Who Should Ration?

A principal component of physician decision making is judging what interventions are clinically appropriate.Due to the inexorable and steady increase of health care costs in the US, physicians are constantly being urged to exercise judicious financial stewardship with due regard for the financial implications of what they prescribe.When applied on a case-bycase basis, this otherwise reasonable approach can lead to either inadvertent or overt and arbitrary restriction of interventions for some patients rather than others on the basis of clinically irrelevant characteristics such as ethnicity, gender, age, or skin color.In the absence of systemwide reform in which the resources saved from one patient or group of patients are reallocated for the benefit of others, prudence is urged in the application of "bedside rationing."Case Mr. J is a 58-year-old black man who has been mostly homeless for the past eight years.He has a number of chronic medical conditions of which end-stage renal failure is his most critical.He has been receiving hemodialysis for six years.Because he does not have health insurance and is not eligible for Medicaid in the state in which he resides, Medicare covers many of the costs associated with care for his kidney disease under the end-stage renal disease benefit.Mr. J is not a known substance abuser but does have significant mental health issues and has preferred to live on the streets rather than in the shelters and the halfway houses to which he has been assigned.He has also proved to be unable to maintain a relationship with outpatient dialysis centers, despite multiple attempts and interventions by social services.He is an ultra-frequent visitor to the university hospital emergency department (ED), with up to ten visits a week in the cold winter months.Most of his dialysis is administered there or at the hospital's inpatient dialysis facility.Not surprisingly, his erratic care and his lifestyle have contributed to a slow deterioration in his overall condition.The physicians who see him most often-ED physicians and hospitalists-believe that further provision of dialysis is a waste of hospital and national resources (and their time); they believe that Mr. J is incorrigible and is "using" them and the system for his own purposes.They wish to unilaterally stop treatment and switch him to hospice care, even though Mr. J retains decision-making capacity and expresses a desire to continue living as he has been doing.Should the