WHO SHOULD MANAGE CARE - THE CASE FOR PATIENTS

After establishing that it is essential that health care be rationed i n some fashion, the paper examines the arguments for and against clini cians as gatekeepers. It first argues that bedside clinicians do not h ave the information needed to make allocation decisions. Then it claim s that physicians at the bedside can be expected to make the wrong cho ice for two reasons: their commitment to the Hippocratic ethic forces them to pursue the patient's best interest (even when resources will p roduce only very marginal benefit and could do much more good elsewher e) and their values will lead them to calculate the net value of treat ments incorrectly. Alternative decision makers are considered. It is a rgued that both groups of physicians and administrators will also make allocations incorrectly and that leaving the allocation decisions to patients themselves is the best approach. Mechanisms for fair and effi cient rationing by patients at the societal and individual level are e xamined.