Explicit rationing needs more debate

EDITOR—In their article on rationing health care in New Zealand Feek et al call for clinicians to accept the link between clinical decision making and resource allocation.1 Clinicians in New Zealand are very aware of this link but ask that politicians accept the complexity and uncertainty inherent in clinical decisions, the changing knowledge base of medicine, and the heterogeneity of patients.

Guidelines to determine access to care have now been introduced for several services (predominantly surgical) in New Zealand. Making these guidelines explicit raises several concerns. Explicit evidence based guidelines may not best serve the interests of patients and society. Although it is optimal to attempt to practise using the best available evidence, this approach has limitations. Evidence is limited; randomised controlled trials cannot be done in all cases (because of ethical and cost constraints) and produce problems in generalising from highly selected subjects …