The purpose of this paper is to explore how rationing decisions are made by government and hospital policy makers and practitioners, at the micro, meso and macro levels of analysis, through examining the rationing of cardiac care in a Canadian hospital, and discussing how the interaction between policy makers and practitioners at each of these levels affects the process and outcomes. Data were collected through in-depth interviews with 20 key informants. We found that decision-making for rationing cardiac care is a complex process. As government and hospital policy makers seek to control costs through greater oversight of clinical decisions, practitioners resist this perceived challenge to their autonomy. Attempts by policy makers at the macro and meso levels to standardize the rationing process have had limited success as practitioners have largely retained their ability to make independent rationing judgments at the micro level. This study underscores the difficulties associated with efforts to constrain the autonomy of practitioners in making “bedside rationing” decisions and the need to move towards a more collaborative model of clinical governance.
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