Psychosocial patient selection criteria in clinical practice guidelines: an ethical basis for rationing?

to health care, the selection of candidates for certain procedures is fraught with difficulty, especially when those procedures are costly and the resources to provide them are limited. Such decisions are made within 2 different ethical frameworks. Deontological or duty-based ethics (from the Greek deon, “binding duty”) declare that every person has a value beyond price and that health care providers are bound to act in the best interest of each individual and must not curtail that obligation for the sake of other objectives (provided that no harm comes to others). In contrast, utilitarian or outcome-based ethics aim above all to maximize the good for the largest number in society, provided that the entitlement of individuals is not unjustly trampled. Primary care providers are able to abide mainly by deontological principles. However, some program directors and most health administrators are obliged also to apply utilitarian principles. It is when resources are limited that these 2 perfectly legitimate ethical approaches clash — and give rise to the difficult decisions involved in health care rationing. To help with such decisions, the movement for evidence-based medicine has promoted the writing of clinical practice guidelines. In this issue (page 634), Mita Giacomini and colleagues analyze the psychosocial content of a broad set of guidelines used in cardiology, rightly surmising that the selection criteria set out in these guidelines might unwittingly hide value judgements that could unjustly limit an individual patient’s access to treatment. They identify the following 6 psychosocial factors deemed to be relevant to the eligibility of patients for cardiac treatment: • behavioural and psychological makeup (e.g., lifestyle, mental competence or stability, capacity to comply with treatment) • availability of family and other support systems, when these are important to a favourable outcome • financial resources • occupation and social roles Psychosocial patient selection criteria in clinical practice guidelines: An ethical basis for rationing?