Double agency and the ethics of rationing health care: a response to Marcia Angell

The arguments against doctors as "double agents" that are presented by Marcia Angell in the preceding article do not defeat the core justification for rationing some relatively high-expense, low-benefit care, and they do not enable us to conclude that clinicians should be barred from any active, substantive role in decisions to limit that care. They do, however, reveal several important conditions that need to govern cost-conscious medial practice in order to preserve an ethic of fidelity to patients: insurers' profits and providers' incomes must be fair, providers must inform patients of any economic reasons that lead to the foregoing of care, and "direct incentive" arrangements must not be used to contain costs.