Medical Resource Allocation

This paper argues against incorporating assessments of individual responsibility into healthcare policies by expanding an existing argument and offering a rebuttal to an argument in favour of such policies. First, it is argued that what primarily underlies discussions surrounding personal responsibility and healthcare is not causal responsibility, moral responsibility or culpability, as one might expect, but biases towards particular highly stigmatised behaviours. A challenge is posed for proponents of taking personal responsibility into account within health policy to either expand the (...) debate to also include socially accepted behaviours or to provide an alternative explanation of the narrowly focused discussion. Second, a critical response is offered to arguments that claim that policies based on personal responsibility would lead to several positive outcomes including healthy behaviour change, better health outcomes and decreases in healthcare spending. It is argued that using individual responsibility as a basis for resource allocation in healthcare is unlikely to motivate positive behaviour changes, and is likely to increase inequality which may lead to worse health outcomes overall. Finally, the case of West Virginia's Medicaid reform is examined, which raises a worry that policies focused on personal responsibility have the potential to lead to increases in medical spending overall. (shrink)

In the effort to address the persistent organ shortage it is sometimes suggested that we should incentivize people to sign up as organ donors. One way of doing so is to give priority in the allocation of organs to those who are themselves registered as donors. Israel introduced such a scheme recently and the preliminary reports indicate increased donation rates. How should we evaluate such initiatives from an ethical perspective? Luck egalitarianism, a responsibility-sensitive approach to distributive justice, provides one possible (...) justification: Those who decide against being organ donors limit the health care resources available to others. As such, a priority rule can be justified by a luck egalitarian approach to distributive justice. Furthermore, a priority rule inspired by luck egalitarianism is well equipped to avoid prominent criticisms of such a procurement system. Luck egalitarianism provides us with reaons to exempt people who are not responsible for their inability to donate from receiving lower priority, provide sufficient information about donation, and mitigate social and natural circumstances affecting people’s choice to donate. (shrink)

The paper discusses the possibility that the benefits of pharmacogenomics will not be distributed equally and will create orphan populations. I argue that since these inequalities are not substantially different from those produced by ‘traditional’ drugs and are not generated with the intention to discriminate, their production needs not be unethical. Still, the final result is going against deep-seated moral feelings and intuitions, as well as broadly accepted principles of just distribution of health outcomes and healthcare. I thus propose two (...) provisos that would prevent the most offensive outcomes and moderate the scope of the produced inequalities. The first proviso rejects pharmacogenomics innovations that worsen existing group inequalities and aggravate the disadvantage of communities with a history of discrimination. The second proviso requires that there is a strategy in place to even out as much as possible the distribution of benefits in the future and that a system of compensations is in place for pharmacogenomic orphans. Given that only one moral problem generated by pharmacogenomics has been tackled, the list of provisos might be expanded when other issues are considered. (shrink)

In this article, I argue that the government’s position against screening persons at increased risk of HCV and publicly funding HCV treatment is ethically unjustifiable. Cost of medication and likelihood of widening existing health inequality are the government’s argument for not funding HCV treatment and for also not having a screening program for at-risk populations. I object to this position and argue in favour of a screening program and public funding of HCV treatment. I argue that these barriers to screening (...) and publicly funded treatment for persons with HCV are ethically unjust. Conclusively, being denied screening and early treatment is being denied the best possible outcome. (shrink)

Biomedical sciences cannot answer the question who should be saved from death if not everyone can be. This is an ethical issue. However, we face exactly this question when deliberating on the criteria for organ allocation. The main aim of this article is to formulate a pluralistic theory of just distribution of organs, which incorporates the tenets of utilitarianism, egalitarianism and sufficientarianism. Each constituent theory adopts a different value as a criterion for organ allocation. For utilitarianism it is a health (...) benefit for the patient, for egalitarianism it is the ratio of deserts and health-related well being, for sufficientarianism what is important is that the candidate for a transplant be situated below the sufficientarian threshold. The article presents a proposal to reconcile these three competing theories. (shrink)

I agree with Professor ter Meulen that there is no need to make a forced choice between “justice” and “solidarity” when it comes to determining what should count as fair access to needed health care. But he also asserts that solidarity is more fundamental than justice. That claim needs critical assessment. Ter Meulen recognizes that the concept of solidarity has been criticized for being excessively vague. He addresses this criticism by introducing the more precise notion of “humanitarian solidarity.” However, I (...) argue that these notions are still not precise enough and are in need of behavioral translation, especially in relation to the problem of fair health care rationing. More specifically, I argue that translation ought to take the form of a well-ordered process of rational democratic deliberation, which I describe and defend in this essay. Such a process is what is required to construct a working model of just solidarity as opposed to a merely abstract idealization of just solidarity. (shrink)

The essential objective of the paper is to demonstrate the complexity of issues related to justice in the medical profession. The author claims that the virtue of justice as the foundation of a good doctor's moral attitude and the concept of justice in allocating medical goods are of primary importance. The most important thesis presented in the paper is that even if the so-called social justice needs to be complied with in the public healthcare system, it has nothing to do (...) with the virtue of justice applicable to the medical profession. The idea of social justice is the foundation of the public healthcare system. However, burdening doctors with the necessity to make decisions about rationing access to medical services increases neither their job satisfaction, nor the well-being of patients. Thus, joint efforts of doctors, economists, ethicists and politicians are required in this area. (shrink)

The purpose of this paper is to explore the meaning of solidarity and its proper position in the legal frames, with particular focus on health care. Solidarity is often identified with welfare arrangements and social guarantees. In this institutional version, it tends to humiliate citizens and restrict their entrepreneurship. Moreover, administrative solidarity is unable to recognize the actual needs of the most vulnerable members of society, which should be one of its primary concerns. Solidarity, in its original meaning, understood as (...) supportive cooperation of fellow citizens, links their rights and freedoms with mutual duties and responsibilities. Hence, an alternative framework for solidarity should be provided. This framework, committed to the idea of decency, introduces the distinction between the minimum and maximum content of solidarity enforceable by legal means, which should be translated into certain health care practices. (shrink)

In the article I justify the acceptability of ex vivo transplantation and I provide the ethical evaluation of trafficking in human organs from the Kantian perspective. Firstly, I refer to passages of Kant's works, where he explicitly states that depriving oneself of one’s body parts for other purposes than self-preservation is not permitted. I explain that the negative ethical evaluation of the disposal of the body parts was given various justifications by Kant. Subsequently, I provide partial criticism of this justification, (...) resulting in the recognition of the admissibility of ex vivo transplantation. Secondly, I analyse the Kantian slippery-slope argument which, as some philosophers believe, supports banning trade in human organs. It turns out, however, that this argument has wider application, namely it applies to all forms of the instrumental treatment of the human body. Using a previously introduced distinction between organs of the first and the second order, I show that the slippery-slope argument is inconclusive. However, I propose a reinterpretation of this reasoning, which results in using this argument as an additional reason to support prohibiting trade in human organs. (shrink)

One of the signs of the rapid development of medical genetics is a gradual increase in the number of genetic tests available. Different aspects of this phenomenon have been addressed and debated in the source literature, but so far relatively little has been said about the obligation to provide equal access – in the social context – to selected kinds of tests. In this article, I attempt to reconstruct those few suggestions, dealing with the principles of funding genetic tests from (...) public resources, that can still be found in the source literature. Accordingly, I have analyzed the possibilities of identifying the criteria of selecting diagnostic and preventive tests to be eligible for refund, as well as of screening programmes. (shrink)

Daniel Callahan has argued that economic and social benefits would result from a policy of withholding medical treatments which prolong life in persons over a certain age. He claims 'the real goal of medicine' is to conquer death and prolong life with the use of technology, regardless of the age and quality of life of the patient, and this has been responsible for the escalation of health care expenditure. Callahan's proposal is based on economic rationalism but there is little evidence (...) to suggest that substantial economic savings could be achieved. Moreover, his argument raises serious moral objections. A policy of withholding treatments from members of a social group involves elements of compulsion and discrimination, both of which would intrude on the doctor-patient relationship, undermine the autonomy of elderly patients, and invoke the slippery slope towards involuntary forms of euthanasia. Life-death decisions should be based on more than the one criterion of age, and take account of more relevant factors such as the patient's usual state of well-being, her/his expressed wishes, informed consent and the type of illness. Any move to the implementation and enforcement of the policy Callahan recommends would be rejected by health professionals and the public. (shrink)

The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a problem, it (...) is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify. (shrink)

The value of health states is often understood to depend on their impact on the goodness of people's lives. As such, prominent health states metrics are grounded in particular conceptions of wellbeing – e.g. hedonism or preference satisfaction. In this paper, I consider how liberals committed to the public justification requirement – the requirement that public officials choose laws and policies that are justifiable to their citizens – should evaluate health states. Since the public justification requirement prohibits public officials from (...) appealing to controversial conceptions of the good life, liberals committed to this principle face a significant puzzle. (shrink)

Comparative valuation of different policy interventions often requires interpersonal comparability of benefit. In the field of health economics, the metric commonly used for such comparison, quality adjusted life years (QALYs) gained, has been criticized for failing to respect the equality of all persons’ intrinsic worth, including particularly those with disabilities. A methodology is proposed that interprets ‘full quality of life’ as the best health prospect that is achievable for the particular individual within the relevant budget constraint. This calibration is challenging (...) both conceptually and operationally as it shifts dramatically when technology or budget developments alter what can be achieved for incapacitated individuals. The proposal nevertheless ensures that the maximal achievable satisfaction of one person’s preferences can carry no more intrinsic value than that of another. This approach, which can be applied to other domains of social valuation, thus prevents implicit discrimination against the elderly and those with irremediable incapacities. (shrink)

Quality-adjusted life years (QALYs) are used to determine how to allocate resources to health programmes or to treatments within those programmes in order to gain maximum utility from those limited, shared healthcare resources. However, if we use those same population- based QALYs when faced with individual treatment decisions we may act unjustly in relation to that individual or in relation to the wider population. A treatment with a population-based incremental cost-effectiveness ratio beyond our willingness to pay threshold may be denied (...) to a patient even if, for that particular patient, the QALYs gained for the cost would fall within that threshold. When considering individual cases, it is proposed that we should take an individualised approach to the cost of treatment and response to treatment (‘individualised QALYs’) and a personalised approach to the valuation of health states (‘personalised QALYs’). Only if we do this, can we maximise utility and give the patient a fair opportunity to benefit. Individualised and personalised QALYs also allow us to express patient choice and religious treatment preferences in terms of utility. Individualised and personalised QALYs are explored in the context of individual funding requests in the National Health Service. In preference to the concept of ‘clinical exceptionality’, individualised and personalised QALYs provide the potential for better and more consistent decisions and improved utility. Rather than treating unequal patients as if they were equal, individualised and personalised QALYs promote fair and unequal access to resources for some of our most unequal patients. Potential challenges are also considered. (shrink)

When financially impoverished persons from resource-poor countries travel to resource-rich countries to seek medical treatment, health-care professionals and hospital administrators must decide how to respond. These financially impoverished "medical travelers" are medically no different from financially impoverished citizens or immigrants, but their national residence and purpose of travel may cause them to be seen as having a lower degree of standing within the communities that hospitals are expected to serve. In responding to such persons, health-care professionals and administrators encounter tension (...) between the mission-driven intention to provide care and a budget-driven intention to protect operating margins. Responses require practical wisdom and a readiness to wrestle with tensions related to objectives (charitable versus financial), role-specific obligations (clinicians versus administrators), and contrasting moral frameworks. There are also challenges of reconciling plural moral values, setting moral priorities, and considering whether national borders should constrain our view of persons as neighbors. Finding a way forward amidst many tensions is hard moral work, but it may be facilitated by granting a moral imperative to physical proximity, respecting role-fidelity among clinicians and administrators, furthering candid moral dialogue, and promoting a presumption to treat whenever it is feasible to do so. (shrink)

Pandemic plans are increasingly attending to groups experiencing health disparities and other social vulnerabilities. Although some pandemic guidance is silent on the issue, guidance that attends to socially vulnerable groups ranges widely, some procedural (often calling for public engagement), and some substantive. Public engagement objectives vary from merely educational to seeking reflective input into the ethical commitments that should guide pandemic planning and response. Some plans that concern rationing during a severe pandemic recommend ways to protect socially vulnerable groups without (...) prioritizing access to scarce resources based on social vulnerability per se. The Minnesota Pandemic Ethics Project (MPEP), a public engagement project on rationing scarce health resources during a severe influenza pandemic, agrees and recommends an integrated set of ways to attend to the needs of socially vulnerable people and avoid exacerbation of health disparities during a severe influenza pandemic. Among other things, MPEP recommends: 1. Engaging socially vulnerable populations to clarify unique needs and effective strategies; 2. Engaging socially vulnerable populations to elicit ethical values and perspectives on rationing; 3. Rejecting rationing based on race, socioeconomic class, citizenship, quality of life, length of life-extension and first-come, first-served; 4. Prioritizing those in the general population for access to resources based on combinations of risk (of death or severe complications from influenza, exposure to influenza, transmitting influenza to vulnerable groups) and the likelihood of responding well to the resource in question. 5. Protecting critical infrastructures on which vulnerable populations and the general public rely; 6. Identifying and removing access barriers during pandemic planning and response; and 7. Collecting and promptly analyzing data during the pandemic to identify groups at disproportionate risk of influenza-related mortality and serious morbidity and to optimize the distribution of resources. (shrink)

The central issue that I consider in this paper is the use of the so‐called ‘Rule of Rescue’ in the context of resource allocation. This ‘Rule’ has played an important role in resource allocation decisions in various parts of the world. It was invoked in Ontario to overturn a decision not to fund treatment for Gaucher's Disease and it has also been used to justify resource decisions in Israel concerning the same condition. -/- In the paper I consider the nature (...) of the Rule of Rescue and its moral justification. The latter involves consideration of the distinction between agent‐relative and agent‐neutral obligations. If the Rule of Rescue is to be justified, it is plausible to think that it will be in the context of agent‐relative obligations. Two problems with this suggestion are considered: the role of identifiability in the Rule of Rescue and the extent to which policy makers in a health care system can be taken to have such obligations. It is argued that in both cases these problems can be overcome and hence that there is a prima facie obligation to follow the Rule of Rescue. (shrink)

Comparing estimates of the cost-effectiveness of human immunodeficiency virus (HIV) interventions can help communities select an HIV prevention portfolio to meet local needs efficiently. The authors developed a spreadsheet tool to estimate the relative cost-effectiveness of 26 HIV prevention interventions. HIV prevalence of the population at risk and the cost per person reached were the two most important factors determining cost-effectiveness. In low-prevalence populations, the most cost-effective interventions had a low per-person cost. Among the most cost-effective interventions overall were showing (...) videos in sexually transmitted disease clinics and raising alcohol taxes. (shrink)

According to some estimates, less than 10% of the world's biomedical research funds are dedicated to addressing problems that are responsible for 90% of the world's burden of disease. This paper explains why this disparity exists and what should be done about it. It argues that the disparity exists because: 1) multinational pharmaceutical and biotechnology companies do not regard research and development investments on the health problems of developing nations to be economically lucrative; and 2) governmental agencies that sponsor biomedical (...) research face little political pressure to allocate funds for the problems of developing nations. This paper argues that developed nations have an obligation to address disparities related to biomedical research funding. To facilitate this effort, developed countries should establish a trust fund dedicated to research on the health problems of developing nations similar to the Global AIDS Fund. (shrink)

This article focuses on healthcare ethics discussions in Estonia. We begin with an overview of the reform policies that the healthcare institutions have undergone since the region regained independence from the Soviet Union in 1991. The principles of distributing healthcare services and questions regarding just what ethical healthcare should look like have received abundant coverage in the national media. An example of this is the exceptionally public case of V—a woman with leukemia whose expensive drugs the national health insurance fund (...) refused to compensate. In our subsequent discussion, we focus on a grand-scale local healthcare and research project—the Estonian Genome Project—that attempts to include 1 million DNA samples into one database. (shrink)

Health care systems have four objectives: (1) the provision of the best possible care for all; while (2) guaranteeing equal access to health care; (3) maintaining freedom of choice for health care providers and patients; and (4) controlling the costs. In an ideal world with abundant resources the realization of these objectives would pose no significant problems. However, any actual health care system will need a trade-off between the different objectives because resources are limited. In Setting Limits Fairly, Norman Daniels (...) and James Sabin investigate how limits can be set in the allocation of health care resources. (shrink)

Utilitarianism is more convincing than resource egalitarianism or welfare egalitarianism as a theory of how resources should be distributed between disabled people and nondisabled people. Unlike resource egalitarianism, utilitarianism can redistribute resources to the disabled when they would benefit more from those resources than nondisabled people. Unlike welfare egalitarianism, utilitarianism can halt redistribution when the disabled would no longer benefit more than the nondisabled from additional resources. -/- The author considers one objection to this view: it has been argued, by (...) Sen and others, that there are circumstances under which utilitarianism would unfairly distribute fewer resources to the physically disabled than to nondisabled people, on the ground that the disabled would derive less benefit from those resources. In response, the author claims that critics of utilitarianism have fallaciously exaggerated the circumstances under which the disabled would benefit less than the nondisabled from additional resources. In those limited circumstances in which the disabled really would benefit less from resources, the author argues, it does not seem unfair to distribute fewer resources to them. (shrink)

In the first part of this article, we considered how Thandi, a 15-year-old girl, was treated when taken by her mother to their GP, Dr Randera. Dr Randera notified them that Thandi was pregnant, HIV positive, and had syphilis and herpes. Dr Randera also informed them that there was a substantial risk that the baby would be born HIV positive. Both Thandi and her mother wanted an abortion. However, Dr Randera, who was morally opposed to abortions, refused to provide the (...) service and did not refer Thandi to another doctor who would perform the abortion.The saga continues:. (shrink)

Rivers et al. raise two ethical issues in relation to the use of medication event monitoring systems (MEMS). The first issue, identified as an 'economic' concern, centres on the waste of health resources caused by patient failure to adhere to medication programmes. The second is the danger that MEMS may pose to 'the trust that should exist between patient and prescriber'. In what follows I offer an analysis of these issues, and their relationship to each other.

One of the major issues in the debate about the future of health care is how to keep costs under control while meeting growing demands for care. Addressing that, especially on an international scale, is far from easy. How are we to determine what the demands for care will most likely be? Even if it is not possible to estimate the future number of dependent elderly persons with any precision, it is hard to ignore the most probable scenario: a substantial (...) increase in the number of the oldest old. (shrink)

There is a growing feeling in many Western countries that every human being has a right to health, or a right to health care. This feeling is reflected in a declaration of the World Health Organization (WHO) from 1976, which states: The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. Our intention in the following is to use the WHO (...) declaration as a basis for considering the allocation of resources in health care. We shall first argue that most of the criteria suggested as grounds for fair allocation of scarce medical resources have their difficulties if one tries to apply them one by one to medical practices. We shall then go on to claim that, if we take the right of all human beings to health or health care even moderately seriously, increasing the resources would in most cases be more ethical than attempting to allocate them ‘fairly’. (shrink)

The U.S. health care system is in the midst of unprecedented change. New health care delivery systems and financing mechanisms are reshaping the health care arena. The thrust of these changes with respect to medical care for most Americans and their implications for the future are difficult issues to assess. In this article we discuss implementation of the Medicare Prospective Payment System (PPS) and the impact of its financial incentives. We specifically identify the ramifications of this cost containment effort on (...) the frail elderly population and suggest a modification to PPS which would provide hospitals more equitable reimbursement for their care. Recent legislation in the state of Pennsylvania is presented illustrating the potential of implementing this modification. (shrink)

This article describes the steps Medicare has taken and will continue to take to fulfill the Reagan Administration's mandate to control health care costs and maintain quality care by increasing reliance on market forces and on appropriate incentives.

Introduction to a special issue on medical cost containment.

Physicians are feeling the heat of cost containment. Pressures on doctors to contain costs have mounted - from hospital and Health Maintenance Organization (HMO) administrators, from state and national government, from medical staffs. Medicare payment reforms, corporate and insurer demands, and market pressures have all come together to pressure health care providers to cap escalating health care costs. This article posits that such pressures to control costs are not always counter to the patient's best interests and that the ethical debate (...) needs to incorporate the emergence of bureaucratic medicine and its sensitivity to cost. The pressure to reduce cost has intensified the tension felt by physicians as they balance their ethical obligations to treat their patients and their desires to maintain the financial health of their health care institutions and their own financial security. The line between pure medical decisions and economic decisions has blurred. The essence of the complaint is simply stated: "... economic imperatives may weaken what should be a strong fiduciary relationship between doctor and patient. A physician cannot easily service his patients as trusted counselor and agent when he has economic ties to profit-seeking businesses that regard those patients as customers. -/- The current ethical debate seems to revolve primarily around middle class medicine, where physician autonomy in treating patients has been most dramatically limited by new modes of health care delivery and reimbursement. Prospective payment mechanisms have been implemented through the federal Medicare program, but hospitals have applied DRG categories across the board to their delivery of health care. As hospitals struggle to contain costs, they have implemented cost controls that affect a doctor's practice generally and not just that segment involving Medicare patients. (shrink)

The future will be controlled by those nations which most intelligently allocate their resources. Our nation's capital is the stored flexibility needed by our children to meet the future. How we allocate our nation's limited resources and capital will dictate the kind of lives our children will lead. We are not correctly or intelligently allocating our nation's health care resources. There are serious internal contradictions in a society that no longer produces the radios, televisions, or video recorders it invented, yet (...) pays for all patients receiving lung transplants and artificial hearts. While moving our basic value-producing industries - steel and automobiles - abroad, we continue to manufacture MX missiles and artificial hearts. We give heart transplants to smokers, but we close our steel mills. We spend freely on military and medicine, yet we refuse to spend enough to succeed in international trade. We overtreat sick people but undertreat our sick economy. Like the fading southern family in William Faulkner novels that "takes sick," as a nation we are treating our illnesses at the expense of our livelihoods. (shrink)

To allocate resources ethically under DRGs, we need an expanded medical ethics. Appealing to traditional patient-centred principles such as beneficence and autonomy will not be sufficient. We also need to take into account the social principles of full beneficence and justice. If marginal benefits must be eliminated, clinicians should not participate in deciding who should get less care but should remain committed to their patients' interests.