Allocation of Medical Resources

Who decides who gets what?How is the decision to be made?

Medical resources are expensive. How are they to be allocated? Who decides who gets what? How do doctors, hospital managers and

society make decisions between patients with competing medical needs?

Key Issues

Should treatment be to everyone regardless of whether their illness is self-inflicted?Smokers, drinkers, drug users, drink drivers, self-harmers?

Should it be regardless of cost? E.g. 1 liver transplant v’s 100 hip replacements?

Should it be regardless of age? E.g. 25 week premature baby v’s 70 yr old pensioner?

Should it b regardless of the patient’s place in society - rich or poor, law-abiding or criminal, post code lottery?

Key questions

QALYs: Quality Adjusted life Years. Ask question: how many years of good

quality life will patient have as a result of treatment?

Doctors use this method when allocating drugs, surgery and technological treatments to competing patients – look at the long-term prognosis of each case.

Medical Method

Natural Institute of Clinical Excellence decides which treatments and technologies – from drugs to artificial hips – should or should not be available on the NHS in England and Wales.

Set up to remove ‘postcode lottery’ of health care and to ensure parity throughout the NHS.

Has to balance clinical effectiveness and cost effectiveness.

NICE

Weighs up: The benefits on any treatment v’s the

benefits of note. Any undesirable side effects The effects of removing NHS availability The impact of any treatment on length and

quality of life The net cost to the NHS The impact of the treatment on NHS

resources

How does NICE make its decisions?

Many expensive new drugs such as beta-interferon do not ‘cure’ a disease but ameliorate (ease) the symptoms of chronic disease such as MS.

Hence NICE rules against its use – money would be better spent on actual cures and effective treatment.

Man who paid £8000 for cryotherapy which has 98% success rate yet not approved by NICE as too expensive for use throughout NHS.

Examples of NICE decisions

Teleological approach Greatest good for the greatest number Motives are unimportant consequences are

what matters. The end justifies the means Utilitarianism and justice do not always

correspond Minority count less than the majority – hard

on some individuals.

Utilitarianism - Bentham

Greatest good for the greatest number – mirrors NICE principles e.g. 100 hip replacements rather than 1 liver transplant, several people on kidney dialysis rather than 1 kidney transplant, inoculating all babies against childhood diseases rather than expensive intensive care treatment for very premature babies.

Examples

Applying HC is similar to applying QALYs Provides a flexible and intelligible guide to

solving the complex issue of resource allocation

Hedonic Calculus

Apply IDCERRP – try to give examples of at least 3 criteria.

e.g. Intensity of pain, duration of pain/disability, remoteness of effect of non-treatment, extent of people affected in person treated or not.

Should doctors look at age, sex, marital status, number of dependents, income, emotional stability, education, occupation, future potential.

Hedonic Calculus

Bentham – no one’s happiness is to be counted as more important than anyone else’s .

“everybody is to count for one, nobody for more than one.”

Supported by Peter Singer – a politician should not count more than a murderer, a mother more than her child, a disabled person more than a scientist with a cure for cancer, a pensioner more than a premature baby – decisions should only be made on clinical medical reasons.

Utilitarian views against unfair allocation of resources

Rule utilitarian – law as a set of principles developed and tested by history to normally ensure the greatest happiness of the greatest number.

Idea of justice & community. One group shouldn’t count more than others. Quality rather than quantity - would look to

QALYs too. Higher pleasures

Mill

Apply to 2nd formulation of CI Treat people as ends not means Example – decide between a young smoker

and an older non-smoker. Using QALYs doctor will choose non-smoker even though older.

Kant – use reason with non-smoker to give up then s/he would have more QALYs, involving patient in decision.

Doctor has duty to preserve life – this doesn’t help decide which person gets the treatment.

Kant

“Matters of life and death” 4 Principles 1. transparency 2. Equality 3. Impartiality 4. Defend the poor and vulnerable

Christian views - Wyatt

Idealistic and in reality not everyone can be treated.

Shouldn’t be selfish in the demand they put on the NHS

Remember that Jesus accepted suffering. Shouldn’t fear death as they believe in the

after life.

Wyatt’s Idealism

Not an issue in 1st C. Have to try to apply and extract principles

Parable of the Talents Matt 25:14-30

Divine Command

Stewardship Gen1 26:30 Use limited resources wisely Give treatment only when it is genuinely

needed. Avoid giving unnecessary treatment Needs v’s wants

Divine Command - stewardship

All created in God’s image Gen1:27 Treat people with care and reverence Body as a temple 1 Cor6:19 Everyone created equal therefore equal

access to medical care.

Sanctity of life

Apply Agapeic calculus: look at individual cases on the basis of Christian LOVE (AGAPE) – involves equality, impartiality, justice and compassion.

Situation Ethics

www.ethicsforschool.org CMF Katie Wasson 2002 principles for decision

making Tom Hale 1999 Time and Money developing

world ethics

Web site articles

Refers to concept of stewardship, sanctity of life, parable of the talents and applies them to resource allocation.

Individuals as needs v’s wants Look at medical needs Rights and duties

Katie Wasson – resource allocation

Justice – fairness and equality Fairness Give people what they deserve Does it mean giving priority to those who

have a disease or accident rather than those who deliberately put themselves at risk?

God treats everyone equally God acts unconditionally out of love and

compassion.

Justice

Avoid discrimination Treat people equally Jesus respected all people regardless Doctors should not let discrimination cloud

their judgement

Equality

People have different needs Inequity is when differences in care are not

morally justified Equity involves weighing up what is best for

the individual with what is fair, equal and just.

Equity

Points out Jesus healed the sick in mind, body and spirit – irrespective of the cause of the illness.

Parable of the Sheep and the Goats Look to God to provide resources Christians look forward to a time when ill-

health and suffering will be a thing of the past when God’s kingdom arrives on earth – Revelation 21:1-5

More than we deserve

Christians have a difficult task making decisions about resource allocation.

Balance individual needs against the Christians principles of justice, equality and equity.

Look forward to a time of not suffering In the meantime decisions will be made that

reflect God’s love, justice and concern for the individual and the disadvantaged.

Wasson - Conclusion

Outline the key features of a utilitarian approach to the allocation of resources in medicine

Explain how the key ideas of the religion you have studied could be applied to the issue of resource allocation in medicine

Questions