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Journal of Medicine and Philosophy 2008 33(1):80-99; doi:10.1093/jmp/jhm007
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© The Author 2008. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

How Physicians Allocate Scarce Resources at the Bedside: A Systematic Review of Qualitative Studies

Daniel Strech

Eberhard-Karls University, Tuebingen, Germany & Department of Bioethics, National Institutes of Health, Bethesda, Maryland, USA

Matthis Synofzik

Eberhard-Karls University, Tuebingen, Germany

Georg Marckmann

Eberhard-Karls University, Tuebingen, Germany

Address correspondence to: Daniel Strech, MD, PhD, Institut für Ethik und Geschichte der Medizin, Eberhard-Karls Universität, Schleichstraße 8, 72076 Tübingen, Germany. E-mail: daniel.strech{at}uni-tuebingen.de


  Abstract

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians’ perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians’ rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources.

Keywords: clinical ethics, health-care rationing, medical decision making, qualitative research, systematic review


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