Citizens, their agents and hearth care rationing: An exploratory study using qualitative methods

This paper considers the application of the theoretical notion of a princip al-agent relationship to societal health care decision making. Current lite rature sheds little light upon whether a citizen-agent relationship exists in health care, with ambiguity about whether citizens want agents to make r ationing decisions on their behalf, and if so, who these societal agents mi ght be. A qualitative approach, using semi-structured interviews as the mai n instrument of data collection and analysis by constant comparison, was us ed to explore these issues with groups of both citizens and their potential agents. The findings of the research suggest that citizens vary considerab ly in the extent to which they want to be directly involved in making ratio ning decisions. Important influences on this issue appear to be knowledge a nd experience, objectivity and the potential distress that denying care may cause. Agents, in contrast, view citizens as needing agents to make decisi ons for them and suggest that it is primarily the health authority's role t o act in this capacity. It is, however, apparent that the citizen-agent rel ationship in health care is both imperfect and complex, with final decision s resulting from the interaction between the utility functions of the vario us actors in the health care system. In practice a system of equivocation c an be envisaged in which different groups collude as they attempt to avoid the disutility associated with denying care, with the consequence that the impact of decisions taken on an explicitly societal or citizen basis may be relatively small. Copyright (C) 2001 John Wiley & Sons, Ltd.