The new Hungarian Labour Code allows informal payments to be accepted, subject only to the prior permission of the employer. In Hungary, the area most affected is Health Care, where informal payments to medical staff are common. The article assesses the practice on ethical terms, focusing on organisational justice. It includes an analysis of distributional injustice, that is, of non-equitable payments to professionals, on the distribution of payments depending on the specialisation and status of the doctor, on his or (...) her rights to allocate Health Care resources and/or on how assertive he or she is. We show, by means of a content analysis of internet postings and of interviews with physicians, the feelings and attitudes of both patients and doctors—thus enabling us to trace interactional and procedural injustice and portray the main driving forces of informal payment with causal loops. We use a new approach (a system dynamics computer simulation) to demonstrate how informal payments influence therapy procedures. The example of treating the common skin disease of psoriasis examines the specific behaviour of doctors in their everyday practice and estimates the extent to which the prescription of unnecessary or more expensive therapy increases the costs. With this multi-method approach, we demonstrate that the legislation allowing informal payment represents bad ethics, since it enforces organisational injustice, creates mistrust between physicians and patients, decreases performance and increases the total costs paid both by society and the Health Insurance Fund. Informal payments distort the allocation of resources, enforce discrimination based solely on money, violate the concept of solidarity and limit Human Rights in terms of health. (shrink)

BackgroundIn the 1970s, the Federal Trade Commission declared that allowing medical providers to advertise directly to consumers would be “providing the public with truthful information about the price, quality or other aspects of their service.” However, our understanding of the advertising content is highly limited.ObjectiveTo assess whether direct-to-consumer medical service advertisements provide relevant information on access, quality and cost of care, a content analysis was conducted.MethodTelevision and online advertisements for medical services directly targeting consumers were collected (...) in two major urban centres in Nevada, USA, identifying 313 television advertisements and 200 non-duplicate online advertisements.ResultsBoth television and online advertisements reliably conveyed information about the services provided and how to make an appointment. At the same time, less than half of the advertisements featured insurance information and hours of operation and less than a quarter of them contained information regarding the quality and price of care. The claims of quality were substantiated in even fewer advertisements. The scarcity of quality and cost information was more severe in television advertisements.ConclusionThere is little evidence that medical service advertising, in its current form, would contribute to lower prices or improved quality of care by providing valuable information to consumers. (shrink)

From a giant of health care policy, an engaging and enlightening account of why American health care is so expensive -- and why it doesn't have to be. Uwe Reinhardt was a towering figure and moral conscience of health care policy in the United States and beyond. Famously bipartisan, he advised presidents and Congress on health reform and originated central features of the Affordable Care Act. In Priced Out, Reinhardt offers an engaging and enlightening account of today's U.S. health care (...) system, explaining why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it. The problem, Reinhardt says, is not one of economics but of social ethics. There is no American political consensus on a fundamental question other countries settled long ago: to what extent should we be our brothers' and sisters' keepers when it comes to health care? Drawing on the best evidence, he guides readers through the chaotic, secretive, and inefficient way America finances health care, and he offers a penetrating ethical analysis of recent reform proposals. At this point, he argues, the United States appears to have three stark choices: the government can make the rich help pay for the health care of the poor, ration care by income, or control costs. Reinhardt proposes an alternative path: that by age 26 all Americans must choose either to join an insurance arrangement with community-rated premiums, or take a chance on being uninsured or relying on a health insurance market that charges premiums based on health status. An incisive look at the American health care system, Priced Out dispels the confusion, ignorance, myths, and misinformation that hinder effective reform. (shrink)

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study (...) used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services. (shrink)

Medicine and Money explores the role of beneficence and cost control in health-care systems. The book's primary concern of morally improving medicine is achieved by dividing the argument into two parts. The first defines the crisis in health-care and justifies beneficence. The second part offers practical suggestions on implementing beneficence into the system. Medicine and Money is one of the few books to provide concrete suggestions on improving the health-care system from the micro level for addressing cost concerns (...) in a morally acceptable manner. (shrink)

Patients and family members (N = 671) were surveyed in five Mid-Atlantic U.S. hospitals to ascertain the number and kinds of ethical concerns they are presently experiencing or have previously experienced while being sick or receiving medical care. Seventy percent of participants had at least one (range 0–14) type of ethical concern or question. The most commonly experienced concerns pertained to being unsure how to plan ahead or complete an advance directive (29.4%), being unsure whether someone in the family (...) was able to make their own decisions (29.2%), deciding about limiting life-sustaining treatments (28.6%), wondering about disclosing personal medical information to others in the family (26.4%) and not being sure whether to undergo treatment because of cost (26.2%). Most were interested to some degree in getting help from ethics consultants in the future (76.6%). Given this prevalence, common concerns might usefully be addressed systematically, rather than exclusively on a case-by-case basis. (shrink)

Patients have a right to refuse medical treatment. But what should happen after a patient has refused recommended treatment? In many cases, patients receive alternative forms of treatment. These forms of care may be less cost-effective. Does respect for autonomy extend to providing these alternatives? How for does justice constrain autonomy? I begin by providing three arguments that such alternatives should not be offered to those who refuse treatment. I argue that the best argument which refusers can appeal (...) to is based on the egalitarian principle of equality of outcome. However, this principle does not ultimately support a right to less cost-effective alternatives. I focus on Jehovah's Witnesses refusing blood and requesting alternative treatments. However, the point applies to many patients who refuse cost-effective medical care. (shrink)

Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. For (...) example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research. (shrink)

Background: The health professionals are involved in the paths of care for patients with different medical conditions. Their life is frequently characterized by psychopathological outcomes so that it is possible to identify consistent burdens. Besides the possibility to develop pathological outcomes, some protective factors such as resilience play a fundamental role in facilitating the adaptation process and the management of maladaptive patterns. Personal characteristics and specific indexes such as burdens and resilience are essential variables useful to study in-depth ongoing (...) conditions and possible interventions. The study was aimed at highlighting the presence and the relations among factors as personal variables, burdens, and resilience, to understand health professionals' specific structure and functions.Methods: The observation group was composed of 210 participants, 55 males, and 155 females, aged from 18 to 30 years old with a mean age of 25.92 years old. The study considered personal characteristics of the subjects, such as age, gender, years of study, days of work per week, hours of work per week, and years of work. Our study had been conducted with the use of measures related to burdens and resilience.Results: The performed analyses consisted of descriptive statistics, correlations, and regressions among the considered variables. Several significant correlations emerged among personal characteristics, CBI, and RSA variables. Specifically, age and work commitment indexes appeared to be significantly related to the development of burdens, differently from the years of study. Significant correlations emerged among personal and RSA variables, indicating precise directions for both domains. Age and gender were identified as predictors to perform multivariate regression analyses concerning CBI factors. Significant dependence relations emerged with reference to all CBI variables.Conclusion: Pathological outcomes and resilience factors represent two sides of the health professionals' experiences, also known as “invisible patients.” Greater knowledge about present conditions and future possibilities is a well-known need in literature so that the current analyses considered fundamental factors. In line with state of the art, future studies are needed in order to deepen elusive phenomena underlying maladjustment. (shrink)

The Oregon Basic Health Services Act of 1989 seeks to establish universal access to basic medical care for all currently uninsured Oregon residents. To control the increasing cost of medical care, the Oregon plan will restrict funding according to a priority list of medical interventions. The basic level of medical care provided to residents with incomes below the federal poverty line will vary according to the funds made available by the Oregon legislature. A rationing plan (...) such as Oregon's which potentially excludes medically necessary procedures from the basic level of health care may be just, for the right to publically-sponsored medical care is restricted by opposing rights of private property. However, the moral acceptability of the Oregon plan cannot be determined in the absence of knowing the level of resources to be provided. Finally, Oregon to date has failed to include the individuals being rationed in discussions as to how the scarce resources are to be distributed. (shrink)

Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons – who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly describe blacklisting in (...) the context of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced. (shrink)

The purpose of this paper is to review the rising influence of commercialism in American medicine and to examine some of the consequences of this trend. Increased competition subverts physician collegiality, draws hospitals into for-profit ownership and behavior, and leads clinical investigators into secrecy and possibly into bias and abuse. Medicine faces a deprofessionalization evidenced in loss of control over the clinical setting and over self-regulation. Health care becomes a commodity relying on cultivation of desires instead of satisfaction of needs, (...) even as many basic needs go unmet. Patients become consumers empowered with lawsuits and the connection of medicine to the relief of suffering is attenuated. Medical encounters are increasingly impersonal, dominated by specialization, technology, and bureaucracy. Patients are losing their physician-advocates to new conflicts of interests, physicians are losing their impulse to charity, and trust in the doctor-patient relationship and in medicine generally is eroding. (shrink)

The question of how to allocate scarce medical resources has become an important public policy issue in recent decades. Cost-Utility Analysis is the most commonly used method for determining the allocation of these resources, but this book counters the argument that overcoming its inherent imbalances is simply a question of implementing methodological changes. The Economics of Resource-Allocation in Healthcare represents the first comprehensive analysis of equity weighting in health care resource allocation that offers a fundamental critique of its (...) basic framework. It offers a heterodox account of health economics, putting the discourse on economic evaluation into it broader socio-political context. Such an approach broadens the debate on fairness in health economics and ties it in with deeper rooted problems in moral philosophy. Ultimately, this interdisciplinary study calls for the adoption of a fundamentally different paradigm to address the distribution of scarce medical resources. This book will be of interest to policy makers, health care professionals or Post-Graduate students looking to broaden their understanding of the economics of the healthcare system. (shrink)

Rehabilitation for disabled children requires long-term programmeswhich are expensive to the family. This study aimed to estimate the costincurred by caregivers’ children with disabilities from Pahang, Terengganu andKelantan participating in Community-Based Rehabilitation and cost of seeking alternative rehabilitation. Costanalysis using the Activity-Based Costing method was used to estimatetwelve-months’ expenditure in 2014 institutional year on 297 caregivers ofchildren with disability, aged 0 to 18 years who attended CBR. Data werecollected using a self-administered costing questionnaire and presentedin median. Results showed that (...) the median direct and indirect costs,excluding medications and alternative care were nearly four times as highin Home-Based compared to Centre-Based vs. RM608. Both groups of caregivers spent a significant amount ofresources on alternative rehabilitation. The high costs incurred for alternativerehabilitation is a major economic burden to the family. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision (...) makers distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

This report is about ethical thinking in the field of health and health care. But it is no abstract philosophical tract. It is designed to be of practical help to those struggling with the complex questions of allocating resources in health care and to encourage a wider involvement at all levels in health debates. The questions it raises stimulate new thinking about today's institutional structures. As we proceeded with our work, we became aware that it is easier to state problems (...) than to solve them. However, we were also aware of the opposite danger of oversimplification implicit in the view that there was a moral calculus to which decisionmakers could turn when they were confronted by an ethical problem in the allocation of resources, and which would yield mechanical solutions to human problems. (shrink)

As costs decline and technology inevitably improves, current trends suggest that artificial intelligence (AI) and a variety of "carebots" will increasingly be adopted in medical care. Medical ethicists have long expressed concerns that such technologies remove the human element from medicine, resulting in dehumanization and depersonalized care. However, we argue that where shame presents a barrier to medical care, it is sometimes ethically permissible and even desirable to deploy AI/carebots because (i) dehumanization in medicine is not always (...) morally wrong, and (ii) dehumanization can sometimes better promote and protect important medical values. Shame is often a consequence of the human-to-human element of medical care and can prevent patients from seeking treatment and from disclosing important information to their healthcare provider. Conditions and treatments that are shame-inducing offer opportunities for introducing AI/carebots in a manner that removes the human element of medicine but does so ethically. We outline numerous examples of shame-inducing interactions and how they are overcome by implementing existing and expected developments of AI/carebot technology that remove the human element from care. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and (...) not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision (...) makers distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it (...) fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially. (shrink)

Julian Le Grand's case for saying that it would be equitable if smokers and smokers alone were to pay the costs of smoking-related health care is considered and found to be deficient.

For-profit managed care organizations face decisions about cost sharing that can involve a tradeoff between the interests of investors and the interests of patients. No successful business can ignore the interests of its investors, but moral philosophy points to ethical reasons for managed care organizations to make patients’ health, rather than investors’ profit, their primary goal. One reason is the ethical obligation of all businesses to avoid wrongful exploitation of vulnerable customers. An insurance company’s cost-sharing policy can exploit (...) customers either by collecting an unfairly large amount of money from them or by unfairly deterring them from making claims for resources they medically need. Another reason stems from the fact that managed care organizations’ profits derive in part from the existence of artificial barriers to access to medicine, notably including patents. Putting a fence around a water well in the desert is legitimate only if doing so facilitates a financial arrangement that maximizes people’s access to water they need. Likewise, patents and other artificial barriers to access to medically necessary drugs are legitimate only if they are used to help finance access to medical resources people need. For these reasons, managed care organizations should make cost-sharing decisions that maximize the sustainable availability of effective drugs to patients who need them. (shrink)

This series of articles by Charles Dougherty, Robert Berenson, and Kathleen Powderly and Elaine Smith, as well as “Cost Containment: Challenging Fidelity and Justice” by E. Haavi Morreim (Hastings Center Report, December 1988), result from a Hastings Center project, “Ethics and Prospective Payment Systems: DRGs.” The two-year project was jointly funded by The General Electric Foundation and the American Medical Association Education and Research Foundation.The project tried to gauge the systematic effects of the introduction of cost containment (...) strategies, prospective payment by Diagnostic Related Groups in particular, on the provision of health care and the ethical practice of medicine. Cost containment strategies, no matter how necessary in curbing spiraling medical costs, leave no sector or participants in the health care system untouched—hospitals and other health care institutions; doctors, nurses, social workers and other health care professionals; patients, their families, and the thirty-six to forty million medically indigent. The articles discuss the several and interrelated ethical issues raised by the DRG prospective payment system (Dougherty); its particular affect on the doctor-patient relationship and how it is transforming the ethical practice of medicine (Berenson and Morreim); and its specific impact on the professions and professional ethics of nursing and social work (Powderly and Smith). The overall message of the articles is that the health professions, their provision of care, and the ethics of their practices—as driven by economic considerations and realities—are in the midst of a more or less radical sea change. (shrink)

Providing care for a baby born at 24 weeks of gestation in a neonatal intensive care unit is one of the most expensive medical treatments in the United States today. The cost can easily run over $300,000 for one baby. Furthermore, many extremely premature babies who survive are left with chronic diseases or disabilities that require further medical expenses and other specialized services throughout childhood or throughout life. When all these expenditures are totaled up, it can seem (...) that neonatal intensive care is just not worth it.Concerns about the cost-effectiveness of NICUs have led to persistent critical scrutiny of these specialized units by physicians, economists, and epidemiologists. These analysts have examined NICUs and the patients in them in order to determine whether there are subpopulations of babies for whom neonatal intensive care is so demonstrably ineffective or so costly that it should not be provided. Such examinations have been carried out in many different countries, at many times over the last 30 years, and have analyzed outcomes for babies by gestational age, birthweight, and illness severity. (shrink)

Animal and human studies suggest that parenting style is transmitted from one generation to the next. The hypotheses of this study were that a mother’s rearing experiences would predict her own parenting resources and current maternal mood, motivation to care for her offspring, and relationship with her parents would underlie this association. In a subsample of 201 first-time mothers participating in the longitudinal Maternal Adversity, Vulnerability and Neurodevelopment project, we assessed a mother’s own childhood maltreatment and rearing experiences using the (...) Childhood Trauma Questionnaire and the Parental Bonding Instrument. At 6 months postpartum, mothers completed questionnaires on parenting stress, symptoms of depression, maternal motivation, and current relationship with their own parents. The sample consisted of mostly high socioeconomic status mothers recruited from Montréal or Hamilton, Canada, with an age range from 18 to 43 years. More severe maltreatment and less supportive rearing by the mother’s parents predicted increased parenting stress at 6 months. These associations were mediated through distinct psychosocial pathways: maltreatment on parenting stress through symptoms of depression ; maternal rearing on parenting stress through maternal motivation and symptoms of depression ; and paternal rearing on parenting stress through current relationship with the father. Maternal rearing experiences predict a mother’s own parenting resources though distinct psychosocial pathways, including depressed mood, maternal motivation, and social support. (shrink)

Animal and human studies suggest that parenting style is transmitted from one generation to the next. The hypotheses of this study were that a mother’s rearing experiences would predict her own parenting resources and current maternal mood, motivation to care for her offspring, and relationship with her parents would underlie this association. In a subsample of 201 first-time mothers participating in the longitudinal Maternal Adversity, Vulnerability and Neurodevelopment project, we assessed a mother’s own childhood maltreatment and rearing experiences using the (...) Childhood Trauma Questionnaire and the Parental Bonding Instrument. At 6 months postpartum, mothers completed questionnaires on parenting stress, symptoms of depression, maternal motivation, and current relationship with their own parents. The sample consisted of mostly high socioeconomic status mothers recruited from Montréal or Hamilton, Canada, with an age range from 18 to 43 years. More severe maltreatment and less supportive rearing by the mother’s parents predicted increased parenting stress at 6 months. These associations were mediated through distinct psychosocial pathways: maltreatment on parenting stress through symptoms of depression ; maternal rearing on parenting stress through maternal motivation and symptoms of depression ; and paternal rearing on parenting stress through current relationship with the father. Maternal rearing experiences predict a mother’s own parenting resources though distinct psychosocial pathways, including depressed mood, maternal motivation, and social support. (shrink)

Neonatal intensive care units (NICUs) and medical intensive care units (MICUs) are both very expensive. The cost-effectiveness of NICUs has been extensively evaluated, as has the long-term outcomes of subpopulations of NICU patients. NICU treatment is among the most cost-effective of high-tech interventions. And most patients do well. There are fewer evaluations of cost-effectiveness in the MICU and almost no long-term outcome studies. Policymakers who scrutinize expensive high-tech interventions would do well to study the examples found (...) in the NICU. (shrink)

Contemporary cost containment measures ignore patients' need for privacy, destroy long-term doctor-patient relationships, and demand ethical and standard of care compromises.Economic considerations have distracted the physician and he/she no longer focuses primarily on the patient's welfare. The superficiality of the doctor-patient relationship and the cost-cutting efforts have jointly contributed to the deterioration of the quality of medical care.

Summary Principles Timely support for patients and people close to them, and effective, sensitive communication are essential. Decisions must be based on the individual patient's circumstances and reviewed regularly. Sensitive advance discussion should always be encouraged, but not forced. Information about CPR and the chances of a successful outcome needs to be realistic. Practical matters Information about CPR policies should be displayed for patients and staff. Leaflets should be available for patients and people close to them explaining about CPR, how (...) decisions are made and their involvement in decisions. Decisions about attempting CPR must be communicated effectively to relevant health professionals. In emergencies If no advance decision has been made or is known, CPR should be attempted unless: the patient has refused CPR; the patient is clearly in the terminal phase of illness; or the burdens of the treatment outweigh the benefits. Advance decision making Competent patients should be involved in discussions about attempting CPR unless they indicate that they do not want to be. Where patients lack competence to participate, people close to them can be helpful in reflecting their views. Legal issues Patients' rights under the Human Rights Act must be taken into account in decision making. Neither patients nor relatives can demand treatment which the health care team judges to be inappropriate, but all efforts will be made to accommodate wishes and preferences. In England, Wales and Northern Ireland relatives and people close to the patient are not entitled in law to take health care decisions for the patient. In Scotland, adults may appoint a health care proxy to give consent to medical treatment. Health professionals need to be aware of the law in relation to decision making for children and young people.IntroductionWhy policies are neededCardiopulmonary resuscitation can be attempted on any person whose cardiac or respiratory functions cease. Failure of these functions is part of dying and thus …. (shrink)

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital (...) in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment. (shrink)

There are two discourses that are used in connection with the provision of good healthcare: a rights discourse and a beneficial design discourse. Although the logical force of these two discourses overlaps, they have distinct and incompatible implications for practical reasoning about health policy. The language of rights can be interpreted as the ground of a well-designed healthcare system stressing the values of equality and inclusion, but it has less application when dealing with questions of cost-effectiveness. This difference reflects (...) the distinction between the deontological status of rights claims and a teleological approach presupposed in the language of beneficial design. However, the value of the separateness of persons contained in the discourse of rights can impose constraints on the adoption of a simple maximizing principle when thinking about the allocation of healthcare resources within a social contract for health. Throughout these issues are discussed by reference to the work of Peter Jones. (shrink)

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only (...) relatively weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)

: Four principal arguments have been offered in support of requiring public and private third-party payers to help fund medical research: (1) many of the costs associated with clinical trial participation are for routine care that would be reimbursed if delivered outside of a trial; (2) there is a need to promote scientific research and medical progress and lack of coverage is an impediment to enrollment; (3) to cover the costs of trials expands health care and treatment options (...) for the sick; and (4) it is beneficial for private insurers to cover the costs associated with cancer clinical trials because doing so makes such companies more attractive to consumers. Although many see third-party-payer coverage as a victory for patients and for the future of research, requiring coverage of services provided in a trial beyond those that would be provided to a comparable patient outside the research context raises a number of concerns. (shrink)

Physicians and institutional providers face expanding liability exposure today, in spite of state tort reform legislation and public awareness of the costs of malpractice for providers. Standards of practice are evolving rapidly; new medical technologies are being introduced at a rapid rate; information is proliferating as to treatment efficacy, patient risk, and diseases generally. Tort standards mirror this change. As medical standards of care evolve, they provide a benchmark against which to measure provider failure. The liability exposure of (...) physicians is affected by the generation of data, including outcomes data usable to profile physician practice, and statistical data that allows for predictions as to treatment efficacy, and patient prognosis; obligations to inform patients and third parties of risk created by contagious disease and other sources of harm; obligations of physicians to disclose risks that the provider creates for the patient; obligations to disclose conflicts of interest arising out of the practice setting; and duties arising from new epidemiological knowledge. (shrink)