Physicians have an ethical responsibility to their patients to offer the best available medical care. This responsibility conflicts with their role as gatekeepers of the limited health care resources available for all patients collectively. It is ethically untenable to expect doctors to face this trade-off during each patient encounter; the physician cannot be expected to compromise the wellbeing of the patient in the office in favour of anonymous patients elsewhere. Hence, as in other domains of public policy where individual and (...) collective interests conflict, some form of collective solution is required. Collective solutions may take the form of placing explicit resource constraints on resources available to physicians, or clinical practice guidelines that recognise cost-effective care as acceptable. Such solutions will be politically and ethically sustainable only if patients as citizens of the larger population accept the need for rationing of limited resources in health care. (shrink)

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most (or all)hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector (even though it varies between the countries),with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are out-of-pocket co-payments for GPconsultations, (...) with upper limits, but consultations forchildren are free. Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity. (shrink)