'But if you look at the coronary anatomy...': Risk and rationing in cardiac surgery

Recently there has been wide public debate in Britain about the denial of cardiac surgery to smokers and other patients possessing negative risk factors. While some senior medical practitioners have insisted that such decisions are based on objective clinical grounds linked to prognosis and effective use of resources, other commentators argue that doctors are policing lifestyle and making judgements about deservingness. One way of shedding light on this controversy is to examine how medical practitioners themselves talk about cases when consequential decisions must be made. This paper presents tape-recorded data from cardiac catheterisation conferences in which cardiologists present cases to a cardiac surgeon, who must decide whether to accept them for surgery, For much of the time, decisions are linked to the technical feasibility of surgery and the details of coronary anatomy. However, in many conferences age, lifestyle, and wider social structural factors figure centrally in discussions and appear to influence outcomes. The analysis explores some of the tensions that occur as doctors move between 'technical' and 'social' discourse frames to make sense of patient histories. Far from remaining exclusively within a neutral medico-technical discourse, doctors construct arguments and counter-arguments that closely resemble the standpoints in the wider public debate on rationing and deservingness.