Ethical principles and the rationing of health care: a qualitative study in general practice

BACKGROUND: Researching sensitive topics, such as the rationing of treatments and denial of care, raises a number of ethical and methodological problems. AIM: To describe the methods and findings from a number of focus group discussions that examined how GPs apply ethical principles when allocating scarce resources. DESIGN OF STUDY: A small-scale qualitative study involving purposive sampling, semi-structured interviews and focus groups. SETTING: Twenty-four GPs from two contrasting areas of London: one relatively affluent and one relatively deprived. METHOD: Initial interviews asked GPs to identify key resource allocation issues. The interviews were transcribed and themes were identified. A number of case studies, each illustrative of an ethical issue related to rationing, were written up in the form of vignettes. In focus group discussions, GPs were given a number of these vignettes to debate. RESULTS: With respect to the ethical basis for decision making, the findings from this part of the study emphasised the role of social and psychological factors, the influence of the quality of the relationship between GPs and patients and confusion among GPs about their role in decision making. CONCLUSION: The use of vignettes developed from prior interviews with GPs creates a non-threatening environment to discuss sensitive or controversial issues. The acceptance by GPs of general moral principles does not entail clarity of coherence of the application of these principles in practice.