THE PROBLEMS WITH RULE-BASED RATIONING

Centralized, democratic rules are often asserted as a superior basis f or rationing than individualized physician discretion. This article co unters this prevailing wisdom by exploring the deficiencies of rule-ba sed rationing. Rules are too imprecise to accurately reflect all the n uances of physical and mental impairment and the complexity of medical science, particularly considering the widely varying personal values that different patients attach to medical risk and benefit. Rule-based rationing also suffers from the biasing effects of interest group pre ssure on political processes and the tendency to absolve physicians fr om any moral responsibility for the rationing decisions they implement . Internalizing cost constraints is a more socially and professionally acceptable means of rationing and, in any event, it is inevitable sin ce even a preponderance of rule-based rationing will leave considerabl e areas of discretion for physician judgment in the implementation and interpretation of the rules. As a consequence, despite the flaws of b edside rationing, it is foolhardy to dispense with it entirely in favo r of an exclusively rule-based system.