Abstract

Two separate problems face both providers and recipients of health care in the United States: adequate access to care for all persons, and a need to control the costs of providing that care. However, as the costs of solutions to access problems are acknowledged by economists, cost containment becomes more difficult. As cost containment measures are implemented, difficulties in assuring adequate access to care are compounded. ;The most persuasive response to these mutually aggravating problems is to ration medical care. A common feature to all rationing mechanisms is the need for a gatekeeping function to safeguard limited medical services and resources. This function may be carried out either by specially empowered individuals or be procedurally determined by strict formula. I argue that primary care physicians ought fulfill the role of gatekeeper using a combination of universal guidelines together with individual "bedside" discretion. ;Several authors have rejected the suggestion that physicians function as gatekeepers on the basis of violating physicians' professional integrity and long standing obligations to patient advocacy. My thesis is that this position reflects an inadequate conception of integrity generally, and a misunderstanding of physicians' professional obligations of patient advocacy specifically. I suggest a way of understanding integrity that shows the moral preferability of having primary care physicians serve as gatekeepers. ;I further argue that in order for the mechanisms and criteria for rationing to be most just, they ought to emerge from a four step process: collective physician action, expert analysis, public participation, and federal legislation. Moreover, this process should originate from organized medicine's explicit and public proposal for a guaranteed minimum package of medical services, together with guidelines for making discretionary bedside rationing decisions. This solution might be understood either as a compromise or as a synthesis of physicians' collective and political obligations, depending on one's understanding of the nature of those obligations. By developing a just and cost-effective program of medical care rationing in the United States, universal and affordable access to care will be attained and the professional and political integrity of physicians will be enhanced