Health Care Analysis

, Volume 27, Issue 2, pp 93–109 | Cite as

Evidence, Emotion and Eminence: A Qualitative and Evaluative Analysis of Doctors’ Skills in Macroallocation

  • Siun GallagherEmail author
  • Miles Little
  • Claire Hooker
Original Article


In this analysis of the ethical dimensions of doctors’ participation in macroallocation we set out to understand the skills they use, how they are acquired, and how they influence performance of the role. Using the principles of grounded moral analysis, we conducted a semi-structured interview study with Australian doctors engaged in macroallocation. We found that they performed expertise as argument, bringing together phronetic and rhetorical skills founded on communication, strategic thinking, finance, and health data. They had made significant, purposeful efforts to gain skills for the role. Our findings challenge common assumptions about doctors’ preferences in argumentation, and reveal an unexpected commitment to practical reason. Using the ethics of Paul Ricoeur in our analysis enabled us to identify the moral meaning of doctors’ skills and learning. We concluded that Ricoeur’s ethics offers an empirically grounded matrix for ethical analysis of the doctor’s role in macroallocation that may help to establish norms for procedure.


Macroallocation Priority setting Ethics Paul Ricoeur Grounded moral analysis Physicians Skills 


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Australian Institute of Health and Welfare. (2014). Medical Workforce 2012. National health workforce series. Canberra: AIHW.Google Scholar
  2. 2.
    Australian Institute of Health and Welfare. (2016). Australia’s Medical Workforce 2015. Canberra.Google Scholar
  3. 3.
    Australian Medical Association. (2017). AMA code of ethics 2004. Editorially Revised 2006. Revised 2016. Accessed April 22, 2017.
  4. 4.
    Belcher, H. (2014). Power, politics and health care. In J. Germov (Ed.), Second opinion: An introduction to health sociology (5th ed., pp. 356–379). Melbourne: Oxford University Press.Google Scholar
  5. 5.
    Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginnners. London: SAGE.Google Scholar
  6. 6.
    Brody, H. (2009). The future of bioethics. Oxford: Oxford University Press.Google Scholar
  7. 7.
    Bujak, J. (2008). Inside the physician mind: Finding common ground with doctors. Chicago, IL: Health Administration Press.Google Scholar
  8. 8.
    Campbell, D. M., Redman, S., Jorm, L., Cooke, M., Zwi, A. B., & Rychetnik, L. (2009). Increasing the use of evidence in health policy: Practice and views of policy makers and researchers. Australia and New Zealand Health Policy, 6(1), 21.CrossRefGoogle Scholar
  9. 9.
    Charmaz, K. (2014). Constructing grounded theory. London: Sage.Google Scholar
  10. 10.
    Croft, D., Jay, S. J., Meslin, E. M., Gaffney, M. M., & Odell, J. D. (2012). Perspective: Is it time for advocacy training in medical education? Academic Medicine, 87(9), 1165–1170. Scholar
  11. 11.
    Daniels, N. (2016). Resource allocation and priority setting. In D. H. Barrett, L. H. Ortmann, A. Dawson, C. Saenz, A. Reis, & G. Bolan (Eds.), Public health ethics (1st ed.). New York: Springer.Google Scholar
  12. 12.
    Danis, M., Clancy, C. M., & Churchill, L. R. (2002). Introduction. In M. Danis, C. M. Clancy, & L. R. Churchill (Eds.), Ethical dimensions of health policy. New York: Oxford University Press.Google Scholar
  13. 13.
    Danziger, M. (1995). Policy analysis postmodernized. Policy Studies Journal, 23(3), 435–450.CrossRefGoogle Scholar
  14. 14.
    Dobson, S., Voyer, S., Hubinette, M., & Regehr, G. (2014). From the clinic to the community: The activities and abilities of effective health advocates. Academic Medicine. Scholar
  15. 15.
    Dowie, J. (2007). Decision analysis: The ethical approach to most health decision making. In R. E. Ashcroft & I. Wiley (Eds.), Principles of health care ethics (pp. 577–583). Hoboken, NJ: Wiley.Google Scholar
  16. 16.
    Duckett, S. J. (1984). Special issue: Health and health care in Australasia structural interests and Australian health policy. Social Science and Medicine, 18(11), 959–966. Scholar
  17. 17.
    Dunn, M., Sheehan, M., Hope, T., & Parker, M. (2012). Toward methodological innovation in empirical ethics research. Cambridge Quarterly of Healthcare Ethics, 21(4), 466–480. Scholar
  18. 18.
    Earnest, M. A., Wong, S. L., & Federico, S. G. (2010). Perspective: Physician advocacy: What is it and how do we do it? Academic Medicine, 85(1), 63–67. Scholar
  19. 19.
    Ebbesen, M., & Pedersen, B. D. (2007). Using empirical research to formulate normative ethical principles in biomedicine. Medicine, Health Care and Philosophy, 10(1), 33–48. Scholar
  20. 20.
    Eckard, N., Janzon, M., & Levin, L. A. (2014). Use of cost-effectiveness data in priority setting decisions: Experiences from the national guidelines for heart diseases in Sweden. International Journal of Health Policy and Management, 3(6), 323–332. Scholar
  21. 21.
    Ehninger, D. (1970). Argument as method: Its nature, its limitations and its uses. Speech Monographs, 37(2), 101–110. Scholar
  22. 22.
    Emanuel, E. J. (2002). Foreword. In M. Danis, C. M. Clancy, & L. R. Churchill (Eds.), Ethical dimensions of health policy (pp. vii–xi). New York: Oxford University Press.Google Scholar
  23. 23.
    Fischer, F. (1998). Beyond empiricism: Policy inquiry in post positivist perspective. Policy Studies Journal, 26(1), 129–146.CrossRefGoogle Scholar
  24. 24.
    Fischer, F. (2004). Professional expertise in a deliberative democracy. The Good Society, 13(1), 21–27. Scholar
  25. 25.
    Fischer, F. (2007). Deliberative policy analysis as practical reason: Integrating empirical and normative arguments. In F. Fischer, G. J. Miller, & M. S. Sidney (Eds.), Handbook of public policy analysis: Theory, politics & methods. Boca Raton: Taylor & Francis.Google Scholar
  26. 26.
    Fischer, F. (2009). Democracy and expertise: Reorienting policy inquiry. New York, NY: Oxford University Press.CrossRefGoogle Scholar
  27. 27.
    Freidson, E. (2013). Professionalism: The third logic. Hoboken: Wiley.Google Scholar
  28. 28.
    Furnham, A., & Ofstein, A. (1997). Ethical ideology and the allocation of scarce medical resources. The British Journal of Medical Psychology, 70(1), 51–63.CrossRefGoogle Scholar
  29. 29.
    Gottweis, H. (2007). Rhetoric in policy making: Between logos, ethos, and pathos. In F. Fischer, G. J. Miller, & M. S. Sidney (Eds.), Handbook of public policy analysis: Theory, politics & methods. Boca Raton: Taylor & Francis.Google Scholar
  30. 30.
    Greenhalgh, T., & Russell, J. (2009). Evidence-based policymaking: A critique. Perspectives in Biology and Medicine, 52(2), 304–318.CrossRefGoogle Scholar
  31. 31.
    Haynes, A. S., Derrick, G. E., Redman, S., Hall, W. D., Gillespie, J. A., Chapman, S., et al. (2012). Identifying trustworthy experts: How do policymakers find and assess public health researchers worth consulting or collaborating with. PLoS ONE, 7(3), e32665.CrossRefGoogle Scholar
  32. 32.
    Hoedemaekers, R., & Dekkers, W. (2003). Key concepts in health care priority setting. Health Care Analysis, 11(4), 309–323. Scholar
  33. 33.
    Homan, M. S. (2004). Promoting community change: Making it happen in the real world (Vol. 3). Belmont, CA: Thomson/Brooks/Cole.Google Scholar
  34. 34.
    Huddle, T. S. (2011). Perspective: Medical professionalism and medical education should not involve commitments to political advocacy. Academic Medicine, 86(3), 378–383. Scholar
  35. 35.
    Huddle, T. S. (2013). The limits of social justice as an aspect of medical professionalism. Journal of Medicine and Philosophy, 38(4), 369–387. Scholar
  36. 36.
    Huddle, T. S. (2014). Political activism is not mandated by medical professionalism. American Journal of Bioethics, 14(9), 51–53. Scholar
  37. 37.
    Ives, J., & Draper, H. (2009). Appropriate methodologies for empirical bioethics: It’s all relative. Bioethics, 23(4), 249–258.CrossRefGoogle Scholar
  38. 38.
    Kenny, A., & Duckett, S. (2004). A question of place: Medical power in rural Australia. Social Science and Medicine, 58(6), 1059–1073. Scholar
  39. 39.
    Kenny, N., & Joffres, C. (2008). An ethical analysis of international health priority-setting. Health Care Analysis, 16(2), 145–160.CrossRefGoogle Scholar
  40. 40.
    Kilner, J. F. (2004). Healthcare resources, allocation of: I. Macroallocation. In S. G. Post (Ed.), Encyclopedia of bioethics (3rd ed., Vol. 2, pp. 1098–1107). New York: Macmillan Reference USA.Google Scholar
  41. 41.
    Kirby, J., & Simpson, C. (2007). An innovative, inclusive process for meso-level health policy development. HEC Forum, 19(2), 161–176. Scholar
  42. 42.
    Kirch, D. G., & Ast, C. (2017). What should guide health policy? A perspective beyond politics. Academic Medicine, 92, 1222–1224.CrossRefGoogle Scholar
  43. 43.
    Klein, R., Day, P., & Redmayne, S. (1996). Managing scarcity: Priority setting and rationing in the National Health Service. Buckingham: Open University Press.Google Scholar
  44. 44.
    Light, D. W., & Hughes, D. (2001). Introduction: A sociological perspective on rationing: Power, rhetoric and situated practices. Sociology of Health & Illness, 23(5), 551–569. Scholar
  45. 45.
    Majdik, Z. P., & Keith, W. M. (2011). Expertise as argument: Authority, democracy, and problem-solving. Argumentation, 25(3), 371.CrossRefGoogle Scholar
  46. 46.
    Majone, G. (1989). Evidence, argument, and persuasion in the policy process. New Haven: Yale University Press.Google Scholar
  47. 47.
    Martin, D., Abelson, J., & Singer, P. (2002). Participation in health care priority-setting through the eyes of the participants. Journal of Health Services Research & Policy, 7(4), 222–229. Scholar
  48. 48.
    McKie, J., Shrimpton, B., Hurworth, R., Bell, C., & Richardson, J. (2008). Who should be involved in health care decision making? A qualitative study. Health Care Analysis, 16(2), 114–126.CrossRefGoogle Scholar
  49. 49.
    Mooney, G., & Houston, S. (2004). An alternative approach to resource allocation. Applied Health Economics and Health Policy, 3(1), 29–33. Scholar
  50. 50.
    Oliver, K., Lorenc, T., & Innvær, S. (2014). New directions in evidence-based policy research: A critical analysis of the literature. Health Research Policy and Systems, 12(1), 34.CrossRefGoogle Scholar
  51. 51.
    Pellegrino, E. D., & Thomasma, D. C. (1993). The virtues in medical practice. New York: Oxford University Press.Google Scholar
  52. 52.
    Perelman, C., & Olbrechts-Tyteca, L. (1971). The new rhetoric: A treatise on argumentation (P. Weaver & J. Wilkinson, Trans.). Notre Dame, London: University of Notre Dame Press.Google Scholar
  53. 53.
    Rich, A. (2004). Think tanks, public policy, and the politics of expertise (pp. 1–6). Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  54. 54.
    Ricœur, P. (1992). Oneself as another. Chicago: University of Chicago Press.Google Scholar
  55. 55.
    Ricœur, P. (2000). The just. Chicago: University of Chicago Press.Google Scholar
  56. 56.
    Ricœur, P. (2007). Reflections on the just. Chicago: University of Chicago Press.Google Scholar
  57. 57.
    Russell, J., Greenhalgh, T., Byrne, E., & McDonnell, J. (2008). Recognizing rhetoric in health care policy analysis. [Research Support, Non-U.S. Gov’t]. Journal of Health Services & Research Policy, 13(1), 40–46.
  58. 58.
    Salloch, S., Wäscher, S., Vollmann, J., & Schildmann, J. (2015). The normative background of empirical-ethical research: First steps towards a transparent and reasoned approach in the selection of an ethical theory. BMC Medical Ethics, 16(1), 20.CrossRefGoogle Scholar
  59. 59.
    Sanderson, I. (2009). Intelligent policy making for a complex world: Pragmatism, evidence and learning. Political Studies, 57(4), 699–719.CrossRefGoogle Scholar
  60. 60.
    Scheunemann, L. P., & White, D. B. (2011). The ethics and reality of rationing in medicine. Chest, 140(6), 1625–1632. Scholar
  61. 61.
    Smith, N., Mitton, C., Davidson, A., & Williams, I. (2014). A politics of priority setting: Ideas, interests and institutions in healthcare resource allocation. Public Policy and Administration, 29(4), 331–347.CrossRefGoogle Scholar
  62. 62.
    Taylor, G. H. (2014). Ricœur and just institutions. Philosophy Today, 58(4), 571–589. Scholar
  63. 63.
    Thistlethwaite, J., & Spencer, J. (2008). Professionalism in medicine. Oxford: Radcliffe Publishing.Google Scholar
  64. 64.
    Thorne, M. L. (2002). Colonizing the new world of NHS management: The shifting power of professionals. Health Services Management Research, 15(1), 14–26. Scholar
  65. 65.
    Throgmorton, J. A. (1991). The rhetorics of policy analysis. Policy Sciences, 24(2), 153–179.CrossRefGoogle Scholar
  66. 66.
    Tilburt, J. C., & Brody, B. (2016). Doubly distributing special obligations: What professional practice can learn from parenting. Journal of Medical Ethics. Scholar
  67. 67.
    Veatch, R. M. (1990). Physicians and cost containment: The ethical conflict. Jurimetrics, 30(4), 461–482.Google Scholar
  68. 68.
    Wild, C. (2005). Ethics of resource allocation: Instruments for rational decision making in support of a sustainable health care. Poiesis & Praxis, 3(4), 296–309. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Sydney Health Ethics, Faculty of MedicineThe University of SydneyCamperdownAustralia
  2. 2.Medical Humanities, Sydney Health Ethics, Faculty of MedicineThe University of SydneyCamperdownAustralia

Personalised recommendations