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?1This 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 …. (shrink)

Nurses and physicians may experience ethical conflict when there is a difference between their own values, their professional values or the values of their organization. The distribution of limited health care resources can be a major source of ethical conflict. Relatively few studies have examined nurses' and physicians' ethical conflict with organizations. This study examined the research question ‘What are the organizational ethical conflicts that hospital nurses and physicians experience in their practice?’ We interviewed 34 registered nurses, 10 nurse managers, (...) and 31 physicians as part of a larger study, and asked them to describe their ethical conflicts with organizations. Through content analysis, we identified themes of nurses' and physicians' ethical conflict with organizations and compared the themes for nurses with those for physicians. (shrink)

Social workers must often decide about priority at a case level, in a context of scarce resources. These decisions are disputable and controversial, which raises the question on what grounds are they made in practice. This article addresses that question through an empirical study of real-life case discussions in youth care in Flanders, the Dutch-speaking part of Belgium. Toulmin’s argumentation model is used to analyse the data. The study finds that most case discussions are processed in a rather technical manner. (...) But where there is active deliberation, key incidents show that the decision-makers undertake active and personal interpretation of the situation at hand, and that they also take a personal stance on the criteria for assigning priority. In other words, their practice can be understood as a hermeneutical activity. The article’s main conclusion is that the prioritisation process illustrates the moral-political core that is present in any social work decision-making practice. As this moral-political core seems to be hidden most of the time behind a technical-rational approach, questions remain whether the professionals involved are aware that it characterises their own judgements and whether insights into its nature are stimulated. (shrink)