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Guidelines and the difficult issue of rationing

Guidelines for cardiac tests or treatment increasingly incorporate psychosocial factors into patient-selection criteria. This potentially introduces social-value judgements into clinical decisions and decisions about the rationing of care.

In the textbooks and guidelines reviewed by Dr. Mita Giacomini and colleagues, psychosocial characteristics are portrayed as either risk factors intrinsic to the candidate or as indicators of need for special intervention. However, the psychosocial factors tend to be inadequately described and substantiated and, if misapplied, could limit access to health care for vulnerable and marginal social groups.

In a related commentary, John Dossetor provides an ethicist’s view. He concludes that if, as seems increasingly likely, clinical practice guidelines are to be used in selecting patients for special services that are limited or rationed, they will require careful ethical analysis.

Additional contact: Dr. John Dossetor, Professor Emeritus of Medicine and Bioethics, University of Alberta, Ottawa; tel 613-236-4214

Guidelines as rationing tools: a qualitative analysis of psychosocial patient selection criteria for cardiac procedures — M.K. Giacomini et al

Psychosocial patient selection criteria in clinical practice guidelines: An ethical basis for rationing? — J.B. Dossetor

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