Balancing the impact of socio-ethical and economic considerations on clinical-hospital decision-making

BACKGROUND: Healthcare systems increasingly operate under chronic scarcity, requiring prioritisation decisions beyond formal coverage policies and bedside clinical judgment. While much of the ethical literature on priority setting has focused on macro-level allocation or individual clinician decision-making, comparatively limited attention has been devoted to the meso level, where senior hospital medical managers shape access through implicit operational decisions under sustained constraint. METHODS: This study examines how senior medical managers approach prioritisation when clinical need, prognosis, and expected benefit are held constant. Using structured allocation scenarios that vary only in socio-ethical and economic patient characteristics, we conceptually distinguish between the practical acceptability of non-clinical criteria and their perceived normative legitimacy. Eighty-two senior medical managers participate. RESULTS: Most respondents appear to reject explicit prioritisation under scarcity, endorsing equal treatment even when resources are insufficient. When prioritisation occurs, younger patients are more frequently favoured, typically on clinical rather than on economic grounds. Economic determinants, including reimbursement status, insurance coverage, and anticipated downstream costs, were rarely endorsed as explicit prioritization criteria despite participants' simultaneous recognition of responsibility for departmental sustainability. CONCLUSIONS: These findings suggest a structured moral tension at the meso level. Economic constraints may be reframed through clinically grounded justifications, potentially obscuring underlying value tradeoffs, while non-prioritisation itself emerges as an ethically meaningful stance with distributive consequences. Using acceptability and legitimacy as a conceptual lens, this study underscores the need for transparent, procedurally robust approaches to hospital-level prioritisation under chronic scarcity.