Intended for healthcare professionals

Education And Debate

Healthcare rationing—are additional criteria needed for assessing evidence based clinical practice guidelines?

BMJ 1999; 319 doi: (Published 27 November 1999) Cite this as: BMJ 1999;319:1426
  1. Ole Frithjof Norheim, associate professor (
  1. Division for General Practice, University of Bergen, N-5009 Bergen, Norway
  • Accepted 12 May 1999

In 1995 the case of “Child B” reached the headlines of British newspapers and stirred public debate about the decision to withhold a second bone marrow transplant from a child with acute myeloid leukaemia. 1 2 The decision was based on the weakness of scientific and clinical evidence of the treatment's efficacy. It was also argued that the decision was in accordance with guidelines for patient selection that were already in place for such specialised treatment. A central issue is why judgments such as this are not perceived as legitimate, even when they are based on clinical guidelines. The explanation may lie partly in the fact that the guidelines used have not been developed through a process considered as legitimate. Why should the patient, her parents, or the public accept some little known guidelines developed within the closed communities of medical experts? This issue is valid for all types of clinical practice guidelines. In this article, I examine guidelines as a mechanism for rationing and argue that this mechanism can be improved by involving the patient and the public.

Summary points

Clinical practice guidelines can be mechanisms for rationing and tools for improving the quality of rationing decisions

However, additional criteria for assessing the acceptability of evidence based clinical practice guidelines are needed

Rationing decisions based on guidelines could be acceptable if guidelines are developed through open and fair procedures

Guidelines used for rationing should be accessible to the public and explicit reasons for recommendations should be provided

Rationing and evidence based medicine

Rationing can be defined as the withholding of potentially beneficial health care through financial or organisational features of the healthcare system in question. The definition is broad enough to encompass the view that withholding of treatment perceived to be beneficial should be seen as a question of rationing.

One of the basic assumptions in …

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