Who Should Do the Work of Access? A Bioethical Allocation Framework for Necessary Patient-Facing Administrative Work in European Health Systems

This study examines who should bear the necessary patient-facing administrative work required to access healthcare in European health systems. It presents a comparative documentary analysis of 24 administrative pathways across Greece, Germany, Sweden and the Netherlands, covering six functional areas: planned cross-border care, outpatient specialist access, physiotherapy and rehabilitation, assistive devices, special/high-cost medicines, and scheduled non-emergency patient transport. The study combines an Administrative Burden Audit Protocol, Framework Method-informed cross-case analysis, document-derived process mapping, exploratory fuzzy-set Qualitative Comparative Analysis (fsQCA), and normative bioethical analysis. Particular attention is given to the distinction between administrative complexity and administrative work actually transferred to patients. The findings indicate that patient-facing administrative burden is shaped not merely by the number of procedural steps, but by the allocation of documentary, navigational, authorization and coordination responsibilities among patients, professionals and institutions. The exploratory QCA results are interpreted cautiously as set-theoretic associations rather than causal effects and demonstrate sensitivity to calibration choices. The study proposes a nine-stage Bioethical Allocation Framework and a Patient-Work Impact Assessment (PWIA) for evaluating whether necessary administrative work should be performed by patients, healthcare professionals, institutions or shared among actors. The central normative distinction is between meaningful patient participation and avoidable administrative offloading. The record includes the English manuscript, a Greek translation, a reproducibility workbook, recognized-software QCA outputs and accompanying documentation.