Drs. Ubel and Goold [1] are to be applauded for helping physicians define and recognize when they are rationing at the bedside. Indeed, the medical literature reflects that silent rationing [2] and implicit rationing [3] have been and continue to be commonplace. My concern is that clinicians may not only ration without awareness but also execute their biases when they do so. Elderly persons, for example, are particularly vulnerable to this type of bedside rationing.

Although we may know that the fastest-growing segment of our population is persons 85 years of age and older, it may not be as obvious that proposals to ration care based on age have been in the literature for more than a decade [4]. Various studies document efficacy and cost-effectiveness in treating older patients, yet elderly patients continue to be labeled as the primary drain on the budget. We obfuscate the discussion by pitting grandparents against grandchildren for the health care dollar. Add physician-assisted suicide, futility guidelines, and capitation, and the need for even more objective data on how well older patients do or do not respond to aggressive therapies becomes imperative.

Ubel and Goold do us a service by awakening us to rationing. The appropriateness of care, not the amount of care, is the real issue as we uncover "ageism" in clinical practice [5]. If we acknowledge rationing as defined by the authors, are we then willing to set these limits across the spectrum of care without singling out one age group or segment of our population? Until our society reaches a consensus on this, physicians should not only become cognizant of their rationing behavior, as suggested by the authors, but incorporate the objective outcome data that are already available. Then, at least, we would not ration out of ignorance or bias.