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Samia A. Hurst, MD; Sara Chandros Hull, PhD; Gordon DuVal, SJD; Marion Danis, MD

Arch Intern Med. 2005;165:639-644.

Background  A common dilemma that confronts physicians in clinical practice is the allocation of scarce resources. Yet the strategies used by physicians in actual situations of resource constraint have not been studied. This study explores the strategies and rationales reported by physicians in situations of resource constraints encountered in practice.

Methods  A national survey of US internists, oncologists, and intensive care specialists was performed by computer-assisted telephone interviews. As part of this survey, we asked physicians to tell us about a recent ethical dilemma encountered in practice. A subset of respondents reported difficulties regarding resource allocation. Transcripts of open-ended responses were coded for content based on consensus.

Results  Of the 600 physicians originally identified, 537 were eligible and 344 participated (response rate, 64%). Internists do not make allocation decisions alone but rather engage in negotiation in their resolution. Furthermore, these decisions are not made as dichotomous choices. Rather they often involve alternative solutions in the face of complexities of both the health care system and situations where limited resources must be allocated. Justice is not commonly the justification for rationing.

Conclusion  Physicians’ experiences in situations of resource constraints appear to be more complex than the normative literature on health care rationing assumes. In addition, reasoning about justice in health care seems to play only a small part in clinical decision making. Bridging this gap could be an important step in fostering fair allocation of resources in difficult cases.

Author Affiliations: Department of Clinical Bioethics, National Institutes of Health, Bethesda, Md (Drs Hurst, Hull, and Danis); and University of Toronto Joint Centre for Bioethics, Toronto, Ontario (Dr DuVal). This work was conducted while Drs Hurst and DuVal were fellows in the Department of Clinical Bioethics at the National Institutes of Health.

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