Rationing by clinical judgment

While rationing by clinical judgment is controversial, its acceptability partly depends on how it is practiced. Here, the authors consider rationing by clinical judgment in three different circumstances that represent increasingly wider circles of resource pools in which the rationing decision takes place: triage during acute shortage, comparison to other potential patients in a context of limited but not immediately strained resources, and determination of whether expected benefit of an intervention is deemed sufficient to warrant its cost by reference to published population-based thresholds. Building on notions of procedural justice, an analytical framework that includes six minimal requisites is applied in order to facilitate fair bedside rationing: (1) a closed system that offers reciprocity, (2) attention to general concerns of justice, (3) respect for individual variations, (4) application of a consistent process, (5) explicitness, and (6) review of decisions. The process could be monitored for its applicability and appropriateness.