ICU physician's ethical role in distributing scarce resources

Of several schemes designed to ration scarce resources in the ICU, implicit rationing (i.e., by society at the macro level of resource input) and explicit rationing (i.e., by society at the level of bedside cost output) have the fewest ethical defects. The former (of which the British National Health Service is an example) threatens the traditional loyalty and honesty between physician and patient, and in the USA would probably transfer legal responsibility for any harm done by rationing from government to physician. The latter, structured in a form analogous to the American judicial system, identifies and leaves intact the respective responsibilities of state, physician, and patient, does not co-opt physicians into the bureaucracy, and encourages them to remain their patients' trustworthy advocates. As a basis for discussion, the public-policy statement offered above details at the macro and micro levels what is judged to be an ethically adequate position for the ICU physician facing this problem today.