Internists and critical care specialists were more likely than oncologists to report a resource allocation dilemma.
In resource allocation cases, most responding physicians reported that the source of difficulty was pressure of some kind (Table 2). In a quarter of cases, the pressure was to forgo using a resource when the physician responding thought it should be used (24%), and in other cases the pressure was to use a resource when the responding physician thought it should not be used (30%). Limitation in the coverage of insured individuals was the source of the difficulty in 36% of cases, whereas complete lack of insurance was the source of the difficulty in relatively fewer cases (20%). The problem of whether it was appropriate to use an expensive or scarce intervention that would yield questionable benefit was mentioned in only 20% of cases.
The resource in question was most commonly a treatment modality (64%), such as chemotherapy, or access to a specific source of care (31%), such as a nursing home. Diagnostic procedures, such as magnetic resonance imaging, were much less frequently mentioned (7%), as was disability designation or sick leave (7%). An excessive delay, or the lack of access to a needed resource within a defined time frame, was the limitation in 17% of cases.
In 45% of cases, physicians engaged in some kind of interaction with the health care system, either negotiating (33%) or on rare occasions manipulating (2%) the rules (Table 3):
[I had] a patient [who] did not want to go on dialysis. He wanted to go on a transplant list. He could wait. . . . The insurance company refused to pay for the transplant because the hospital was not in the insurance program. . . . I taped [the insurance company’s] conversations. . . . I threatened to go to court. Eventually the patient got the transplant and the insurance company paid for it.
Discussions with the patient or the patient’s family were also reported frequently (22%). In one situation where the physician “doubted [the] need of aggressive management” of a terminally ill patient, he reported:
I just explained to [the] family the current condition, gave them brief description [of] what's going on with relative, loved one and I left [the] decision to them to make . . . they came next day . . . he's suffering, . . . they decided on their own to minimize the care to supportive care from aggressive intensive care.
The other strategies reported included financing the needed care (22%) and refusing requests (16%).
Physicians’ comments were consistent with their accepting the apparent limitations of the situation in 20% of cases and not accepting them in 33% of cases. In the remaining cases, comments did not indicate whether the limitation was accepted.
Based on closed-ended questions, the following strategies were used to address the situation: meetings were initiated with the clinical team in 38% of cases; the situation was discussed with the patient or family in 85% of cases, with the department head in 13% of cases, and with the hospital lawyer in 13% of cases; and a formal ethics consultation was requested in 13% of cases. Some responding physicians mentioned strategies in the closed-ended questions that they had not mentioned in the open-ended questions. Holding a discussion with the patient or family, for example, was mentioned much more frequently in the closed-ended questions. There were no significant differences between the strategies reported in the closed-ended questions by responding physicians who gave an allocation example and responding physicians who gave other kinds of examples of ethical difficulties.
Concern for the patient’s well-being was the most frequently articulated rationale for the strategies used (62%) (Table 4). It included concern for “our obligation to give [the] patient the best treatment” (44%), the commitment to treat the patient despite reimbursement structures (5%) or institutional obstacles (4%), concern for quality of life (16%), and following the patient’s wishes (9%). Saving resources and preventing futile care was the reported rationale in 27% of cases. A concern for justice was reported as the rationale in 11% of cases. This was mostly framed as a concern for equal treatment (7%):
The main issue I see is really [a] patient I have been treating for many years and I know his medical problems and I'm not able to help him. If I do it for him I have to do it for everyone.
Pragmatic rationales, which aimed to explain the strategy on the basis of some practical aspect of the case, were offered in 11% of cases (Table 4).
The patients were reported to have obtained the resource in question in 45% of cases, to have partially obtained it in 22% of cases, and to have failed to obtain it in 22% of cases. Responding physicians who gave an allocation example were significantly less likely to be satisfied with th e decisions that were made than responding physicians who gave other kinds of examples of ethical difficulties (52% and 69%, P = .02).
Almost half the responding physicians would have welcomed help in clarifying the issue (43%), help in obtaining additional information (32%), help in mediating conflict (41%), suggestions for acceptable alternative courses of action (49%), help in reviewing ethical standards (43%), and professional reassurance that their decision was correct (58%). One in 5 (20%) responding physicians thought an ethics consultation would have helped them. There were no significant differences between responding physicians who gave an allocation example and responding physicians who gave other kinds of examples of ethical difficulties in the kind of help they thought would have been useful in the case described.
This study offers a unique exploration of resource allocation at the bedside in a national sample of US physicians. Results indicate that therapeutic, rather than diagnostic, interventions are the focus of concern about resource allocation. Clinicians use a variety of strategies in arriving at these decisions. Although some strategies entailed decisions made by physicians on their own, most involved negotiations with patients, families, third-party payers, administrators, colleagues, and other participants in the health care system. In most cases, the source of the difficulty was external pressure. Lack of insurance was a frequent problem, but it is noteworthy that situations of underinsurance were more frequent than complete lack of insurance. Difficulties due to patients’ lack of ability to pay were not limited to the uninsured.25- 27
Since our sample included only general internists, oncologists, and critical care specialists, generalizations to other medical specialties should, of course, be made cautiously. Responding physicians are also likely to have reported the cases most striking to them rather than the most frequent and representative ones and to have selected the elements most remarkable to them. This approach is likely to give insight into the types of cases that are most salient to them when they perceive a case as ethically difficult. In this regard, the differences between the strategies reported in the open-ended responses and those reported in the closed-ended responses are interesting. The closed-ended responses were asked later, and responding physicians were thus not selectively reminded of the strategies explored when they answered the open-ended questions. Some of the strategies mentioned in the closed-ended responses may not have been considered sufficiently helpful in coming to a resolution to merit being mentioned in the open-ended responses.
To our knowledge, this is the first study that explores the strategies reported by physicians in real-life allocation situations they encountered in their practices. In one study, Ayres28 reports attitudes of general practitioners in the United Kingdom regarding the relevance and impact of rationing and the strategies they would advocate for resolving rationing dilemmas, both at the individual and population levels. The attitudinal data, however, and the focus on acceptable policies for resource allocation at the macrolevel mean that their experience of day-to-day clinical strategies used in dealing with scarce resources is incompletely addressed.
Current debates on physician resource allocation focus on whether physicians ought to ration care, in the sense of allowing patients to go without the most beneficial health care service.3- 7,9 Two commonly held assumptions seem to be the following: first, physicians are making these decisions on their own, and second, the decisions to ration are simple dichotomous choices.
Our study indicates that these assumptions are too simplistic. This exploratory study points out 2 important realities about bedside rationing that have been underrecognized in efforts to address the question from a normative standpoint. First, most of the cases reported to us involved some form of negotiation in their resolution. Responding physicians were, in effect, not making these decisions alone. Second, many decisions were not handled as dichotomous choices. Rather they often involved alternative solutions in the face of complexities of both the health care system and each particular situation.
The literature on resource allocation outlines a variety of strategies that can be used to forgo treatment. One such list includes denial, selection, deflection, deterrence, delay, dilution, and termination.29 Our findings confirm the presence of some of these strategies in situations where internists allocate resources in clinical practice. Responding physicians reported refusing requests (denial), refusing or attempting to refuse requests from patients who seemed either unlikely to benefit or somehow undeserving (selection), choosing to shift authority to others (deflection), offering less expensive alternatives (dilution), and terminating care that they deemed unhelpful (termination). Deterrence and delay, intentional or not, typically exist in a systemwide fashion and would be more difficult to detect based on physicians’ accounts of what they did. It is therefore not surprising that they did not appear in our sample.
In addition, however, our findings suggest that physicians are sometimes able to negotiate alternatives. What this kind of list fails to capture is the reality that clinicians will struggle first with the question of whether to allow a patient to go without a benefit, in some cases even when this benefit is small. In so doing, it seems that they are sometimes able to come up with alternatives that are not on the radar screen if the question is “to give or not to give” a particular resource. The situations described were often handled by negotiating a solution, rather than primarily withholding an intervention. This contrasts with the manner in which the issue of bedside rationing is sometimes addressed in the conceptual literature.
It has also been pointed out that conflicting obligations perceived by physicians can lead them to “game” the system, with potentially dangerous consequences.8,30,31 On this point also it seems that the decision is not a simple dichotomous choice, either to apply a rule unquestioningly or to game the system. Although our respondents reported being pitted between conflicting obligations, most of them found overt ways of negotiating solutions without resorting to covert rule breaking.
Our findings also suggest that justice is relatively rarely explicit in the rationale that underlies the resource allocation decisions in clinical practice. This contrasts with the normative literature. Two interpretations of this result are possible: physicians may not perceive justice arguments as the prime rationale for rationing. They could resist the idea of letting any patient go without a benefit, even if this were compatible with, or even necessary to ensure, a just distribution of resources. In this case, questions of distributive justice could seem irrelevant to them. Although it may be reassuring that responding physicians took their role as patient advocate seriously, if justice in resource allocation seems irrelevant to them in an environment where allocation decisions must be made, this could be a cause for concern. Further research is needed to determine whether this is the case.
Our findings suggest that a real disconnect may exist in the debate that surrounds health care rationing. On the one hand, physicians’ experiences in situations of resource constraints appear to be more complex than the normative literature assumes. On the other hand, reasoning about justice in health care seems to play only a small part in clinical decision making about resource allocation. Bridging this gap could be an important step in grounding the debate and fostering fair allocation of resources in difficult cases.
Correspondence: Samia A. Hurst, MD, Unité de Recherche et d’Enseignement en Bioéthique, Villa Thury 8, Centre Médical Universitaire, Rue Michel Servet 1, 1211 Genève 4, Switzerland (firstname.lastname@example.org).
Accepted for Publication: July 21, 2004.
Financial Disclosure: None.
Funding/Support: This study was funded by the National Institutes of Health, Bethesda, Md. Dr Hurst was supported by a grant from the Oltramare Foundation, Geneva, Switzerland, and by the University Hospitals of Geneva.
Disclaimer: The views expressed herein are those of the authors and do not reflect the positions of the National Institutes of Health, the US Public Health Service, the US Department of Health and Human Services, the Oltramare Foundation, or the University Hospitals of Geneva.
Acknowledgment: We thank Ezekiel Emanuel, MD, PhD, Philip Greenland, MD, and the anonymous reviewers for their invaluable criticism of the manuscript, as well as Michael Ferry, MA, and Leah Sartorius, BS, for technical help.
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