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To the Editor: Dr Bloche and Mr Jacobson¹ have clearly presented the dilemma that arises when physicians are mandated to become surrogates for a society that seeks to escape its responsibility for allocating health care to its individual members. While it may be necessary to "ration" health care, this policy should be decided openly and its consequences should apply to all—society should not risk the obvious conflicts of interest analyzed by the court in the Pegram case² to conceal its role in decision making, no matter how unpleasant the consequences. The concept of "fiduciary" in the Pegram decision vitiates this principle by allowing hidden economic incentives to play an inappropriate role in the actions of individual physicians treating individual patients.

What if the Pegram approach were applied to the legal profession? Would we wish to live in a society where public defenders received a bonus for practicing cost-efficient law—a bonus . . . [Full Text of this Article]

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The Supreme Court and Bedside Rationing
M. Gregg Bloche and Peter D. Jacobson
JAMA. 2000;284(21):2776-2779.
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