How Do We Ascertain Our Priorities In Health Care?

October 09, 1998

The second phase of priority setting

Drawing on his own experiences, in this week's BMJ Professor Jim Sabin from Harvard Medical School writes a moving account of the quandary clinicians find themselves in when involved in a rationing process. He believes that patients are able to understand the need for priority setting if the case is presented simply and honestly to them. By using simple common sense terms that make fundamental human sense, the author says that patients can understand the concept of rationing just as they can understand interrupting their appointment to tend to an emergency with another patient.

Sabin concludes that resolving the inherent conflict between acting for the good of the individual and acting for the benefit of the community requires more of the heart than the brain. He believes that the US experience of rationing to date has been adversarial and argues that patients and society need clinicians and managers to join with them in deliberating about solutions to "this painful but ultimately unavoidable conflict of the heart".

In his paper Dr S¯ren Holm from the University of Copenhagen describes how priority setting in Scandinavia has passed through two phases. He explains that the first phase was based on the idea that it is possible to devise a rational priority setting system that will produce legitimate decisions. The second stage realised that the concept of devising a simple set of rules to govern rationing is fundamentally flawed. He concludes that current thinking is now focussed on the priority setting process itself and methods to ensure its transparency.

Dr David Chinitz et al report that Israel's 1995 National Health Insurance law included an explicit rationing process which, under pressures for cost control, was carried out implicitly. Their analysis of the development of this process concludes that explicit and implicit approaches to rationing and priority setting are not exclusive alternatives but rather complementary tools which support each other.

Contacts: The following authors will all be in London from 8 - 10 October at the second international conference on priorities in health care and contactable through Jill Shepherd in the BMJ press office

Professor Jim Sabin, Associate Clinical Professor of Psychiatry, Centre for Ethics in Managed Care, Harvard Pilgrim Health Care and Harvard Medical School, Boston, USA email:

Dr S¯ren Holm, Department of Medical Philosophy and Clinical Theory, University of Copenhagen, Denmark

Dr David Chinitz, Lecturer, Hebrew University-Hadassah, School of Public Health, Jerusalem, Israel


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