Psychosocial patient selection criteria in clinical practice guidelines: an ethical basis for rationing?

To help with such decisions, the movement for evidence-based medicine has promoted the writing of clinical practice guidelines. In this issue (page 634), Mita Giacomini and colleagues analyze the psychosocial content of a broad set of guidelines used in cardiology, rightly surmising that the selection criteria set out in these guidelines might unwittingly hide value judgements that could unjustly limit an individual patient's access to treatment.' The authors demonstrate competently the merits of scrutinizing clinical practice guidelines for their psychosocial biases, and this is the strength of their report. However, their discussion does not make explicit the implications of bringing selection criteria to bear on procedures that are both very costly and in limited supply (as in the case of heart transplantation) as opposed to selecting candidates for procedures that are available to all without the need for rationing. Severe material limitations (financial or biological) need not limit entitlement for patients in need of procedures that are reasonably accessible, such as pacemaker implantation, cardiac catheterization, angioplasty, coronary artery stent insertion, echocardiography or even coronary artery bypass surgery. In such cases, psychosocial selection criteria remain within the field of deontology. That is, in considering factors such as the patient's competence, family or other support systems, occupation-related considerations or even transport from remote locations, the ethical drive is still to maximize benefit for that patient. Weighing psychosocial factors in this context is evidence of a deontological commitment to nonmaleficence, not of a utilitarian commitment to collective outcomes. Clinical practice guidelines will probably play an increasingly important role in guiding decision-making by front-line health care providers in the selection of recipients for special services, including services that are rationed. If this is to happen, then guidelines will need to be legitimated by means other than simply relying on the expertise of physician "gatekeepers." This aspect, which is not part of the report by Giacomini and colleagues, is nevertheless a foreseeable outcome of future research in guideline development. The question of what constitutes full legitimization is addressed by Norheim,' who insists that, to be legitimate and authentic, clinical practice guidelines must pass public as well as widespread stakeholder standards of acceptabilit