“Ruling in” and “ruling out”: Two approaches to the micro-rationing of health care

doi:10.1016/S0277-9536(96)00207-9

Social Science & Medicine

Volume 44, Issue 5, March 1997, Pages 589-599

https://doi.org/10.1016/S0277-9536(96)00207-9 Get rights and content

Abstract

Much of the implicit rationing said to characterise British health care occurs as doctors decide what resources to allocate to individual patients. This paper examines this process using data from case studies of selection of patients for cardiac surgery and admission to a specialist neurological rehabilitation centre. The analysis focuses on cardiac catheterisation conferences in which cardiologists present surgical candidates to a cardiac surgeon, and neuro-rehabilitation admissions conferences in which a multidisciplinary team assess the suitability of head injury and stroke patients referred by hospital doctors. For much of the time participants in both settings discuss patients within a clinical discourse that relies on technical assessments of coronary anatomy, ADL scores and the like. However, there are many examples where the discourse “frame” shifts to address patient characteristics of a social or moral nature. Information of this kind tends to be deployed in two ways: it can be used to signal the patient's unsuitability, usually on the basis that past behaviour implies poor prognosis (“ruling out”), or it can be used to suggest that a patient is especially deserving of help (“ruling in”). Analysis of the data suggests that “ruling out” is more salient within the cardiac catheterisation conferences, and “ruling in” within the neuro-rehabilitation admissions conferences. The authors suggest that this reflects differences in the work organisation of the two specialties, including the division of labour, the organisation of waiting lists as a queue or a pool, and the putative significance of patient agency in the genesis of disease and recovery.

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“Ruling in” and “ruling out”: Two approaches to the micro-rationing of health care

Abstract

Social Science & Medicine

Social Science & Medicine

The Painful Prescription: Rationing Health Care

Notes on the sociology of medical discourse: the language of case presentation

Journal of Health and Social Behavior

The ethnography of a medical setting: reading, writing and rhetoric

Qualitative Health Research

Rhetoric as skill in a medical setting

Medical Talk and Medical Work

The inevitability of rationing: a case study of rationing in the British National Health Service

Secret summit plans rationing for NHS

The Guardian

Bringing social structure back into clinical decision making

Social Science & Medicine

Medical language as symptom: doctor talk in a teaching hospital

Perspectives in Biology and Medicine

The influence of age on policies for admission and thrombolysis in coronary care units in the United Kingdom

Age and Ageing

Sociologic influences on decision making by clinicians

Annals of Internal Medicine

Rationing and Rationality in the National Health Service

Typification in a neuro-rehabilitation centre: Scheff revisited?

Sociological Review

“Innocent parties” and “disheartening” experiences: natural rhetorics in neurorehabilitation admissions conferences

Qualitative Health Research

Health care rationing: its effects on cardiologists in the United States and Britain

Sociology of Health and Illness