Simpson Christopher S, Hoffmaster Barry, Dorian Paul
Arrhythmia Service (Cardiology), Department of Medicine, Queen's University, Kingston, Canada.
Can J Cardiol. 2005 May 15;21(7):595-9.
Implantable cardioverter defibrillators have been shown to reduce all-cause mortality in some patient populations at risk of sudden death. New Canadian guidelines recommend implantable cardioverter defibrillator therapy for these patients. However, the need for these devices exceeds the funded volumes in many Canadian jurisdictions. As a result, rationing of this resource has been necessary. While rationing at the macro (Ministry of Health) and meso (hospital) levels has achieved some level of acceptance by society, the responsibility for the decisions taken at the micro (individual) patient level actually rests with the physician at the bedside. This 'bedside rationing' creates a moral dilemma for physicians, who are torn between their traditional fiduciary role as 'patient advocate' and the competing role of 'gatekeeper'. This 'downward delegation' of rationing decision-making obscures the reality that rationing occurs, and encourages covert, opaque and inconsistent approaches. The remedy is the development of fair, legitimate procedures for making rationing decisions that include guidelines that structure and constrain those decisions. Macro- and meso-level stakeholders must also recognize and take responsibility for their part in restricting resources in a broadly inclusive and transparent process.
植入式心脏复律除颤器已被证明可降低某些有猝死风险患者群体的全因死亡率。加拿大新指南建议对这些患者采用植入式心脏复律除颤器治疗。然而，在加拿大许多司法管辖区，对这些设备的需求超过了资金支持的数量。因此，必须对这种资源进行配给。虽然在宏观（卫生部）和中观（医院）层面的配给已在一定程度上为社会所接受，但微观（个体）患者层面决策的责任实际上落在了床边的医生身上。这种“床边配给”给医生带来了道德困境，他们在作为“患者代言人”的传统受托角色和“守门人”这一相互冲突的角色之间左右为难。这种配给决策的“向下委托”掩盖了配给发生的现实，并助长了隐蔽、不透明和不一致的做法。补救办法是制定公平、合理的配给决策程序，包括构建和约束这些决策的指南。宏观和中观层面的利益相关者也必须认识到并为他们在广泛包容和透明的过程中限制资源所起的作用承担责任。
