1. Resource Allocation Alan Sanders, PhD System Ethicist, Catholic Health East Director, Center for Ethics Saint Joseph’s Health System

2. Our Political Climate?

3. Goals for Today: Education & Policy Development Resource allocation expresses value Different acceptable ways to allocate resources, often very dependent upon individual circumstances –People tend to allocate resources based upon personally held values and professional training Process is just as important, if not more important, than Product

4. Case Mrs. Norman is a 50-year-old woman with a history of non small cell lung cancer. Diagnosed 3-4 years ago and treated with lobectomy (no adjuvant chemotherapy or radiation). Over next 2 years a repeated pattern of pleural effusions, but no definitive diagnosis of recurrent cancer. Referred to SJ physician and diagnosed with adenocarcinoma, found to be significant involving the pleural space, both lungs, and pericardium. Now in ICU with respiratory insufficiency.

5. Case Intubated on day 2 of admission, eventual peg tube and trach’, vent, IV meds, chemo, multiple drips, bronchoscopies, etc. Length of first stay – 95 days –Cost $761,459 Length of second stay – 20 days –Cost $271,681

6. Technical Criteria Fallacy Any list of objectively measurable criteria cannot be translated directly into decisions that are also about values –Life Sustaining Treatment –Drug Coverage –Pandemic Such decisions also include values about life’s goals, quality of life, and the common good Veatch, “The Technical Criteria Fallacy” Hastings Center Report, 7(4), 1977: 15-16.

7. Legitimacy & Accountability Norman Daniels, James Sabin. Setting Limits Fairly: Can We Learn to Share Medical Resources? Oxford University Press, 2002.

8. Legitimacy and Accountability: 4 Conditions Publicity –Transparency –Rationale is available to affected parties Relevance –Attention to purpose & goals –Makes sense to those affected Revision & Appeals –Mechanism for dispute resolution –Opportunity for revision & improvement Regulative –Oversight to help ensure that top 3 conditions are met and sustained

10. Other Considerations Formal Analysis of Policies Are purpose and values clearly stated? Are definitions clear? Is it clear about who should decide? How decisions are made? Are there checks and balances? Is there room for exceptions? How are exceptions addressed or appealed?

11. Other Considerations Informal Analysis of Policies Practice vs. Paper –Is the policy followed or used? –Is it evenly applied? –Does it work? Authorship –Who devised it & when is it used? –What are the goals of the mechanism? Whose goals?

12. Catholic Teaching Directive #3 In accord with its mission, Catholic health care should distinguish itself by service to and advocacy for those people whose social condition puts them at the margins of our society and makes them particularly vulnerable to discrimination: the poor; the uninsured and the underinsured; children and the unborn; single parents; the elderly; those with incurable diseases and chemical dependencies; racial minorities; immigrants and refugees. In particular, the person with mental or physical disabilities, regardless of the cause or severity, must be treated as a unique person of incomparable worth, with the same right to life and to adequate health care as all other persons.

13. Acting in Patients’ Best Interests Ideal –The absolute best –Helpful for guiding overall policy Reasonable Plan –Working within limits –“Best” under the given circumstances Minimum Threshold –That which below is unacceptable –Providing less than minimum threshold may be considered unsafe, abuse, etc.

14. Or, a Theological Question?

15. Caritas in Veritate (Charity in Truth): Pope Benedict XVI, 2009 Sometimes modern man is wrongly convinced that he is the sole author of himself, his life and society…. Many people today would claim that they owe nothing to anyone, except to themselves. They are concerned only with their rights, and they often have great difficulty in taking responsibility for their own and other people's integral development…. Individual rights, when detached from a framework of duties which grants them their full meaning, can run wild, leading to an escalation of demands which is effectively unlimited and indiscriminate….

16. Caritas in Veritate (Charity in Truth): Pope Benedict XVI, 2009 The sharing of reciprocal duties is a more powerful incentive to action than the mere assertion of rights…. Thinking of this kind requires a deeper critical evaluation of the category of relation… As a spiritual being, the human creature is defined through interpersonal relations. The more authentically he or she lives these relations, the more his or her own personal identity matures. It is not by isolation that man establishes his worth, but by placing himself in relation with others and with God. Hence these relations take on fundamental importance….

17. Discussion