Citizens, their agents and health care rationing: an exploratory study using qualitative methods

This paper considers the application of the theoretical notion of a principal-agent relationship to societal health care decision making. Current literature sheds little light upon whether a citizen-agent relationship exists in health care, with ambiguity about whether citizens want agents to make rationing decisions on their behalf, and if so, who these societal agents might be. A qualitative approach, using semi-structured interviews as the main instrument of data collection and analysis by constant comparison, was used to explore these issues with groups of both citizens and their potential agents. The findings of the research suggest that citizens vary considerably in the extent to which they want to be directly involved in making rationing decisions. Important influences on this issue appear to be knowledge and experience, objectivity and the potential distress that denying care may cause. Agents, in contrast, view citizens as needing agents to make decisions for them and suggest that it is primarily the health authority's role to act in this capacity. It is, however, apparent that the citizen-agent relationship in health care is both imperfect and complex, with final decisions resulting from the interaction between the utility functions of the various actors in the health care system. In practice a system of equivocation can be envisaged in which different groups collude as they attempt to avoid the disutility associated with denying care, with the consequence that the impact of decisions taken on an explicitly societal or citizen basis may be relatively small.