Resource Allocation in Healthcare: Implications of Models of Medicine as a Profession

Abstract

For decades, the problem of how to allocate healthcare resources in a just and equitable fashion has been the subject of concerted discussion and analysis, yet the issue has stubbornly resisted resolution. This article suggests that a major reason for this is that the discussion has focused exclusively on the nature and status of the material resources, and that the nature and role of the medical profession have been entirely ignored. Because physicians are gatekeepers to healthcare resources, their role in allocation is central from a process perspective. This article identifies 3 distinct interpretations of the nature of medicine, shows how each mandates a different method of allocation, and argues that unless an appropriate model of medicine is developed that acknowledges the valid points contained in each of the 3 approaches, the allocation problem will remain unsolvable.

Introduction

When resources are limited and demand exceeds supply, allocation becomes a problem. How that problem is solved depends largely on the nature of the resources themselves. When the resources are construed as social goods, allocation may proceed either in terms of competition between individuals on the basis of the relative strengths of their competing rights, or on an aggregate basis by evaluating which distribution would (be likely to) produce the greatest amount of good for the greatest number of people. When the resources are construed as commodities, the allocation problem assumes a different orientation. Notions of competing rights or of maximizing the aggregate good drop out of the picture and economic considerations take their place. On the microlevel, allocation is then resolved on the basis of the ability to pay; on the macrolevel, the question becomes whether the economic structure that governs the cost/price relationship for the commodities is sufficiently robust to allow for the survival of the economic enterprise that is associated with the production and sale of the goods in question.

These considerations apply to healthcare as much as they do to anything else. Healthcare resources, whether understood in material or in human terms, are limited, nor is this a function of how healthcare is delivered. The fact of limitation is inherent in the human condition. Whether healthcare is delivered in a private or in a public setting – or even in a mixture of both – the number of people who can deliver the care is always limited because not everyone can be a healthcare professional (and even healthcare professionals may fall ill and require care, thus making them unavailable as healthcare providers). The amount of resources will always be limited because there is a limit to the number of facilities that can be constructed, the number of instruments that can be manufactured, or the number of organs, amount of blood, etc that will be available. The demand for healthcare resources, therefore, will always and necessarily exceed supply. That means that limitation is not an artifact, and that there will always be an allocation problem. How is it to be resolved?

Traditionally, the issue has been dealt with by a complex mix of approaches that try to balance competing rights and duties with cost and outcome measures. However, if the current literature and current policy discussions are anything to go on, these attempts cannot really be considered successful. The issue requires an overall solution that can be consistently applied across the whole field of healthcare, not something that works in isolated instances and that can be applied in only selected areas and in a piecemeal fashion. In this article, I want to explore why the healthcare resource allocation problem has so stubbornly resisted solution, and sketch the beginnings of a solution.

I am going to suggest that the usual approaches to the allocation problem are based on a selective approach to what actually goes on in healthcare resource allocation, and that the reason the problem has proved so intractable is precisely because it has been approached in this limited fashion. Specifically, I am going to suggest that concentrating mainly on the material resources – which is the traditional way of approaching the issue – is part of the problem. It ignores the fact that it is the healthcare professionals – which is to say, the human resources – who turn what otherwise are merely material things into healthcare resources. Moreover, from a process perspective, it is the healthcare professionals who function as gatekeepers to the material resources that are in short supply. They are, so to speak, the choke point in the access and distribution systems. That is why how they function determines what shape the resource allocation issue will ultimately take. This is not to say that the status of the material healthcare resources – whether they are treated as social goods or as commodities – is unimportant. Clearly, that would be a mistake. However, it is to say that this is only part of the picture and, from a process perspective, a secondary part at that. Until the role of the human resources – of the healthcare professionals – has been clarified, the whole debate over the status of the material resources contributes very little to a solution, and the question of what allocation mechanism is appropriate can receive only a partial answer.

The discussion that follows will attempt to show how this is the case. Therefore, it will not deal with healthcare resources as understood in the material sense, but only with the human side of the equation, ie, it will deal only with the nature, role, and ethical status of the healthcare professions and with the implications that this has for resource allocation. Even here the discussion will be limited. It will consider only a specific subgroup of healthcare professionals, namely, physicians. It will identify and briefly sketch several distinct conceptualizations of the profession of medicine, trace their ethical implications, and show how they legitimate different approaches to resource allocation because of the distinctive gatekeeper roles that physicians play within these different conceptualizations. Subsequent discussions will then deal with the ethical status of material healthcare resources, integrate this into a process model of healthcare professionals as gatekeepers, and develop a general framework for healthcare resource allocation that takes these various factors into account.

Healthcare Resources in Human Terms

The Hippocratic Model

Medicine – and, to reiterate, the present discussion is confined to human healthcare resources as focused in the medical profession – has traditionally presented its nature and purpose as being embodied in the spirit of the Hippocratic oath. In that oath, the physician promises, “Whatever house I may visit, I will come for the benefit of the sick.”[1] In more modern times, this has been restated in the Declaration of Geneva as the injunction that “the health of [the] patient will be [the physician's] first consideration,”[2] and in the International Code of Medical Ethics as the statement that “a physician shall owe his patients complete loyalty and all the resources of his science.”[3] The same sentiment is also expressed in the clause that “a physician shall always act in the patient's best interest when providing medical care.”[3] Similar expressions can be found in the codes of ethics of almost every national medical association.[4–8]

From the Hippocratic perspective, the focus of medical action gravitates around the physician-patient encounter. It establishes a fiduciary relationship between the physician and the patient.[9–12] This means that the physician's duty toward the individual patient overrides all other considerations except insofar as these affect the physician's ability to fulfill her or his patient-related duties. Therefore, the physician must abstain from considerations, such as the social cost of the treatment, the likelihood that the patient will return to a productive life, the effect that ministering to the patient's needs will have on third parties, etc, except as they bear on the welfare of the patient. Above all, it means that when resources are limited and allocation decisions arise, the physician cannot approach the problem by balancing the patient's rights against the interests of other members of society. In fact, because the physician's duty is to advance the good of the patient – to act “for the benefit of the sick” and “in the patient's bests interest when providing medical care” – the physician cannot even entertain the notion of balancing rights as a legitimate concern.

The point is sufficiently important to deserve restating. If the nature and purpose of medicine are captured by the Hippocratic model, then the fiduciary nature of that model entails that the physician cannot treat allocation issues as genuine issues that involve competition, and cannot approach the scarcity of resources from the perspective of balancing competing rights. Instead, the physician is obligated to determine what is in the best interests of the patient, and has a fiduciary duty to acquire the resources that are necessary to meet those interests and to advance the good of the patient. The physician must do so regardless of the impact that such actions might have on other persons who might also have a need, on overall healthcare budgets, or on the ability of society to provide healthcare for its members.

In other words, the concept of balancing rights, whether that is at the individual or at the aggregate level, cannot then be part of the physician's conceptual framework. Balancing would never be in the patient's best interests. Moreover, outcome considerations will be relevant only if in this specific case the outcome is negative for this specific patient. Therefore, outcome considerations are germane only insofar as they are therapeutically relevant, ie, only insofar as they allow the physician to determine what particular treatment is therapeutically the most appropriate. Cost-benefit and cost-effectiveness considerations must be completely abandoned because they violate the fiduciary obligation that this physician has toward this patient here and now.

Scarcity does not give rise to an allocation problem but to an acquisition problem, ie, the issue for the physician is not one of how to allocate – of what counts as a fair and equitable distribution – but one of acquisition: of how to acquire the resources that are necessary for the physician to fulfill the fiduciary duty of care that is triggered by the inception of the physician-patient relationship. Each physician must proceed as though her/his patient's right was supreme. On a consistent application of the Hippocratic model, therefore, the resolution to resource scarcity will ultimately have to occur not in terms of an ethics of allocation but in terms of professional power and persuasiveness.

The Social Service Model

By contrast, what might be called the social service model approaches medicine from a much broader perspective. It construes medicine as one among several social enterprises of which the overall purpose is to advance the well-being of members of society.[13–21] The sole distinguishing feature of medicine when viewed from this perspective is that, unlike other social undertakings, its focus is the health status of members of society. This means that on this approach, although medicine must acknowledge the importance of the physician-patient encounter, it cannot consider this encounter to be the raison d'être of medicine as a profession. Instead, the importance that it attaches to the physician-patient encounter will be derivative of the profession's mandate to advance the welfare of members of society in general. The physician-patient encounter becomes, so to speak, nothing more nor less than the actualization or expression of the profession's social role.

On this approach, therefore, the physician is society's agent and, as such, has delegated authority in matters of healthcare delivery. That is why, in order to be able to exercise this socially derived office, society accords physicians certain privileges. For instance, it is physicians and physicians alone who may prescribe drugs, perform surgeries, or engage in the other health-oriented interventions that society prohibits to all other individuals – all on the assumption that unless physicians have this socially mandated service-provider monopoly, the welfare of society will be worse off. The physician-patient encounter, therefore, becomes merely the way in which the overall role that has been assigned by society to the profession of medicine expresses itself at the hands-on level. It is, so to speak, the operationalization of medicine as a kind of social service.

When medicine is considered from this social service perspective, allocation issues assume an entirely different nature. Although the physician-patient encounter retains an element of fiduciary duty, that element is limited by the constraints that are imposed by the embedding of medicine as a social service profession. Specifically, both on the micro- and the macrolevel – that is to say, on the level of individual and one-on-one competition between the patients of one and the same physician and between patients of different physicians, as well as on the level of competition between individual patients and groups of patients – it becomes appropriate to balance competing right claims. Moreover, in each case, the allocation issue has to be resolved in terms of an ethics that treats the rights of the individual not as something that belongs to the individual in isolation from her or his social embedding. Instead, it proceeds on the principle that something is a right if and only if it produces (or is likely to produce) the greatest good for the greatest number.

In other words, to use traditional terminology, the social service approach to the nature of medicine mandates a utilitarian interpretation of the notion of a right and a utilitarian approach to resource allocation. It also means that cost-benefit and cost-effectiveness considerations acquire the legitimacy that they lack on the Hippocratic interpretation, and outcome measures that center in the aggregate good and that focus on the social impact of a given intervention become determining.

The Business Model

A third approach to medicine, and one that also affects the nature of resource allocation, may be called the business model. It construes medicine neither as the sort of fiduciary undertaking that is characterized by the Hippocratic approach nor as a health-oriented profession that operationalizes society's duty to do the best for its members. Instead, it becomes one among many other types of profit-making enterprises that are allowed by society in economic terms. In other words, it portrays physicians as entrepreneurs who have undergone the socially validated regimen of education and training that is necessary before receiving a license to practice – much the way that chartered accountants or airline pilots undergo education and training before being licensed – and who now have a sophisticated socially approved service for sale.[22–26] With this interpretation, the monopolistic position of medicine derives from the fact that society is eager to ensure that certain standards of service are met – just as in the case of accountants and airline pilots – and professional medical ethics becomes a species of business ethics. With this perspective, also, the patient becomes a service consumer or customer, and the physician-patient relationship is defined in purely contractual terms. Fiduciary considerations become relevant only within the limits set by the contract and therefore are subject to terms that find their basis in contract law, not in the traditional ethics of the profession.

The business model has its unique way of structuring resource allocation. The physician, as licensed service provider, still retains a gatekeeping function – just as in the social service model. However, the gatekeeping determinants are not ethical in nature and do not involve a balancing of competing rights. Instead, the economics of the marketplace become the primary determinants, and allocation decisions become a purely financial matter. Not to put too fine a point on it: A patient's right to healthcare resources becomes defined in terms of the patient's financial capacity.

In other words, with this approach, resource allocation does not arise as an ethical issue as soon as resources are limited and supply is exceeded by demand. Instead, it arises only within the context of financial arrangements, which is to say that the problem of healthcare resource allocation arises only when the healthcare consumer has entered into a contractual relationship with the physician and the physician is faced with limited resources. Outside of that contractual relationship, health resource allocation is simply not an issue because medicine is a business, and there is no objective and independent right to healthcare resources any more than there is a right to the services of a chartered accountant or of an airline pilot independently of the contractual arrangements that trigger the corresponding service obligations. However, once the contractual relationship has been confirmed and thereby a physician-patient relationship has been established, resource allocation does become a problem if demand exceeds supply – because access to the relevant resources then becomes a necessary condition in order for the physician to be able to fulfill that contract.

Moreover, when that situation occurs, resource allocation has to be settled not on the basis of competing ethical rights but on the basis of contract law. Need and similar considerations become irrelevant except insofar as they figure as elements in the contract itself. In other words, a patient's need will trigger a rights claim only if the patient has a contract that stipulates such a right, because such a right will exist only within the contractual domain.[26] Trivially, this means that the resource claims of those who have contracts will always trump the claims of those who do not have contracts because only the former have a right. With this interpretation, therefore, the operant question for healthcare resource allocation becomes whether the consumer can afford (and has contracted for) the relevant services. Also, outcome measures, in general, and cost-benefit and cost-effectiveness considerations, in particular, become irrelevant as far as determining access and allocation is concerned. They enter the picture only insofar as they relate to the physician's market competitiveness and the consumer's ability to pay. Fiduciary obligations become contract-driven, and neither individual nor aggregate rights play any role in these calculations.

Analysis

Issues for the Hippocratic Model

Each of these approaches has its own unique problems. For instance, the Hippocratic model ignores 2 facts that are important in the context of allocation. First, it ignores the fact that physicians tend to have more than 1 patient, and that each of these patients stands in a fiduciary relationship with the physician. Therefore, the fact that a particular individual has entered into a physician-patient relationship with a specific physician does not mean that the physician can ignore the competing healthcare claims of other persons. Minimally, the physician must evaluate that claim relative to the equal and competing rights of the physician's other patients. However, the model provides no conflict resolution mechanism for this eventuality.

Second, the Hippocratic model ignores the fact that no rights are absolute. All rights arise in a social context, and therefore are conditioned by the equal and competing rights of others. However, every patient is a member of society – which is to say that every patient is a person among persons. Therefore, by focusing solely on the needs of the individual patient who has entered into a fiduciary relationship with the physician, and by offering only considerations of best interests as the determining criterion for access to resources, this approach ignores the fact that the rights claim of a specific patient cannot be evaluated in isolation and solely on the basis of this patient's need. The equal and competing rights of others must also be taken into account. It means that there will be limits to the rights of the individual patient, and it may happen that this patient's rights must be overruled by the rights of that patient because of some ethically relevant difference that is independent of the fiduciary obligation that the physician owes to this patient.

Moreover, at a still more fundamental level, the pure Hippocratic model is much too simplistic in how it characterizes the nature and role of medicine. Its focus is on the physician-patient encounter and on the individual patient, and it accords a special status to the individual patient – and, correspondingly, places a special duty on the individual physician – because the patient, by interacting with the physician, has acquired a special claim on the physician, and the physician has acquired special duties relative to this patient. In a sense, of course, this is correct. However, that is not the end of the matter, nor does it mean that the realm of ethically relevant considerations is confined within the limits of this fiduciary relationship, whether that is with respect to resource allocation or anything else. What is also ethically important is that the inception of the physician-patient relationship depends on nonmedical factors, such as the ability of the individual to present in the physician's clinic or to engage with the physician in some other way. This, in turn, is conditioned by socioeconomic and geographic factors. Clearly, someone who cannot afford to take time off from work to see a physician, who cannot afford to travel the requisite distance, or who cannot engage the relevant communication devices cannot establish this sort of physician-patient relationship. Therefore, the Hippocratic model leads to an allocation model that, in fact, gives preferential standing to the rights of those who have been able to surmount the socioeconomic, geographic, or other barriers that limit access to physicians in the first place.

Another consequence of the model is that what may be best for a particular patient may have downstream consequences that have a negative impact on the ability of the physician to adequately address the rights claims of other patients. For instance, one of the consequences of treating extremely premature newborns is the increased likelihood of negative health-related sequelae that require continued and costly healthcare interventions. The Hippocratic model requires that as long as the relevant lifesaving and/or sustaining interventions are possible, the physician has a duty to demand them for the patient regardless of the fact that providing them will mean that doing so will lead to a general unavailability of healthcare resources for the rest of society. To put it bluntly, by eschewing cost-effectiveness and cost-benefit considerations, the Hippocratic model treats the healthcare claims of the individual patient who presents here and now as paramount over the claims of all other patients of all other physicians. However, because this holds true for all physicians, it leads to a situation in which there is no way of resolving conflicting allocation claims – either within the practice of the individual physician or within the overall picture of society in general – and no way of acknowledging the impact of particular resource claims on the healthcare system as a whole.

Issues for the Social Service Model

The social service model faces what to some degree is the very mirror image of the problems that are faced by the Hippocratic approach. From this perspective, the physician's fiduciary obligations toward individual patients will always be subject to outcome measures, and competing rights claims for limited resources have to be settled in terms of the greatest good. In other words, according to this perspective only those patients whose condition can be treated by an intervention that has a socially positive outcome coefficient have a legitimate rights claim to healthcare.

The social service model, therefore, is based on utilitarian ethics. The problem with utilitarian ethics as applied to healthcare, and to the profession of medicine, in particular, is that it makes certain assumptions that are difficult to defend. For instance, it assumes that patients qua patients all count equally and that conditions, treatments, and outcomes can be quantified in commensurate terms that allow the development of aggregate scores that can be numerically balanced. This is not necessarily correct.

In the first place, this requires standardized means for translating quality-of-life considerations into numerical terms. However, although there are various proposals for achieving this task, there is no set of standardized measures that encompasses all health conditions and all aspects of healthcare.[27–30]

In the second place, it treats the strength of a given right as a function of the effectiveness of the intervention. This, in turn, assumes that effectiveness quotients for interventions have the same weight. That is not correct. It is well known that the effectiveness of an intervention is not only a function of the severity of the relevant condition, but is also related to the amount of research that has been expended on developing and perfecting the intervention and to the number of times that it is performed. Therefore, conditions that are dealt with only infrequently or only with a small number of patients are unlikely to achieve the same effectiveness quotients as those that are researched more thoroughly and treated on a more frequent basis. Consequently, with this approach, allocation decisions involve a systematic and incorrigible bias.

It is also well known that the cost of tools and devices used in healthcare – for instance, of pharmaceuticals – is functionally related to their volume of production. This virtually guarantees that the cost-benefit coefficient of the tools and devices for treating rare conditions will always be lower than those used in treating common conditions. Again, it is questionable whether this can form a firm basis for the claim that the right of patients whose treatment shows a lower cost-effectiveness or a lower cost-benefit coefficient is less than that of others and consequently must rank lower in their claim to resource allocation.

The preceding considerations have been couched in general terms and at the policy level. However, similar considerations apply at the level of hands-on practice. If medicine is construed as a social service model, this would mean that physicians must allocate scarce healthcare resources by applying the criterion of the greatest good for the greatest number in the case of each individual patient. This, however, becomes problematic in actual practice. Although physicians are best placed to diagnose and recommend treatments in purely medical terms, they lack the appropriate training to make social utility calculations. They also lack the time. Consequently, they would have to rely on diagnosis-related allocation rules on the basis of aggregate cost-benefit and cost-effectiveness calculations – rules that have been reached at the policy level and that involve measures, such as disability – and quality-adjusted life years (DALYs and QALYs), regardless of the particulars of a given case. It is not clear that this would be good medicine.

The social service approach faces another series of difficulties at the hands-on level. Trivially, such an approach requires that physicians apply outcome-oriented measures when making microallocation decisions. However, that will be fair if and only if all members of society have the same opportunity to access physicians, because delay in access has a negative effect on the severity of the condition for which treatment is being sought. That assumption is highly questionable because the ability to access physicians is functionally related to socioeconomic status. Therefore, this approach amounts to redefining fairness in terms that have nothing to do with healthcare.

What is potentially even more important is that unless physicians take the time to evaluate the claims of individual patients, they cannot make judgments as to which patient's condition shows a more positive cost-benefit and cost-effectiveness coefficient, and therefore which patient has a greater right. Unfortunately, one of the scarcest healthcare resources of all is physicians' time. Therefore, by failing to treat physicians' time as a scarce resource, the approach fails in one of its operant conditions.

Finally, the social service model runs into severe social difficulties, that is, current law states that physicians have a duty of care toward their patients that is related to the condition of the patient and the physician's ability and training,[31,32] and it insists that the physician's understanding of that duty is not subject to utilitarian considerations. As one court put it: “The maximization of social utility may well be a goal of legislative policy, but....the system of positive law...cannot permit acts in violation of legal obligation to be justified on the grounds that social utility is thereby increased.”[33]

Therefore, the social service approach is at odds with the law as it stands, and would require a fundamental restructuring of the physician-patient relationship as it is legally perceived. That would prove difficult.

Issues for the Business Model

The business model is not without its problems either. In the first instance, it assumes that what physicians offer for sale – their knowledge and expertise – is something that is theirs to sell. However, that is true only to a limited degree. The practice of medicine would be impossible if it were not for the willingness of members of society to participate in the research and experimentation that provide physicians with their stock-in-trade. People do not participate in medical research and experimentation in order to enable physicians to function as entrepreneurs and make a profit. They do it to benefit members of society who might experience a similar medical need regardless of whether these other people might have a contract with a physician-entrepreneur.

Therefore, although physicians own their expertise in the sense that they have acquired the ability to practice medicine through the education and training that they have received, that education and training have an unquantifiable social component in which society, through its members who have volunteered to participate in experimentation and as training subjects, has a stake. This social component uniquely characterizes medicine because no other profession requires prospective clients to risk life and limb so that professionals can acquire the knowledge and the expertise that the professional will later offer for sale. It is only by ignoring this fact that medicine can treat access to the limited resource of physician time in purely financial terms.

Furthermore, the model has an unrealistic view of some of the biological resources that are involved in some areas of healthcare. Transplantation is a case in point. Transplantation is impossible without organs. In a business model, the physician approaches transplantation logically the same way that a mechanic approaches the problem of replacing a faulty ignition in a car. The mechanic provides a service to the customer by installing an ignition that the mechanic has purchased and resells to the customer. If the mechanic could not buy an ignition, the mechanic could not enter into a contract with the customer and could not practice his or her trade.

Because car parts can be bought and sold, the business model is appropriate for mechanics and other trades. However, this is fundamentally different from what happens in transplantation. There is no ownership in human bodies. This means that human organs cannot be treated as items of commerce and cannot be bought or sold in the marketplace. Therefore, if medicine were understood as a business model, the transplant surgeon would be selling services with goods that the surgeon does not own, even though the surgeon does not charge for the organ – nor does the fact that the surgeon does not charge for organs change the situation. Organs are still necessary. However, organs are not donated to specific physicians or healthcare institutions, nor are they donated with the intent of financially benefiting a particular physician, healthcare institution, or insurer. They are donated to society in order to help those in need regardless of their contractual or financial position. Therefore, they are social goods, and access to them cannot ethically be claimed on the basis of one who has a wealthy client who can afford the services of an operating theater, a transplant team, and follow-up medical care. The pure business approach to medicine, therefore, is ethically inappropriate. With due alteration of detail, the same applies to any medical intervention with human biologics that have been donated. A great deal of surgery would thereby be implicated.

Third, the business model is unable to deal with allocation that involves competition between 2 (or more) patients of one and the same physician. Each of these patients can claim a contractually based fiduciary relationship. However, unless each service contract includes an algorithm that stipulates under what conditions one patient's right to care and resources takes priority over the rights of another patient having an analogous contract, there is no way of adjudicating between their competing claims. In practice, of course, the resolution will be effected either in terms of the severity of the respective conditions or by contracting with another physician to provide the relevant services. However, that assumes that there is a difference in severity/need, and that another healthcare provider is available. As to the first, it assumes something that is inherently antithetical to the business approach, namely, that need is an ethically relevant consideration regardless of contract. The second is based on an unrealistic assumption, because alternative healthcare providers are not always available. That is why triage protocols are necessary even in the private healthcare setting. However, that means that in order to be workable, the business approach to medicine cannot be consistently applied.

Medicine as a Monopoly

Despite their limited usefulness, each of these 3 approaches captures an important aspect of medicine as a profession. The Hippocratic model captures the fact that the physician's efforts should primarily be directed toward the best interests of the patient; the social service model captures the fact that medical practice occurs in a social setting and that therefore societal considerations are also relevant; and the business model captures the fact that physicians are professionals and therefore entitled to give some weight to entrepreneurial concerns.

Correspondingly, the allocation model entailed by each of these approaches captures something important about the ethics of healthcare and of healthcare resource allocation. The Hippocratic model captures the fact that healthcare delivery occurs at the hands-on level and consequently that allocation issues arise because of individual need; the social service model captures the fact that because healthcare is a social enterprise, more than 1 person has a need, which means that competing needs have to be balanced; and the business model captures the fact that modern physicians practice in a corporate environment and that an accommodation must be found that balances professional contracts with individual and social obligations.

Nevertheless, one conclusion seems patent: The problem of how to deal with healthcare resource allocation is importantly conditioned by how the nature and status of the profession of medicine is understood. Also, it is equally clear that simply picking one model of the profession over another cannot solve this problem. That would be to ignore the important ethical facts that are emphasized by each of the distinct approaches. Therefore, to properly deal with healthcare resource allocation requires a reconceptualizing of the role of physicians and of the nature of medicine as a profession: a reconceptualization that acknowledges the valid issues that are raised in each of the models, respectively.

However, it also seems clear that such a reconceptualization cannot be achieved simply by combining the various elements of the 3 models. Not only are certain aspects of these models mutually incompatible, but all of these models pay insufficient attention to an important fact that is integral to medicine as a profession within contemporary society and that itself has serious implications for allocation. This is the fact that medicine is a service-provider monopoly: All and only those individuals who meet certain socially approved standards of training and expertise will receive a license to practice medicine. Everyone else is prohibited from doing so.

To put this into context and show why this is important for the allocation debate, it may be useful to focus briefly on the notion of a service-provider monopoly itself. A service-provider monopoly is a right that is conferred by society and that gives the monopoly holder the exclusive right to provide the relevant service. It also bars anyone else from providing that service on pain of legal sanction. Therefore, the conferral of a service monopoly bestows certain advantages on the monopoly holder. However, it also imposes certain obligations. In particular, it imposes the obligation to provide the best possible service in as equitable a manner as possible so that no member of society who otherwise could have a claim on those services is excluded or disadvantaged. Therefore, although society's conferral of a service monopoly may have considerable benefit for the monopoly holder, its ultimate aim is not to advantage the monopoly holder but to benefit society and its individual members.

Therefore, the fact that the profession of medicine is a service-provider monopoly means that the profession has a duty to ensure not merely that the quality of medical services is as good as possible, but also that there is equitable access to the services that can be provided only by its members, and that the rules under which the resources that are controlled by the profession are provided are applied equitably. The crucial term here is “equitably”. Mere consistency of application is insufficient because the application of a distribution rule may be consistent but systematically unfair. It therefore follows that an ethically defensible and internally consistent approach to healthcare resource allocation cannot simply look at the material resources, but must also consider the role of physicians as the gatekeepers of these resources.

Moreover, it means looking at what is involved in constituting medicine as a socially sanctioned and monopolistically protected profession, but not only at the profession as profession. After all, although it is the profession that has the monopoly, it is the individual physician who provides the actual services and acts as the gatekeeper.

Therefore, it is important to consider how the service obligations of the profession as a whole translate into the obligations of the individual physician. The two, although superficially independent of each other, are logically linked by the fact that the individual physician practices within the monopolistic framework that characterizes the relationship between the profession (of which the physician is a member) and society as a whole. This means that the fiduciary obligations of the individual physician that arise within the physician-patient encounter arise within the monopolistic framework of the societal embedding of the profession as a whole.

This has important implications for resource allocations. A purely Hippocratic approach to medicine is blind to some of these implications because it misses the very important point that the physician is not merely a patient advocate but also a gatekeeper within a social context. That is to say, it ignores the fact that as a member of a service-provider monopoly, the physician's approach to the needs of the individual patient must acknowledge that the patient is a member of society, and that allocation will be ethically defensible if and only if it gives appropriate weight to the fact that a physician's fiduciary obligation toward the individual patient is conditioned by the equal and competing fiduciary obligations that other physicians have toward their patients.

Equally as importantly, however, it means that the social service model must acknowledge that the individual physician is not identical to the medical profession, and therefore that although ethically defensible resource allocation policies may (and should) incorporate overall social considerations, they also have to acknowledge that individual physicians have a fiduciary obligation toward their individual patients.

Finally, it means that although the business model cannot be an appropriate model for the ethics of healthcare resource allocation because it ignores the ethical implications of medicine as a service-provider monopoly (and the social nature of some healthcare goods), it can provide some useful tools for structuring the means of delivery once allocation has been settled.

Conclusion

Healthcare resource allocation presents an intractable problem because there are 3 important issues that must be resolved before one can even begin to attempt a solution:

• There must be a consistent and valid model of the nature and role of medicine as a monopolistic profession and of its individual members as practitioners within that setting;

• There must be a coherent and consistent model of the ethical status of the goods and services that are allocated by members of that profession; and

• There must be a consistent and coherent model of what role social values should be allowed to play in developing allocation algorithms for what, to a large degree, is a socially funded enterprise.

The preceding discussion has outlined how a lack of clarity in the understanding of medicine as a profession contributes significantly to the allocation problem. It has not suggested how an appropriate model of the profession should be constructed, nor has it addressed the issues of healthcare resources as social goods or the relevance and role of social values. These tasks will be addressed in subsequent articles.