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Society should not accept the inevitability of rationing medical resources, at least not in the short term. Because of the high degree of waste and duplication that characterize the Canadian and, even more, the American healthcare system, the invitation to focus on rationing procedures known to be useful is likely to divert attention from the need to eliminate waste. If and when extensive rationing becomes necessary, however, Ubel's proposal that we adopt bedside rationing by physicians ought nevertheless to be rejected because it is ethically objectionable. Such a scheme would violate the bond of trust between doctor and patient, leading to arbitrary and discriminatory decisions. Since most physicians lack both the time and the expertise to perform cost-benefit calculations properly, Ubel's scheme would be inefficient as well as unethical. There is a better alternative.

In his essay on bedside rationing, Peter Ubel argues that in an era of rising healthcare costs, it is time to relax the patient-centered ethic of physicians as unconditional patient advocates so they can individualize rationing decisions. This paper raises several concerns with the arguments and the examples he provides to make his case. First, he overlooks cost-effectiveness when making medical spending decisions. Second, his examples of wasteful, unproven and potentially harmful interventions call for physician education, not rationing, as he suggests. Third, informed patients can play a role in lowering costs through shared decision making. Fourth, individualized rationing decisions will worsen already pervasive disparities in medical care. The paper envisions the ideal cost-conscious physician as one who is knowledgeable about cost-effective practices, avoids unproven interventions whenever possible, and facilitates shared decision making through patient education. Such an individual would not, however, withhold interventions of proven benefit except when accommodating a patient's preferences for a particular therapy. The doctor and patient can only work together within the constraints of system-wide rationing if the fiduciary relationship is never violated.

Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways

Peter Ubel's main conclusion is that physician participation in bedside rationing is essential to controlling healthcare costs. This conclusion is out of step with the current focus of thinking and policy debate within Canada and other countries with universal public healthcare systems. In the Canadian context, collectively we need to better understand the limits and choices in defining the "medicare commons," which occurs at the intersection of the overall level of funding, the range of services provided (comprehensiveness) and the level of access that we are able to provide. This will require a deliberative process that must engage patients/the public at all levels of decision-making. Physicians must accept responsibility to use scarce resources prudently, but this is a collective responsibility and must be exercised in a transparent manner.

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.