Why Saying No to Patients in the United States Is So Hard

If cost-containment measures, such as the use of Medicare's diagnosis-related groups (DRGs), involved trimming only unnecessary health care services from public budgets, they would pose no moral problems. Instead, such measures lead physicians and hospitals to deny some possibly beneficial care, such as longer hospitalization or more diagnostic tests, to their own patients — that is, at the "micro" level.1 Similarly, if the "macro" decision not to disseminate a new medical procedure, such as liver transplantation, resulted only in the avoidance of waste, then it would pose no moral problem. When is it morally justifiable to say no to beneficial . . .