The doctor's dilemma

The close relationship between expenditure on health care and the countless individual judgements made by doctors for their patients means that any discussion about rationing must involve the process of clinical decision-making. Increasingly, doctors are being drawn into rationing by two powerful forces. Firstly, through the corporate responsibilities of those working within a managed health care system in which organisational objectives and budgetary constraints are agreed and specified in a much more explicit way than ever before. Secondly, by the professionally-led movement towards more clinically effective practice. These, in combination, are leading towards a fundamental review of the nature and ethical basis of clinical practice in which the duty of doctors to individual patients must be balanced against the wider considerations.