Abstract

There is no denying the existence of rationing in healthcare. It is an example par excellence of a "wicked issue." Faced with the reality of rationing, the issues are: who should ration, and how rule-bound and explicit should it be? Clinicians are ambivalent on these matters. Many would prefer governments and politicians to make these decisions openly in publicly funded healthcare systems, since they decide how much to spend on healthcare. Others believe it to be the responsibility of clinicians to decide how finite resources should best be used in individual cases.

Ubel's thesis in favour of "bedside rationing" is persuasive and probably comes closest to what people actually want. They remain ambivalent about the merits of implicit versus explicit approaches to rationing and appear to favour a middle way that encourages defensible and transparent decision-making processes while also allowing individual clinicians the discretion to exercise their judgement and experience when it comes to determining resource allocation. Rationing will always be messy and imperfect. Nevertheless, it is still possible to improve the way in which decisions are made without imposing additional rules and bureaucracy that will prove unworkable in practice.Hence the appeal of what has been termed "muddling through elegantly."