Biom550: Allocation Of Scarce Medical Resources
Allocation of scarce Medical Resources
Prepared By: Noura B. Younes
Supervised By: Dr. Khalid Al Ali
Course
: BIOM550: Medical Lab. Laws & Ethics L01
Abstract
Allocation of scarce medical resources and access to medical care are major bioethical concerns in today’s society. Allocation refers to the distribution of available health –care resources. Access refers to whether people who should have health care are able to receive that care. Winners in the arena of access to health care are most likely healthy and well- insured individuals with good corporate coverage. Losers in this dilemma are often children, persons of color, and those who are poor and powerless. Allocation decision deal with how much shall be expended for medical …show more content…
resources and how these resources are to be distributed. For discussion, it is easier to define the problem in terms of macroallocation and microallocation of scarce resources.8 Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favoring the worst-off, maximizing total benefits, and promoting and rewarding social usefulness. 9-12 In early 2010, PHI and Hamad Medical Corporation (HMC) of Qatar entered into a formal agreement that enables HMC to draw upon PHI’s expertise in health system development and integration. PHI provides on-going support to HMC in the development of leadership and management practices that promote local decision-making, ensure appropriate resource allocation, and improve service levels across the continuum.
Many times allocation and access to scarce medical resources post more questions than answers. Influences, such as economics, geographic location, availability of health-care professionals, politics,and insurance coverage, determine both allocation and access to health care. How decisions are made and who decides are critical questions to be asked. As health-care professional, It is important to help clients to recognize what services are available to them and to help them determine where or how to access other services if needed. If time has not been spent thinking through some of these difficult choices, responding ethically becomes a challenge. In health care, as elsewhere, scarcity is the mother of allocation.1 Although the extent is debated,2,3 the scarcity of many specific interventions including beds in intensive care units,4 organs, and vaccines during pandemic influenza5 is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary.6 Allocation of scarce medical interventions is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria.7 During the 1960s, committees in
Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependents as criteria.7 Whenever health-care access and allocation decisions are made, improving health care should be the primary goal. Health professionals, researchers and member of nearly all academic disciplines have been formally debating such issues for many years. For discussion, it is easier to define the problem in terms of macroallocation and microallocation of scarce resources.
Macroallocation and Microallocation
Allocation decision deal with how much shall be expended for medical resources and how these resources are to be distributed.
Macroallocation decisions are made by larger bodies, such as government, health system agencies, health organizations, private foundations and health insurance carriers.
Macroallocation decisions also are evident when determinations are made regarding funding of medical research. How much should be allotted for cancer research, for preventive medicine, or for technological advance in medical equipment?
Microallocation decision concerning who shall obtain the resource available are made on an individual basis, usually by local hospital policy and doctors. Decisions at the microallocation level cut deeper in to conscience, because of their personal closeness to everyday living.8
How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested.9–12 Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multi-principle allocation systems.
Simple allocation principles
Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favoring the worst-off, maximizing total benefits, and promoting and rewarding social usefulness (table 1). We do not regard ability to pay as a plausible option for the scarce lifesaving inter venations we discuss.
Some people wrongly suggest that allocation can be based purely on scientific or clinical facts, often using the term “medical need”.13,14 There are no value-free medical criteria for allocation.15,16 Although biomedical facts determine a person’s post-transplant prognosis or the dose of vaccine that would confer immunity, responding to these facts requires ethical, value-based judgments. When evaluating principles, we need to distinguish between those that are insufficient and those that are flawed. Insufficient principles ignore some morally relevant considerations. Conversely, flawed principles recognize morally irrelevant considerations: inherently flawed principles necessarily recognize irrelevant considerations, whereas practically flawed principles allow irrelevant considerations to affect allocation. Principles that are individually insufficient could form part of an acceptable multi-principle system, whereas systems that include flawed principles are untenable because they will always recognize irrelevant considerations.
A. Treating people equally
Many scarce medical interventions, such as organ transplants, are indivisible. For indivisible goods, benefiting people equally entails providing equal chances at the scarce intervention—equality of opportunity, rather than equal amounts of it.1 Two principles attempt to embody this value.
Lottery
Allocation by lottery has been used, sometimes with explicit judicial and legislative endorsement, in military conscription, immigration, education, and distribution of vaccines.10, 17, 18 Lotteries have several attractions. Equal moral status supports an equal claim to scarce resources.19
Even among only roughly equal candidates, lotteries prevent small differences from drastically affecting outcome.18 Some people also support lottery allocation because “each person’s desire to stay alive should be regarded as of the same importance and deserving the same respect as that of anyone else”.20 Practically, lottery allocation is quick and requires little knowledge about recipients.18 Finally, lotteries resist corruption.18 The major disadvantage of lotteries is their blindness to many seemingly relevant factors.21,22
Random decisions between someone who can gain 40 years and someone who can gain only 4 months, or someone who has already lived for 80 years and someone who has lived only 20 years, are inappropriate.
Treating people equally often fails to treat them as equals.23 Ultimately, although allocation solely by lottery is insufficient, the lottery’s simplicity and resistance to corruption suggests that it could be incorporated into a multi-principle system.22
First-come, first-served
Within health care, many people endorse a first-come, first-served distribution of beds in intensive care units
24 or organs for transplant.25 The American Thoracic Society defends this principle as “a natural lottery— an egalitarian approach for fair [intensive care unit] resource allocation.”24 Others believe it promotes fair equality of opportunity,25 and allows physicians to avoid discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals.26 Some people simply equate it to lottery allocation.19 As with lottery allocation, many people endorse a first-come, first-served distribution of beds in intensive care units24 or organs for transplant.25 The American Thoracic Society defends this principle as “a natural lottery—an egalitarian approach for fair [intensive care unit] resource allocation.”24 Others believe it promotes fair equality of opportunity,25 and allows physicians to avoid
discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals.26 Some people simply equate it to lottery allocation.19
As with lottery allocation, first-come, first-served ignores relevant differences between people, but in practice, fails even to treat people equally. It favors people who are well-off , who become informed, and travel more quickly, and can queue for interventions without competing for employment or child-care concerns.27 Queues are also vulnerable to additional corruption. As New York State’s pandemic influenza planners stated, “Those who could figuratively (and sometimes literally) push to the front of the line would be vaccinated and stand the best chance for survival”.28 First-come, first-served allows morally irrelevant qualities—such as wealth, power, and connections—to decide who receives scarce interventions, and is therefore practically flawed.
B. Favoring the worst-off : prioritarianism
Franklin Roosevelt argued that “the test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little”.29 Philosophers call this preference for the worst-off prioritarianism.30 Some define being worst-off as currently lacking valuable goods, whereas others define it as lacking valuable goods throughout one’s entire life.8 Two principles embody these two interpretations.
Sickest first
Treating the sickest people first prioritizes those with the worst future prospects if left untreated. The socalled rule of rescue, which claims that “our moral response to the imminence of death demands that we rescue the doomed”, exemplifies this principle.31 Transplantable livers and hearts, as well as emergencyroom care, are allocated to the sickest individuals fi rst.21 Some people might argue that treating the sickest individuals fi rst is intuitively obvious.32 Others claim that the sickest people are also probably worst off overall, because healthier people might recover unaided or be saved later by new interventions.33 Finally, sickest-first allocation appeals to prognosis if untreated—a criterion clinicians frequently consider.14 On its own, sickest-first allocation ignores post-treatment prognosis: it applies even when only minor gains at high cost can be achieved.
To circumvent this result, some misleadingly claim that sick people with a small but clear chance of benefit do not have a medical need.13 Sick recipients’ prognoses are wrongly assumed to be normal, even though many interventions—such as liver transplants—are less effective for the sickest
people.34 If the failure to take account of prognosis were its only problem, sickest-first allocation would merely be insufficient. However, it myopically bases allocation on how sick someone is at the current time—a morally arbitrary factor in genuine scarcity.16 Preferential allocation of a scarce liver to an acutely ill person unjustly ignores a currently healthier person with progressive liver disease, who might be worse off when he or she later suffers liver failure.8,22 Favoring those who are currently sickest seems to assume that resource scarcity is temporary: that we can save the person who is now sickest and then save the progressively ill …show more content…
person later.8,22 However, even temporary scarcity does not guarantee another chance to save the progressively ill person. Furthermore, when interventions are persistently scarce, saving the progressively ill person later will always involve depriving others. When we cannot save everyone, saving the sickest first is inherently flawed and inconsistent with the core idea of priority to the worst-off .
Youngest first
Although not always recognized as such, youngest-first allocation directs resources to those who have had less of something supremely valuable—life-years.8 Dialysis machines and scarce organs have been allocated to younger recipients fi rst,35 and proposals for allocation in pandemic influenza priorities infants and children.36 Daniel Callahan37 has suggested strict age cut-off s for scarce life-saving interventions, whereas
Alan Williams38 has suggested a system that allocates interventions based on individuals’ distance from a normal life-span if left unaided. Prioritizing the youngest gives priority to the worst-off —those who would otherwise die having had the fewest life-years—and is thus fundamentally different from favoritism towards adults or people who are well-off .8,9 Also, allocating preferentially to the young has an appeal that favoring other worst-off individuals such as women, poor people, or minorities lacks: “Because [all people] age, treating people of different ages differently does not mean that we are treating persons unequally.”39
Prudent planners would allocate life-saving interventions to themselves earlier in life to improve their chances of living to old age.39 These justifications explain much of the public preference for allocating scarce life-saving interventions to younger people.40,41 Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect.5 The death of a 20-year-old young woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life.40 The 20-year-old
has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects. Youngest-first allocation also ignores prognosis,42 and categorically excludes older people.34 Thus, youngest-first allocation seems insufficient on its own, but it could be combined with prognosis and lottery principles in a multiprinciple allocation system.34
C. Maximizing total benefits: utilitarianism
Maximizing benefits is a utilitarian value, although principles differ about which benefits to maximize.
Save the most lives
One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccine5 and responses to bioterrorism.43 Since each life is valuable, this principle seems to need no special justification. It also avoids comparing individual lives.
Other things being equal, we should always save five lives rather than one.44 However, other things are rarely equal. Some lives have been shorter than others; 20-year-olds have lived less than 70-year-olds.40
Similarly, some lives can be extended longer than others. How to weigh these other relevant considerations against saving more lives—whether to save one 20-year-old, who might live another 60 years if saved, or three 70-year-olds who could only live for 10 years each—is unclear.45 Although insufficient on its own, saving more lives should be part of a multi-principle allocation system.
Prognosis or life-years
Rather than saving the most lives, prognosis allocation aims to save the most life-years. This strategy has been used in disaster triage and penicillin allocation, and motivates the exclusion of people with poor prognoses from organ transplantation waiting lists.7,21,46 Maximizing life-years has intuitive appeal. Living more years is valuable, so saving more years also seems valuable.8 However, even supporters of prognosisbased allocation acknowledge its inability to consider distribution as well as quantity.46 Making a well-off person slightly better off rather than slightly improving a worse-off person’s life would be unjust; likewise, why give an extra year to a person who has lived for many when it could be given to someone who would otherwise die having had few?8,47 Similarly, giving a few life-years to many differs from giving many lifeyears to a few.8 As with the principle of saving the most lives, prognosis is undeniably relevant but insufficient alone.
D. Promoting and rewarding social
usefulness
Unlike the previous values, social value cannot direct allocation on its own.20 Rather; social value allocation prioritizes specific individuals to enable them to promote other important values, or rewards them for having promoted these values. In view of the multiplicity of reasonable values in society and in view of what is at stake, social value allocation must not legislate socially conventional mainstream values.1 When Seattle’s dialysis policy favored parents and church-goers, it was criticized:
“ The Pacific Northwest is no place for a Henry David Thoreau with kidney failure.”48 Allocators must also avoid directing interventions earmarked for health needs to those not relevant to the health problem at hand, which covertly exacerbates scarcity.8,49 For instance, funeral directors might be essential to preserving health in an influenza pandemic, but not during a shortage of intensive-care beds.5
Instrumental value
Instrumental value allocation prioritizes specific individuals to enable or encourage future usefulness.
Guidelines that prioritize workers producing influenza vaccine exemplify instrumental value allocation to save the most lives.5 Responsibility-based allocation—e.g., allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation.50 This approach is necessarily insufficient, because it derives its appeal from promoting other values, such as saving more lives:
“all whose continued existence is clearly required so that others might live have a good claim to priority”.20
Prioritizing essential health-care staff does not treat them as counting for more in themselves, but rather prioritizes them to benefit others. Instrumental value allocation thus arguably recognizes the moral importance of each person, even those not instrumentally valuable. Student military deferments have shown that instrumental value allocation can encourage abuse of the system.51 People also disagree about usefulness: is saving all legislators necessary in an influenza pandemic? 20 Decisions on usefulness can involve complicated and demeaning inquiries.52 However, where a specific person is genuinely indispensable in promoting morally relevant principles, instrumental value allocation can be appropriate.
Reciprocity
Reciprocity allocation is backward-looking, rewarding past usefulness or sacrifice. As such, many describe this allocative principle as desert or rectificatory justice, rather than reciprocity. For important health-related
values, reciprocity might involve preferential allocation to past organ donors,8 to participants in vaccine research who assumed risk for others’ benefit,53 or to people who made healthy lifestyle choices that reduced their need for resources.50 Priority to military veterans embodies reciprocity for promoting non-health values.54 Proponents claim that “justice as reciprocity calls for providing something in return for contributions that people have made”.53 Reciprocity might also be relevant when people are conscripted into risky tasks. For instance, nurses required to care for contagious patients could deserve reciprocity, especially if they did not volunteer.
Reciprocity allocation, like instrumental value allocation, might potentially require time consuming, intrusive, and demeaning inquiries, such as investigating whether a person adhered to a healthy lifestyle.52,22
Furthermore, unlike instrumental value, reciprocity does not have the future-directed appeal of promoting important health values. Ultimately, the appropriateness of allocation based on reciprocity seems to depend in a complex way on several factors, such as seriousness of sacrifice and irreplaceability. For instance, former organ donors seem to deserve reciprocity since they make a serious sacrifice and since there is no surplus of organ donors. By contrast, laboratory staff who serve as vaccine production workers do not incur serious risk nor are they irreplaceable, so reciprocity seems less appropriate for them.
Assessing principles: International examples for allocation systems
Which principles best embody morally relevant values? First-come, first-served is flawed in practice because it unwittingly allows irrelevant considerations, such as wealth, to affect allocation decisions, whereas a lottery
is insufficient but not flawed. Similarly, sickest-first allocation is inherently flawed, whereas the youngestfirst principle, though insufficient, recognizes the important value of priority to the worst-off . Both utilitarian principles—maximizing lives saved and prognosis—are relevant but insufficient, and usefulness and reciprocity are relevant where irreplaceable individuals make serious sacrifices, such as those during public health emergencies. Ultimately, no principle is sufficient on its own to recognize all morally relevant considerations. Combining principles into systems increases complexity and controversy, but is inevitable if allocations are to incorporate the complexity of our moral values (table 2). People disagree about which principles to include and how to balance them. Many allocation systems do not make their content explicit, nor do they justify their choices about inclusion, balancing, and specification.1 Elucidating, comparing, and evaluating allocation systems should be a research priority.9
Qatar vision towards health allocation: (Hamad Medical Corporation experience)
In early 2010, PHI and Hamad Medical Corporation (HMC) of Qatar entered into a formal agreement that enables HMC to draw upon PHI’s expertise in health system development and integration. PHI provides ongoing support to HMC in the development of leadership and management practices that promote local decision-making, ensure appropriate resource allocation, and improve service levels across the continuum.
Partners HealthCare International® (PHI) is an academically based international health care organization whose mission it is to enhance the capabilities of health care systems worldwide. Partners HealthCare
International, founded in 1997, is the international division of Partners HealthCare, an integrated health care system founded by Massachusetts General Hospital and Brigham and Women’s Hospital, the two largest teaching hospitals of Harvard Medical School.53
Summary:
Many times allocation and access to scarce medical resources post more questions than answers. Influences, such as economics, geographic location, availability of health-care professionals, politics,and insurance coverage, determine both allocation and access to health care. How decisions are made and who decides are critical questions to be asked. As health-care professional, It is important to help clients to recognize what services are available to them and to help them determine where or how to access other services if needed. If time has not been spent thinking through some of these difficult choices, responding ethically becomes a challenge. The following point can summarize the previous topic:
Scarce resources create a conflict of ethical decisions
There are several ethical principles that can be used to guide decisions about resource allocation.
An allocation system should make clear that all individuals are worth saving, and that no ethical principle to guide resource allocation is sufficient on its own
A multi-principle strategy has the potential to decrease the conflict of how to allocate resources
It is the responsibility of everyone to discriminate wherever necessary to ensure that our limited resources go where they will do the most good.
Conclusion:
•
Prepare for the worse case
•
Have a triage criteria that is ethical, defensible and fair to all
•
Maintain human dignity of all patients.
References:
1 Rawls J. A theory of justice. Oxford: Oxford University Press, 1999.
2 Harris J. QALYfying the value of life. J Med Ethics 1987; 13: 117–23.
3 Caplan AL. Organ transplant rationing: a window to the future? Health Prog 1987; 68: 40–45.
4 Truog RD, Brock DW, Cook DJ, et al. Rationing in the intensive care unit. Crit Care Med 2006; 34: 958–63.
5 Emanuel EJ, Wertheimer A. Who should get influenza vaccine when not all can? Science 2006; 312: 854–55.
6 Veatch RM. Disaster preparedness and triage. Mount Sinai J Med 2005; 72: 236–41.
7 McGough LJ, Reynolds SJ, Quinn TC, Zenilman JM. Which patients first? Setting priorities for antiretroviral therapy where resources are limited. Am J Pub Health 2005; 95: 1173–80.
8 Marcia A. Lewis . Medical Law Ethics, & Bioethics for health professions.Seven edition 2002 ; Page 180-187
9 Cookson R, Dolan P. Principles of justice in health care rationing. J Med Ethics 2000; 26: 323–29.
10 Arras JD. Rationing vaccine during an avian influenza pandemic: why it won’t be easy. Yale J Biol Med 2005;
78: 287–300.
11 Rescher N. The allocation of exotic medical lifesaving therapy. Ethics 1969; 79: 173–86.
12 Beauchamp T, Childress JF. Principles of biomedical ethics. New York: Oxford University Press, 2001.
13 Langford MJ. Who should get the kidney machine? J Med Ethics 1992; 18: 12–17.
14 Liss P-E. Hard choices in public health: the allocation of scarce resources. Scand J Public Health 2003; 31:
156–57.
15 Hope T, Sprigings D, Crisp R. “Not clinically indicated”: patients’ interests or resource allocation? BMJ 1993;
306: 379–81.
16 Brock DW. The misplaced role of urgency in allocation of persistently scarce life-saving organs. In: Gutmann
T, Land W, Daar AS, Sells RA, eds. Ethical, legal, and social issues in organ transplantation. Lengerich, Germany:
Pabst Science Publishers 2004: 41–48.
17 Silverman WA, Chalmers I. Casting and drawing lots: a time honoured way of dealing with uncertainty and ensuring fairness. BMJ 2001; 323: 1467–68.
18 Broome J. Selecting people randomly. Ethics 1984; 95: 38–55.
19 Ramsey P. The patient as person: exploration in medical ethics. New Haven, CT: Yale University Press, 2002.
20 Harris J. The value of life. London: Routledge & Kegan Paul, 1985.
21 Stein MS. The distribution of life-saving medical resources: equality, life expectancy, and choice behind the veil. Soc Philos Policy 2002; 19: 212–45.
22 Elhauge E. Allocating health care morally. Calif Law Rev 1994; 82: 1449–1544.
23 Dworkin RM. Sovereign virtue: the theory and practice of equality. New York: Harvard University Press, 2002.
24 American Thoracic Society Bioethics Task Force. Fair allocation of intensive care unit resources. Am J Respir
Crit Care Med 1997; 156: 1282–1301.
25 Childress JF. Putting patients first in organ allocation: an ethical analysis of the US debate. Camb Q Healthc
Ethics 2001; 10: 365–76.
26 Lo B, White DB. Intensive care unit triage during an influenza pandemic: the need for specific clinical guidelines. Paper presented at: Ethical and legal considerations in mitigating pandemic disease. Washington, DC;
2007.
27 Daniels N. Fair process in patient selection for antiretroviral treatment in WHO’s goal of 3 by 5. Lancet 2005;
366: 169–71.
28 Billittier AJ. Who goes fi rst? J Public Health Manag Pract 2005; 11: 267–68.
29 Roosevelt FD. Second Inaugural Address, 1937; Washington, DC.
30 Parfi t D. Equality and priority. Ratio 1997; 10: 202–21.
31 Jonsen AR. Bentham in a box: technology assessment and health care allocation. Law Med Health Care 1986;
14: 172–74.
32 McKerlie D. Justice between the young and the old. Philos Publ Aff 2001; 30: 152–77.
33 Veatch RM. Equity in liver allocation: Professor Veatch’s reply. Med Ethics 2001: 7.
34 Howard DH. Hope versus effi ciency in organ allocation. Transplantation 2001; 72: 1169–73.
35 Rutecki GW, Kilner JF. Dialysis as a resource allocation paradigm: confronting tragic choices once again?
Semin Dial 1999; 12: 38–43.
36 Department of Health and Human Services. Draft guidance on allocating and targeting pandemic influenza vaccine. http://www. pandemicflu.gov/vaccine/prioritization.pdf
(Accessed Dec 19, 2013).
37 Callahan DD. Setting limits: medical goals in an aging society. Washington, DC: Georgetown University Press;
1995.
38 Williams A. Inequalities in health and intergenerational equity. Ethical Theory Moral Pract 1999; 2: 47–55.
39 Daniels N. Am I my parents’ keeper? An essay on justice between the young and the old. Oxford University
Press, 1988.
40 McKie J, Richardson J. Neglected equity issues in cost-effectiveness analysis, Part 1: severity of pre-treatment condition, realisation of potential for health, concentration and dispersion of health benefits, and age-related social preferences. Melbourne: Centre for Health
Program Evaluation, 2005.
41 Tsuchiya A, Dolan P, Shaw R. Measuring people’s preferences regarding ageism in health: some methodological issues and some fresh evidence. Soc Sci Med 2003; 57: 687.
42 Brock DW. Children’s rights to health care. J Med Philos 2001; 26: 163–77.
43 Phillips S. Current status of surge research. Acad Emerg Med 2006; 13: 1103–08.
44 Hsieh N-H, Strudler A, Wasserman D. The numbers problem. Philos Publ Aff 2006; 34: 352–72.
45 Glover J. Causing death and saving lives. New York: Penguin, 1977.
46 Russell LB, Siegel JE, Daniels N, Gold MR, Luce BR, Mandelblatt JS. Cost-eff ectiveness analysis as a guide to resource allocation in health: roles and limitations. In: Gold MR, Siegel JE,
Russell LB, Weinstein MC, eds. Cost-eff ectiveness in health and medicine. New York: Oxford University Press;
1996: 3–24.
47 Kappel K, Sandّe P. QALYs, age and fairness. Bioethics 1992; 6: 297–316.
48 Sanders D, Dukeminier J. Medical advance and legal lag: hemodialysis and kidney transplantation. UCLA Law Rev 1968; 15: 357–419.
49 Brock DW. Separate spheres and indirect benefits. Cost Eff Resour Alloc 2003; 1: 4.
50 Morreim EH. Lifestyles of the risky and infamous. From managed care to managed lives. Hastings Center
Report 1995; 25: 5–12.
51 Burgess EW. The eff ect of war on the American family. Am J Sociol 1942; 48: 343–52.
52 Anderson ES. What is the point of equality? Ethics 1999; 109: 287–337.
53 Partnership to Transform the National Healthcare System of Qatar. http://www.partners.org/international/OurProjects/Hamad-Medical-Corporation.aspx. (Accessed Dec 19, 2013).
Prepared By: Noura B. Younes
Supervised By: Dr. Khalid Al Ali
Course
: BIOM550: Medical Lab. Laws & Ethics L01
Abstract
Allocation of scarce medical resources and access to medical care are major bioethical concerns in today’s society. Allocation refers to the distribution of available health –care resources. Access refers to whether people who should have health care are able to receive that care. Winners in the arena of access to health care are most likely healthy and well- insured individuals with good corporate coverage. Losers in this dilemma are often children, persons of color, and those who are poor and powerless. Allocation decision deal with how much shall be expended for medical …show more content…
resources and how these resources are to be distributed. For discussion, it is easier to define the problem in terms of macroallocation and microallocation of scarce resources.8 Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favoring the worst-off, maximizing total benefits, and promoting and rewarding social usefulness. 9-12 In early 2010, PHI and Hamad Medical Corporation (HMC) of Qatar entered into a formal agreement that enables HMC to draw upon PHI’s expertise in health system development and integration. PHI provides on-going support to HMC in the development of leadership and management practices that promote local decision-making, ensure appropriate resource allocation, and improve service levels across the continuum.
Many times allocation and access to scarce medical resources post more questions than answers. Influences, such as economics, geographic location, availability of health-care professionals, politics,and insurance coverage, determine both allocation and access to health care. How decisions are made and who decides are critical questions to be asked. As health-care professional, It is important to help clients to recognize what services are available to them and to help them determine where or how to access other services if needed. If time has not been spent thinking through some of these difficult choices, responding ethically becomes a challenge. In health care, as elsewhere, scarcity is the mother of allocation.1 Although the extent is debated,2,3 the scarcity of many specific interventions including beds in intensive care units,4 organs, and vaccines during pandemic influenza5 is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary.6 Allocation of scarce medical interventions is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria.7 During the 1960s, committees in
Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependents as criteria.7 Whenever health-care access and allocation decisions are made, improving health care should be the primary goal. Health professionals, researchers and member of nearly all academic disciplines have been formally debating such issues for many years. For discussion, it is easier to define the problem in terms of macroallocation and microallocation of scarce resources.
Macroallocation and Microallocation
Allocation decision deal with how much shall be expended for medical resources and how these resources are to be distributed.
Macroallocation decisions are made by larger bodies, such as government, health system agencies, health organizations, private foundations and health insurance carriers.
Macroallocation decisions also are evident when determinations are made regarding funding of medical research. How much should be allotted for cancer research, for preventive medicine, or for technological advance in medical equipment?
Microallocation decision concerning who shall obtain the resource available are made on an individual basis, usually by local hospital policy and doctors. Decisions at the microallocation level cut deeper in to conscience, because of their personal closeness to everyday living.8
How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested.9–12 Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multi-principle allocation systems.
Simple allocation principles
Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favoring the worst-off, maximizing total benefits, and promoting and rewarding social usefulness (table 1). We do not regard ability to pay as a plausible option for the scarce lifesaving inter venations we discuss.
Some people wrongly suggest that allocation can be based purely on scientific or clinical facts, often using the term “medical need”.13,14 There are no value-free medical criteria for allocation.15,16 Although biomedical facts determine a person’s post-transplant prognosis or the dose of vaccine that would confer immunity, responding to these facts requires ethical, value-based judgments. When evaluating principles, we need to distinguish between those that are insufficient and those that are flawed. Insufficient principles ignore some morally relevant considerations. Conversely, flawed principles recognize morally irrelevant considerations: inherently flawed principles necessarily recognize irrelevant considerations, whereas practically flawed principles allow irrelevant considerations to affect allocation. Principles that are individually insufficient could form part of an acceptable multi-principle system, whereas systems that include flawed principles are untenable because they will always recognize irrelevant considerations.
A. Treating people equally
Many scarce medical interventions, such as organ transplants, are indivisible. For indivisible goods, benefiting people equally entails providing equal chances at the scarce intervention—equality of opportunity, rather than equal amounts of it.1 Two principles attempt to embody this value.
Lottery
Allocation by lottery has been used, sometimes with explicit judicial and legislative endorsement, in military conscription, immigration, education, and distribution of vaccines.10, 17, 18 Lotteries have several attractions. Equal moral status supports an equal claim to scarce resources.19
Even among only roughly equal candidates, lotteries prevent small differences from drastically affecting outcome.18 Some people also support lottery allocation because “each person’s desire to stay alive should be regarded as of the same importance and deserving the same respect as that of anyone else”.20 Practically, lottery allocation is quick and requires little knowledge about recipients.18 Finally, lotteries resist corruption.18 The major disadvantage of lotteries is their blindness to many seemingly relevant factors.21,22
Random decisions between someone who can gain 40 years and someone who can gain only 4 months, or someone who has already lived for 80 years and someone who has lived only 20 years, are inappropriate.
Treating people equally often fails to treat them as equals.23 Ultimately, although allocation solely by lottery is insufficient, the lottery’s simplicity and resistance to corruption suggests that it could be incorporated into a multi-principle system.22
First-come, first-served
Within health care, many people endorse a first-come, first-served distribution of beds in intensive care units
24 or organs for transplant.25 The American Thoracic Society defends this principle as “a natural lottery— an egalitarian approach for fair [intensive care unit] resource allocation.”24 Others believe it promotes fair equality of opportunity,25 and allows physicians to avoid discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals.26 Some people simply equate it to lottery allocation.19 As with lottery allocation, many people endorse a first-come, first-served distribution of beds in intensive care units24 or organs for transplant.25 The American Thoracic Society defends this principle as “a natural lottery—an egalitarian approach for fair [intensive care unit] resource allocation.”24 Others believe it promotes fair equality of opportunity,25 and allows physicians to avoid
discontinuing interventions, such as respirators, even when other criteria support moving those interventions to new arrivals.26 Some people simply equate it to lottery allocation.19
As with lottery allocation, first-come, first-served ignores relevant differences between people, but in practice, fails even to treat people equally. It favors people who are well-off , who become informed, and travel more quickly, and can queue for interventions without competing for employment or child-care concerns.27 Queues are also vulnerable to additional corruption. As New York State’s pandemic influenza planners stated, “Those who could figuratively (and sometimes literally) push to the front of the line would be vaccinated and stand the best chance for survival”.28 First-come, first-served allows morally irrelevant qualities—such as wealth, power, and connections—to decide who receives scarce interventions, and is therefore practically flawed.
B. Favoring the worst-off : prioritarianism
Franklin Roosevelt argued that “the test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little”.29 Philosophers call this preference for the worst-off prioritarianism.30 Some define being worst-off as currently lacking valuable goods, whereas others define it as lacking valuable goods throughout one’s entire life.8 Two principles embody these two interpretations.
Sickest first
Treating the sickest people first prioritizes those with the worst future prospects if left untreated. The socalled rule of rescue, which claims that “our moral response to the imminence of death demands that we rescue the doomed”, exemplifies this principle.31 Transplantable livers and hearts, as well as emergencyroom care, are allocated to the sickest individuals fi rst.21 Some people might argue that treating the sickest individuals fi rst is intuitively obvious.32 Others claim that the sickest people are also probably worst off overall, because healthier people might recover unaided or be saved later by new interventions.33 Finally, sickest-first allocation appeals to prognosis if untreated—a criterion clinicians frequently consider.14 On its own, sickest-first allocation ignores post-treatment prognosis: it applies even when only minor gains at high cost can be achieved.
To circumvent this result, some misleadingly claim that sick people with a small but clear chance of benefit do not have a medical need.13 Sick recipients’ prognoses are wrongly assumed to be normal, even though many interventions—such as liver transplants—are less effective for the sickest
people.34 If the failure to take account of prognosis were its only problem, sickest-first allocation would merely be insufficient. However, it myopically bases allocation on how sick someone is at the current time—a morally arbitrary factor in genuine scarcity.16 Preferential allocation of a scarce liver to an acutely ill person unjustly ignores a currently healthier person with progressive liver disease, who might be worse off when he or she later suffers liver failure.8,22 Favoring those who are currently sickest seems to assume that resource scarcity is temporary: that we can save the person who is now sickest and then save the progressively ill …show more content…
person later.8,22 However, even temporary scarcity does not guarantee another chance to save the progressively ill person. Furthermore, when interventions are persistently scarce, saving the progressively ill person later will always involve depriving others. When we cannot save everyone, saving the sickest first is inherently flawed and inconsistent with the core idea of priority to the worst-off .
Youngest first
Although not always recognized as such, youngest-first allocation directs resources to those who have had less of something supremely valuable—life-years.8 Dialysis machines and scarce organs have been allocated to younger recipients fi rst,35 and proposals for allocation in pandemic influenza priorities infants and children.36 Daniel Callahan37 has suggested strict age cut-off s for scarce life-saving interventions, whereas
Alan Williams38 has suggested a system that allocates interventions based on individuals’ distance from a normal life-span if left unaided. Prioritizing the youngest gives priority to the worst-off —those who would otherwise die having had the fewest life-years—and is thus fundamentally different from favoritism towards adults or people who are well-off .8,9 Also, allocating preferentially to the young has an appeal that favoring other worst-off individuals such as women, poor people, or minorities lacks: “Because [all people] age, treating people of different ages differently does not mean that we are treating persons unequally.”39
Prudent planners would allocate life-saving interventions to themselves earlier in life to improve their chances of living to old age.39 These justifications explain much of the public preference for allocating scarce life-saving interventions to younger people.40,41 Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect.5 The death of a 20-year-old young woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life.40 The 20-year-old
has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects. Youngest-first allocation also ignores prognosis,42 and categorically excludes older people.34 Thus, youngest-first allocation seems insufficient on its own, but it could be combined with prognosis and lottery principles in a multiprinciple allocation system.34
C. Maximizing total benefits: utilitarianism
Maximizing benefits is a utilitarian value, although principles differ about which benefits to maximize.
Save the most lives
One maximizing strategy involves saving the most individual lives, and it has motivated policies on allocation of influenza vaccine5 and responses to bioterrorism.43 Since each life is valuable, this principle seems to need no special justification. It also avoids comparing individual lives.
Other things being equal, we should always save five lives rather than one.44 However, other things are rarely equal. Some lives have been shorter than others; 20-year-olds have lived less than 70-year-olds.40
Similarly, some lives can be extended longer than others. How to weigh these other relevant considerations against saving more lives—whether to save one 20-year-old, who might live another 60 years if saved, or three 70-year-olds who could only live for 10 years each—is unclear.45 Although insufficient on its own, saving more lives should be part of a multi-principle allocation system.
Prognosis or life-years
Rather than saving the most lives, prognosis allocation aims to save the most life-years. This strategy has been used in disaster triage and penicillin allocation, and motivates the exclusion of people with poor prognoses from organ transplantation waiting lists.7,21,46 Maximizing life-years has intuitive appeal. Living more years is valuable, so saving more years also seems valuable.8 However, even supporters of prognosisbased allocation acknowledge its inability to consider distribution as well as quantity.46 Making a well-off person slightly better off rather than slightly improving a worse-off person’s life would be unjust; likewise, why give an extra year to a person who has lived for many when it could be given to someone who would otherwise die having had few?8,47 Similarly, giving a few life-years to many differs from giving many lifeyears to a few.8 As with the principle of saving the most lives, prognosis is undeniably relevant but insufficient alone.
D. Promoting and rewarding social
usefulness
Unlike the previous values, social value cannot direct allocation on its own.20 Rather; social value allocation prioritizes specific individuals to enable them to promote other important values, or rewards them for having promoted these values. In view of the multiplicity of reasonable values in society and in view of what is at stake, social value allocation must not legislate socially conventional mainstream values.1 When Seattle’s dialysis policy favored parents and church-goers, it was criticized:
“ The Pacific Northwest is no place for a Henry David Thoreau with kidney failure.”48 Allocators must also avoid directing interventions earmarked for health needs to those not relevant to the health problem at hand, which covertly exacerbates scarcity.8,49 For instance, funeral directors might be essential to preserving health in an influenza pandemic, but not during a shortage of intensive-care beds.5
Instrumental value
Instrumental value allocation prioritizes specific individuals to enable or encourage future usefulness.
Guidelines that prioritize workers producing influenza vaccine exemplify instrumental value allocation to save the most lives.5 Responsibility-based allocation—e.g., allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation.50 This approach is necessarily insufficient, because it derives its appeal from promoting other values, such as saving more lives:
“all whose continued existence is clearly required so that others might live have a good claim to priority”.20
Prioritizing essential health-care staff does not treat them as counting for more in themselves, but rather prioritizes them to benefit others. Instrumental value allocation thus arguably recognizes the moral importance of each person, even those not instrumentally valuable. Student military deferments have shown that instrumental value allocation can encourage abuse of the system.51 People also disagree about usefulness: is saving all legislators necessary in an influenza pandemic? 20 Decisions on usefulness can involve complicated and demeaning inquiries.52 However, where a specific person is genuinely indispensable in promoting morally relevant principles, instrumental value allocation can be appropriate.
Reciprocity
Reciprocity allocation is backward-looking, rewarding past usefulness or sacrifice. As such, many describe this allocative principle as desert or rectificatory justice, rather than reciprocity. For important health-related
values, reciprocity might involve preferential allocation to past organ donors,8 to participants in vaccine research who assumed risk for others’ benefit,53 or to people who made healthy lifestyle choices that reduced their need for resources.50 Priority to military veterans embodies reciprocity for promoting non-health values.54 Proponents claim that “justice as reciprocity calls for providing something in return for contributions that people have made”.53 Reciprocity might also be relevant when people are conscripted into risky tasks. For instance, nurses required to care for contagious patients could deserve reciprocity, especially if they did not volunteer.
Reciprocity allocation, like instrumental value allocation, might potentially require time consuming, intrusive, and demeaning inquiries, such as investigating whether a person adhered to a healthy lifestyle.52,22
Furthermore, unlike instrumental value, reciprocity does not have the future-directed appeal of promoting important health values. Ultimately, the appropriateness of allocation based on reciprocity seems to depend in a complex way on several factors, such as seriousness of sacrifice and irreplaceability. For instance, former organ donors seem to deserve reciprocity since they make a serious sacrifice and since there is no surplus of organ donors. By contrast, laboratory staff who serve as vaccine production workers do not incur serious risk nor are they irreplaceable, so reciprocity seems less appropriate for them.
Assessing principles: International examples for allocation systems
Which principles best embody morally relevant values? First-come, first-served is flawed in practice because it unwittingly allows irrelevant considerations, such as wealth, to affect allocation decisions, whereas a lottery
is insufficient but not flawed. Similarly, sickest-first allocation is inherently flawed, whereas the youngestfirst principle, though insufficient, recognizes the important value of priority to the worst-off . Both utilitarian principles—maximizing lives saved and prognosis—are relevant but insufficient, and usefulness and reciprocity are relevant where irreplaceable individuals make serious sacrifices, such as those during public health emergencies. Ultimately, no principle is sufficient on its own to recognize all morally relevant considerations. Combining principles into systems increases complexity and controversy, but is inevitable if allocations are to incorporate the complexity of our moral values (table 2). People disagree about which principles to include and how to balance them. Many allocation systems do not make their content explicit, nor do they justify their choices about inclusion, balancing, and specification.1 Elucidating, comparing, and evaluating allocation systems should be a research priority.9
Qatar vision towards health allocation: (Hamad Medical Corporation experience)
In early 2010, PHI and Hamad Medical Corporation (HMC) of Qatar entered into a formal agreement that enables HMC to draw upon PHI’s expertise in health system development and integration. PHI provides ongoing support to HMC in the development of leadership and management practices that promote local decision-making, ensure appropriate resource allocation, and improve service levels across the continuum.
Partners HealthCare International® (PHI) is an academically based international health care organization whose mission it is to enhance the capabilities of health care systems worldwide. Partners HealthCare
International, founded in 1997, is the international division of Partners HealthCare, an integrated health care system founded by Massachusetts General Hospital and Brigham and Women’s Hospital, the two largest teaching hospitals of Harvard Medical School.53
Summary:
Many times allocation and access to scarce medical resources post more questions than answers. Influences, such as economics, geographic location, availability of health-care professionals, politics,and insurance coverage, determine both allocation and access to health care. How decisions are made and who decides are critical questions to be asked. As health-care professional, It is important to help clients to recognize what services are available to them and to help them determine where or how to access other services if needed. If time has not been spent thinking through some of these difficult choices, responding ethically becomes a challenge. The following point can summarize the previous topic:
Scarce resources create a conflict of ethical decisions
There are several ethical principles that can be used to guide decisions about resource allocation.
An allocation system should make clear that all individuals are worth saving, and that no ethical principle to guide resource allocation is sufficient on its own
A multi-principle strategy has the potential to decrease the conflict of how to allocate resources
It is the responsibility of everyone to discriminate wherever necessary to ensure that our limited resources go where they will do the most good.
Conclusion:
•
Prepare for the worse case
•
Have a triage criteria that is ethical, defensible and fair to all
•
Maintain human dignity of all patients.
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