Ethical issues permeate medicine, starting with our duty to do no harm. Beyond that are the issues of deciding what is best for patients' welfare, telling patients about our errors and those of other physicians, deciding whether assisting a suicide breaches the physician-patient bond, and the difficult responsibility of honoring the wishes of patients when they can no longer express them. The marketplace is forcing healthcare budgets into fairly narrow ranges, so MCOs must decide how to designate dollars for best effect. This allocation of resources by principle rather than at random is rationing in the good sense. Rationing simply means setting limits and is not in itself an ethical issue.
Ethics become involved when value judgments are made in setting the limits.
Value judgments are often of concern when restrictions are imposed on patients' choice of physician, treatments offered, or accessibility of care. MCOs attempt to reduce unnecessary use of healthcare dollars through various mechanisms. They may require concurrent review programs to second-guess physicians' orders for referrals, tests, or treatments. Review programs may delay or obstruct needed care and be burdensome to physicians. However, they also may detect and correct for variations in practice that lead to unfair allocation of resources and so serve as a quality check.