Medical Resource Allocation

With a growing number of genetic tests becoming available to the health and consumer markets, genetic health care providers in Canada are faced with the challenge of developing robust decision rules or guidelines to allocate a finite number of public resources. The objective of this study was to gain Canadian genetic health providers' perspectives on factors and criteria that influence and shape resource allocation decisions for publically funded predictive genetic testing in Canada. The authors conducted semi-structured interviews with 16 senior (...) lab directors and clinicians at publically funded Canadian predictive genetic testing facilities. Participants were drawn from British Columbia, Alberta, Manitoba, Ontario, Quebec and Nova Scotia. Given the community sampled was identified as being relatively small and challenging to access, purposive sampling coupled with snowball sampling methodologies were utilized. Surveyed lab directors and clinicians indicated that predictive genetic tests were funded provincially by one of two predominant funding models, but they themselves played a significant role in how these funds were allocated for specific tests and services. They also rated and identified several factors that influenced allocation decisions and patients' decisions regarding testing. Lastly, participants provided recommendations regarding changes to existing allocation models and showed support for a national evaluation process for predictive testing. Our findings suggest that largely local and relatively ad hoc decision making processes are being made in relation to resource allocations for predictive genetic tests and that a more coordinated and, potentially, national approach to allocation decisions in this context may be appropriate. (shrink)

Medical tourists, persons that travel across international borders with the intention to access non-emergency medical care, may not be adequately informed of safety and ethical concerns related to the practice of medical tourism. Researchers indicate that the sources of information frequently used by medical tourists during their decision-making process may be biased and/or lack comprehensive information regarding individual safety and treatment outcomes, as well as potential impacts of the medical tourism industry on third parties. This paper explores the feedback from (...) former Canadian medical tourists regarding the use of an information sheet to address this knowledge gap and raise awareness of the safety and ethical concerns related to medical tourism. (shrink)

Organ tourism occurs when individuals in countries with existing organ transplant procedures, such as the United States, are unable to procure an organ by using those transplant procedures in enough time to save their life. In this paper, I am concerned with the following question: When organ tourists return to the United States and need another transplant, do US transplant physicians have an obligation to place them on a transplant list? I argue that transplant physicians have a duty not to (...) relist organ tourists. Specifically, I contend that we should locate physicians’ duties in these cases within the new role of “transplant physician.” This role results from transplant physicians’ participation in a system that depends on organ donors’ voluntary act of donation. (shrink)

A cost analysis of the utilization of new expensive vascular grafts is performed, applying the methodology of decision analysis to the theoretical case of a sixty year old male patient undergoing femoropopliteal grafting for limb threatening ischemia. The problem is presented graphically as a decision tree, uncertainties are quantified in terms of probabilities and end outcomes are evaluated in monetary terms. This informations is then utilized to calculate cost values associated with alternative actions.Based on initial cumulative patency figures of the (...) new more expensive grafts and the known performance of the older grafts, the initial high expense for the new grafts is justified economically, if the saphenous vein is not available. This analysis, apart from giving an answer to a specific clinical problem, can be viewed as a general model for cost analysis of surgical procedures. (shrink)

In this paper I analyze the alleged conflict between economic incentives to efficiently utilize health care resources and the obligation to provide patients with the best possible medical care. My analysis is developed in four stages. First, I discuss briefly the nature of prospective payment systems and economic incentives as well as the issue of professional autonomy. Second, I disscuss the notion of an incentive for action both as an economic incentive and as a concept of moral psychology. Third, I (...) analyze several definitions of the physician's professional obligation and discuss four conditions that morally qualify the obligation. And fourth, I explore why the views of economists and physicians differ so strikingly on the question of economic incentives. In the process of this analysis, I argue that criticisms of prospective payment systems which are premised primarily on the conflict between economic incentives to contain cost and the professional obligation of beneficence are probably as much a matter of rhetoric as serious argumentation. Keywords: autonomy, beneficence, cost containment, economic incentives, moral obligation, prospective payment CiteULike Connotea Del.icio.us What's this? (shrink)

The bioethics literature on managed care has devoted significant attention to a broad range of conflicts that managed care is perceived to have introduced into the practice of medicine. In the first part of this paper we discuss three kinds of conflict of interest: conflicts of economic incentives, conflicts with patient and physician autonomy, and conflicts with the fiduciary character of the physician–patient relationship. We argue that the conflicts are either not as serious as they are often alleged to be (...) or not unique to managed care. In part two we argue that managed care represents a new paradigm for medical care that features a new concept of management. We discuss three types or levels of management that managed care highlights, namely, administrative, clinical, and resource, which together offer a more sophisticated vantage point from which to assess patient care. We do not endorse managed care, but attempt to highlight some of the positive changes brought by managed care that were difficult to attain under traditional reimbursement systems. (shrink)

Should we grant a fresh start to those who come to regret their past lifestyle choices? A negative response to this question can be located in the luck egalitarian literature. As a responsibility-sensitive theory of justice, luck egalitarianism considers it just that people’s relative positions reflect their past choices, including those they regret. In a recent article, Vansteenkiste, Devooght and Schokkaert argue against the luck egalitarian view, maintaining instead that those who regret their past choices in health are disadvantaged in (...) a relevant way and should receive compensation. Employing the ideal that people should be made equal as measured by equivalent resources, they purport to show the fairness of such an arrangement through a hypothetical scenario. Relaxing the implicit assumptions of this scenario brings forth several unattractive consequences of the fresh-start idea. The main problem is that in striving to ensure that people’s past choices do not affect their own opportunities, the authors must accept that these choices put heavy strains on the opportunities available to other people. Furthermore, the luck egalitarian position is more compelling than they admit. (shrink)

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative claim types. We identify (...) the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming. (shrink)

The “Time trade-off” (TTO), is the most widely used method to “quality adjust” life years for “QALYs” in cost utility analysis. In this paper we ask if it is theoretically likely that the TTO is valid for this use. The TTO consists in a trade off between longevity and quality of life. Firstly, we argue that it is impossible to control for all factors that may influence one’s willingness to sacrifice lifetime. Secondly, that longevity and quality of life are too (...) closely interrelated for the hypothetical trade off to reveal real preferences. Thirdly, that the TTO handles the value of a life year inconsistently because it simultaneously assumes that it changes (as an outcome measure) and that it doesn’t change (as a currency unit). Lastly, we ask whether the difficulties stem from an inherent contradiction in trying to quantify quality of life. The problems of theoretical validity and internal consistency, contrast the use of the results as exact measurements. We conclude that cost utility analysis based on TTO cannot be trusted as a tool for setting priorities in health. (shrink)

In this paper I argue that resource allocation in publicly funded medical systems cannot be done using a purely substantive theory of justice, but must also involve procedural justice. I argue further that procedural justice requires institutions and that these must be “local” in a specific sense which I define. The argument rests on the informational constraints on any non-market method for allocating scarce resources among competing claims of need. However, I resist the identification of this normative account of local (...) justice with the actual approach to local decision-making taken within the UK National Health Service. I illustrate my argument with reference to the case of provision of In Vitro Fertilisation within the UK NHS. (shrink)

The international disparities in health and health-care provision comprise the gravest problem of medical ethics. The implications are explored of three theories of justice: an expanded version of Rawlsian contractarianism, Nozick's historical account, and a consequentialism which prioritizes the satisfaction of basic needs. The second too little satisfies medical needs to be cogent. The third is found to incorporate the strengths of the others, and to uphold fair rules and practices. Like the first, it also involves obligations transcending those to (...) an agent's relations and fellow-citizens. These conclusions are applied to international health-care provision, which they would transform. (shrink)

Since before we can remember, humanity aims to overcome its biological limitations; such a goal has certainly played a key role in the advent of technique. However, despite the benefits that technique may bring, the people who make use of it will inevitably be under risk of harm. Even though human technical wisdom consists in attaining the best result without compromising anybody’s safety, misuses are always a possibility in the horizon. Nowadays, technology can be used for more than just improving (...) human capacities, preserving and restoring health or promoting human well-being. It also enables us to overcome human limitations and reach way beyond our "natural design". That being said, what could possibly justify the fear for these new directions of biotechnology? Should medicine and health care change their traditional goals and begin searching for artificial improvements to wellness in human nature? In this paper, I will hereby present and briefly discuss the main topics of the contemporary issue of human enhancement: the therapy-enhancement distinction, the possibility of cognitive enhancements and better physical performances, the fight against senescence, the arguments for and against human eugenics, the search for perfection, the quest of moral enhancement, the problem of public priorities, and some questions on medical ethics. Then, finally, I will want to present some realist perspectives on the subject. (shrink)

Paul Menzel and Donald Light ("A Conservative Case for Universal Access to Health Care," Jul-Aug 2006) tell a story that is plausible. However, based on my twenty-five years of experience as a policy analyst interested in access to health care, I find it inaccurate for a number of reasons.

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

The central ideas in this work are health as a moral entitlement and equity in health. It is a discourse on distributive justice in health and takes Uganda as a case study. It describes Uganda health system especially the extent and distribution of health-related injustice brought about by severe poverty and the manner health resources are raised and allocated. This manner disproportionately adversely affects the poor's access to health services and endangers their livelihoods due to catastrophic health expenditure. This work (...) further critically reviews the theory of utilitarianism which is popularly used in the allocation of scarce health resources. Utilitarianism is accepted as good for ensuring efficiency in health resource allocation, but not good enough to ensure equity in health. This being the case a discussion of other ethical principles of health resource allocation that attempt to close the 'fairness gap' left by the theory of utilitarianism becomes necessary. Having critically examined QALYs and other moral principles, it emerges that a discourse on these per se is good but not good enough to guarantee equity in health in Uganda, even if a harmony between these suggestions were found. The main reason for this is that the said discourse is based on a subtle, yet wrong assumption, that all health services in Uganda are financed by the state and therefore health equity would be achieved if those resources are equitably distributed. This assumption ignores the fact that due to severe poverty and a very steep social gradient, out-of-pocket payment for health services is a prohibitive factor in the use of private health services. This leads to unequal access to health services between social classes since 50% of health out-put is from the private health service providers, hence must be paid for. This points to the fact that there is a strong spiral cause relationship between poverty and health inequity, the fact that is ignored in the discourse on QALYs and other allocation principles that aim at health equity. Therefore, since the poor are disproportionately adversely affected in the current system, developing an equitable financing mechanism for the health care system which takes into consideration the special needs of the poor should be a key priority in Uganda. (shrink)

With increasing momentum for health care reform, attention is shifting to finance reform that will provide for direct methods for controlling health care spending. This article outlines the two principal paths to direct cost control and outlines a national plan that retains our multiple sources of payment, yet also contains a powerful direct cost control technique: a single fund to finance all health care.

In Setting Limits, Daniel Callahan advances the provocative thesis that age be a limiting factor in decisions to allocate certain kinds of health services to the elderly. However, when one looks at available data, one discovers that there are many more elderly women than there are elderly men, and these older women are poorer, more apt to live alone, and less likely to have informal social and personal supports than their male counterparts. Older women, therefore, will make the heaviest demand (...) on health care resources. If age were to become a limiting factor, as Dr. Callahan suggests it should, the limits that will be set are limits that will affect women more drastically than they affect men. This review essay examines the implications of Callahan's thesis for elderly women. (shrink)

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health (...) care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community interms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services. (shrink)

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care , we are guided (...) less by principles of justice and more by the duty to relieve suffering and society's commitment to protecting the professional's obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries. (shrink)

This commentary focuses on two moral values implied by the case study but not specified in the working party's conclusions, namely equitable treatment of the most vulnerable and the value of political government.

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

What is immediately striking about the general problem of how to allocate resources equitably is that although the task cannot be done, it nevertheless requires to be done. Imperfection is the most we can hope for. But of course some instances of imperfection are considerably worse than others: and those evidenced in all too much of the thinking of medical specialists, whether in the current discussion concerning cancer care or, for instance, by those involved in the management of kidney transplants (...) are frightening in their resolute refusal even to consider, let alone take adequately into account, the impact on the wider polity of their policies and practices. (shrink)

In my article above, I cite an earlier article by Frances Kamm, ???Deciding Whom to Help, Health-Adjusted Life Years, and Disabilities???, in Public Health, Ethics, and Equity , eds. S. Anand, F. Peters, and A. Sen circulated as a working paper of the Center for Population Studies, Harvard University). However, I failed to correctly identify her position on one view that she took up in that article, and also failed to cite a proposal she developed in that article similar to (...) one I took up in my paper. (shrink)

This chapter examines whether an individual’s being worse off than others should be a relevant consideration in the allocation of limited medical resources. It reviews arguments pressed by proponents of different theories of justice about whether being worse off than others makes special demands on health care resource prioritization. Even if there is good reason to restrict the concern for the worse off to those with worse health in the prioritization and allocation of health care resources, additional issues remain. One (...) is how to determine who has worse health, and whether the worse off are those with the worse overall health or those with the most serious medical condition now in need of treatment. Another issue is whether only individuals’ present health, or instead their lifetime health, including past and expected future health, is relevant. (shrink)

The dominant methodology in health policy for prioritizing and rationing health care resources is cost-effectiveness analysis, typically using quality adjusted life years (QALYs) or disability adjusted life years (DALYs) to measure health outcomes. The construction of these measures involves a number of moral or value choices, including: How should states of health and disability be evaluated, and whose preferences (e.g., the disabled or non-disabled) should be used? How should these evaluations reflect that prioritization will involve tradeoffs between health benefits for (...) different persons or groups? Do all QALYs count equally, no matter what age at which they are received? Should discount rates be applied to health benefits? I will show the nature of the moral issues at stake in answering these questions, and briefly argue how they should be answered. (shrink)

In this paper I address the relation between just claims to health care and severe cognitive impairment from dementia. Two general approaches to justice in allocation of health care are distinguished – prudential allocation and interpersonal distribution. First, I analyze why a patient who has died has no further claims to health care. Second, I show why prudential allocators would not provide for health care treatment should they be in a persistent vegetative state. Third, I argue that the destruction of (...) personal identity from severe dementia implies that only claims to palliative, but not life-sustaining, health care remain. Finally, I argue that the prudential allocator approach is indeterminate regarding life-sustaining care for the moderately demented and that social policy should not deny that care to patients. Keywords: elderly, health care, the severely-demented, justice CiteULike Connotea Del.icio.us What's this? (shrink)

This essay challenges the view that the provision of health care must take place within a competitive-free system. The author argues that, presuming that there is a requirement to meet the demands of those who cannot pay for health care, a competitive market provides a good way to deal with injustices within the health care system. The author concludes that the demands for justice are best met when indigent individuals use some portion of the funds they receive from the government (...) to purchase one of the many competing forms of health care. This scheme requires a competitive market in the delivery of health care. (shrink)

Counting QALYs has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they can't. There need be (...) no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task , and make a start on the second. (shrink)

Public health ethics is a relatively new academic field. Crucially, it is distinguished from traditional medical ethics by its focus on populations rather than individuals. Still, the ethics of public health cannot be perceived completely detached from the ethics of individuals, as populations are made up of individuals. One issue that clearly falls within the intersection of a population- and an individual based perspective on ethics is resource allocation. Resource allocation takes place at various stages within the organisation of healthcare, (...) i.e. at the micro-, meso- and macro level [3]. Resources are almost always limited, with the consequence that some healthcare is prioritised while other care is rationed. In this manner, resource allocation creates winners and losers; those who get the best care available, those who do not receive the best care and those who do not receive care at all. It seems prudent to assume that any adequate public health ethics involved in population-based decision-making will have to address all ethical aspects of resource allocation, all the way from the macrolevel policy-making process to the micro-level implementation where it affects specific and identifiable individuals. More specifically, such an ethics must be able to deal with the ethical tensions arising between population-based concerns framing the policy design process, and individual concerns in the realisation of the resource allocations. In the following, I will identify an inherent ethical tension involved in ‘legitimate resource allocation’, which is related to the challenge of meeting the ethical requirements from a population- and an individual based perspective at the same time. (shrink)

Resource allocation is a central part of the decision-making process in any health care system. Resources have always been finite, thus the ethical issues raised are not new. The debate is now more open, and there is greater public awareness of the issues. It is increasingly recognised that it is the technology which determines resources. The ethical issues involved are often conflicting and relate to issues of individual rights and community benefits. One central feature of resource allocation is the basing (...) of decisions on the outcomes of health care and on their subsequent economic evaluation. The knowledge base is therefore of great importance as is the audit of results of clinical treatment. Public involvement is seen as an integral part of this process. For all parts of the process, better methodologies are required. (shrink)

It is widely assumed that disability is typically a bad thing for those who are disabled. Our purpose in this essay is to critique this view and defend a more nuanced picture of the relationship between disability and well-being. We first examine four interpretations of the above view and argue that it is false on each interpretation. We then ask whether disability is thereby a neutral trait. Our view is that most disabilities are neutral in one sense, though we cannot (...) make simple generalizations about disability's relationship to well-being in other important senses. After defending this view, we discuss its practical implications for selective abortion for disability, nondisabled people's interactions with disabled people, and the use of QALYs in health policy. (shrink)

We clarify options for conceptualizing equity, or what we refer to as justice, in resource allocation. We do this by systematically differentiating, expounding, and then illustrating eight different substantive principles of justice. In doing this, we compare different meanings that can be attributed to “need” and “the capacity to benefit”. Our comparison is sharpened by two analytical tools. First, quantification helps to clarify the divergent consequences of allocations commended by competing principles. Second, a diagrammatic approach developed by economists Culyer and (...) Wagstaff offers a visual and conceptual aid. Of the eight principles we illustrate, only two treat as relevant both a person’s initial health state and a person’s CTB per resource unit expended: allocate resources so as to most closely equalize final health states and allocate resources so as to equally restore health states to population norms. These allocative principles ought to be preferred to the alternatives if one deems relevant both a person’s initial health state and a person’s CTB per resource unit expended. Finally, we examine some possibilities for conceptualizing benefits as relative to how badly off someone is, extending Parfit’s thought on Prioritarianism. Questions arise as to how much intervention effects accruing to the worse off count for more and how this changes with improving health. We explicate some recent efforts to answer these questions, including in Dutch and British government circles. These efforts can be viewed as efforts to operationalize need as an allocative principle. Each effort seeks to maximize in the aggregate quanta of effect that are differentially valued in favor of the worst off. In this respect, each effort constitutes one type of Prioritarianism, which Parfit failed to differentiate from other types. (shrink)

In order to slow down the inexorable increase in spending on health care, the British government has implemented an initiative proposed by Griffiths. This initiative is designed to make doctors more accountable for the decisions they may take. In this essay I argue first, that the conflation of two decisions (financial and clinical) leads to unnecessary ethical dilemmas and secondly, that as psychologically it is difficult to take two decisions simultaneously, inevitably the clinician is forced to name either the financial (...) or the clinical decision as the prior problem. To decide for the former inevitably strains the traditional doctor/patient relationship of mutual trust. (shrink)

Bitton and Eyal's lengthy critique of our article on unassisted cessation was premised on several straw-man arguments. These are corrected in our reply. It also confused the key concepts of efficacy and effectiveness in assessing the impact of cessation interventions and policies in real-world settings; ignored any consideration of reach (cost, consumer acceptability and accessibility) and failed to consider that clinical cessation interventions which fail more than they succeed also may ‘harm’ smokers by reducing agency. Our article addresses each of (...) these problems, concluding that any consideration of the ethics of promoting smoking cessation in low-income nations should begin and end with the question of whether the strategies to be adopted have any prospect of influencing significant numbers of smokers to quit. (shrink)