The ethics of gatekeeping in rehabilitation medicine

Everywhere one looks in health care, concern is being expressed about the ethical issues raised by efforts to contain costs. Managed care bears much of the brunt of these concerns. Many health policy analysts argue that the central issue raised by the need to contain costs is the need to arrive at a set of rules or principles that will permit the fair and equitable allocation of resources. However, the main moral challenge posed by cost containment is not arriving at agreed-upon principles. Rather, it is the moral dilemma created when health care providers are asked to serve in the roles of both bedside patient advocate and guardian of societal resources. This is especially true in the field of rehabilitation medicine, where patients often cannot protect their own interests due to impairments of competency or loss of freedom as a result of institutionalization, or because they find it hard to deal with the team approach, in which the locus of authority can be difficult to determine.