In their lengthy article, Hall and Berenson [1] attempt to provide "a realistic set of ethical principles" for physicians. It is a vain attempt. A system that seeks to influence treatment decisions by holding a physician's livelihood hostage is fundamentally unethical, no matter how strong "a dose of realism" or rationalization is applied.

The authors state that bedside rationing is preferable to "centralized, role-based rationing," but this is precisely not the case. At the bedside, the physician's time-honored and essential role is to be nothing else than the patient's advocate. Anything that compromises this must be repudiated. This seems self-evident, but it becomes unmistakable in the event of an unfortunate medical outcome, when the treatment choices made often come into question. If physicians are then known to have been rewarded for economizing, their treatment decisions cannot escape appearing tainted by this, and the invaluable solace that patients and families traditionally received from the conviction that everything possible was done will be lost.

This is unacceptable. Physicians must reject attempts to make them responsible for rationing services for their patients. If rationing is to be done, it should probably be by our society at large. Physicians must be left free to struggle uncompromisingly on behalf of their patients. The "preservation of patients' trust in their physicians," which the authors cite as being essential, requires nothing less.

As an option for the individual physician, the authors recommend a "red-faced" test to avoid entering into "incentive arrangements that they are embarrassed to described accurately to their patients." This is unrealistic; in many parts of the United States, physicians have little choice but to accept these arrangements or to leave practice. The only remaining choice is to speak out against all arrangements that fail to keep physicians' incomes at least a barge pole's length away from their treatment decisions.