Caring and cost: The challenge for physician advocacy

How should physicians respond to the growing tension between care and cost? One option is to reinforce the ideal of doing everything to further the be st interests of the individual patient. Others, however, have argued that b ecause health care resources are shared and limited, physicians should cons ciously participate In rationing by saying "no" to patients' requests for s ome marginally beneficial services. But even physicians who endorse the idea of rationing wonder whether patien t-physician relationships could ever survive a frank admission of rationing at the bedside. This article explores the idea that caring about costs can be brought to the bedside in a way that will sustain trust among patients and the public. By illustrating a hypothetical case and the ensuing convers ation between a physician and her patient, a mode of "proportional" patient advocacy is presented in which physicians can remain forceful agents for p atient good while acting within a framework that admits to the boundaries o f responsible budgets for health care needs.