1. Allocation of Medical Resources

2. Some thoughts for starters…
You can’t put a price on a human life…
There is a right to health…
There is a right to health care…

3. Limits on the right to health care…
If each citizen of a community has a right to healthcare
What happens when they conflict?
Can I rightfully claim an organ from a healthy person?
What if two people need a donated kidney?
Even where our rights don’t conflict, there will always be limits in the form of available resources to the degree that our ‘rights’ may be satisfied:

4. Key Issues Medical resources are expensive.
How are they to be allocated?
Who decides who gets what?
How do doctors, hospital managers and society make decisions between patients with competing medical needs?

5. Key questions
Should treatment be to everyone regardless of whether their illness is self-inflicted? Smokers, drinkers, drug users, drink drivers, self-harmers?
Should it be regardless of cost? E.g. 1 liver transplant v’s 100 hip replacements?
Should it be regardless of age? E.g. 25 week premature baby v’s 70 yr old pensioner?
Should it b regardless of the patient’s place in society - rich or poor, law-abiding or criminal, post code lottery?

6. Limited Resources Resources are indefinitely limited
There is a limit, but it is not always obvious where that limit is
Scarcity of resources can be radical or comparative
Radical: not enough for everyone
Comparative: not enough to treat everyone now

7. What limits resources…?
Financial Constraints
No money to spend
Unfair distribution of what money there is
Increased supply and demand
Improved treatments and technology allows medicine to treat more disease.
Innovations are frequently brought ‘to the market’ by biotechnology/ pharmaceutical companies who need to generate profit from their investment – Herceptin example.
People live longer and expect to live longer
With longer lives the nature of the treatment to be delivered changes over time.

8. Types of distribution problems
Macro-allocation
Department of Health
HSE
Fighting for and then apportioning its budget
Hospitals
Micro-allocation
Deciding between patients

9. Macro-allocation of resources
Global
Clear problems in terms of equity:
Insufficient resources for essential medicines e.g. anti-retrovirals
Doctors often have to train abroad
Staff are often lured abroad
Responses
Individual – is there a moral duty to a country?
Government aid - may be ‘strings attached’ with regard to foreign policies.
Suppliers (esp. Drug Companies)
Do drug companies have any moral obligation
Issues for this country?
National
Are some regions favoured over others?
Does socio-economic status affect access to healthcare?

10. How to macro-allocate…
Need based analysis
How is need defined?
How are different needs evaluated / compared?
Does kidney dialysis count for more or less than a ruptured appendix?
Does a fractured hip in an elderly person count for more or less than a young adult?
How to assess Value of Life.

11. Problems…
A range of people have input into the decisions that are made:
Medical professionals
Managers
Economists
Politicians
Public opinion
Lobby groups
Media
Each group will have its own priorities and bias.

12. Some ways of deciding… Cost : benefit of treatment Avoiding suffering
As opposed to say lifestyle treatments
Example of sildenafil (Irish & UK experiences on limiting its use)
Prolonging life
Role of clinical data: NICE (in UK) and herceptin & beta interferon
Private healthcare

13. Medical Method QALYs: Quality Adjusted life Years.
Ask question: how many years of good quality life will patient have as a result of treatment?
Doctors use this method when allocating drugs, surgery and technological treatments to competing patients – look at the long-term prognosis of each case.

14. QALYs - Quality Adjusted Life Years
A common mechanism for working out who to treat
Term comes from Health Economics, rather than Ethics
Based on the idea of questioning people about how they see certain disorders.
Asked to rank living with certain conditions/disabilites/symptoms
1 = Completely normal life
0 = Death
Multiplied by the number of years that the person can be expected to live
The more QALYs a given treatment will produce - having regard to the cost of that treatment - the clearer the indication as to whether that treatment should be given to that particular person

15. Problems with QALYs
Assessment might not take enough consideration of how a person who actually has the condition etc… might feel
May therefore involve value judgment about how people are likely to think rather than how they actually will think
Numerical bias: two years of life for one person is ‘better’ than one year of life for two people (because cost of treating them is higher).
May discriminate:
Elderly
People with conditions that are cheaper to treat
Those with pre-existing conditions

16. NICE
Natural Institute of Clinical Excellence decides which treatments and technologies – from drugs to artificial hips – should or should not be available on the NHS in England and Wales.
Set up to remove ‘postcode lottery’ of health care and to ensure parity throughout the NHS.
Has to balance clinical effectiveness and cost effectiveness.

17. How does NICE make its decisions?
Weighs up:
The benefits on any treatment vs. the benefits of note.
Any undesirable side effects
The effects of removing NHS availability
The impact of any treatment on length and quality of life
The net cost to the NHS
The impact of the treatment on NHS resources

18. Examples of NICE decisions
Many expensive new drugs such as beta-interferon do not ‘cure’ a disease but ameliorate (ease) the symptoms of chronic disease such as MS.
Hence NICE rules against its use – money would be better spent on actual cures and effective treatment.
Man who paid £8000 for cryotherapy which has 98% success rate yet not approved by NICE as too expensive for use throughout NHS.

19. Utilitarianism Greatest good for the greatest number
Motives are unimportant consequences are what matters.
The end justifies the means
Utilitarianism and justice do not always correspond
Minority count less than the majority – hard on some individuals.

20. Examples
Greatest good for the greatest number – mirrors NICE principles e.g. 100 hip replacements rather than 1 liver transplant, several people on kidney dialysis rather than 1 kidney transplant, inoculating all babies against childhood diseases rather than expensive intensive care treatment for very premature babies.

21. Hedonic Calculus Applying HC is similar to applying QALYs
Provides a flexible and intelligible guide to solving the complex issue of resource allocation

22. Hedonic Calculus
Apply IDCERRP – try to give examples of at least 3 criteria.
e.g. Intensity of pain, duration of pain/disability, remoteness of effect of non-treatment, extent of people affected in person treated or not.
Should doctors look at age, sex, marital status, number of dependents, income, emotional stability, education, occupation, future potential.

23. Utilitarian views against unfair allocation of resources
no one’s happiness is to be counted as more important than anyone else’s .
“everybody is to count for one, nobody for more than one.”
Supported by Peter Singer – a politician should not count more than a murderer, a mother more than her child, a disabled person more than a scientist with a cure for cancer, a pensioner more than a premature baby – decisions should only be made on clinical medical reasons.

24. Mill
Rule utilitarian – law as a set of principles developed and tested by history to normally ensure the greatest happiness of the greatest number.
Idea of justice & community.
One group shouldn’t count more than others.
Quality rather than quantity - would look to QALYs too.
Higher pleasures

25. Kant Apply to 2nd formulation of CI Treat people as ends not means
Example – decide between a young smoker and an older non-smoker. Using QALYs doctor will choose non-smoker even though older.
Kant – use reason with non-smoker to give up then s/he would have more QALYs, involving patient in decision.
Doctor has duty to preserve life – this doesn’t help decide which person gets the treatment.

26. Christian views - Wyatt
“Matters of life and death”
4 Principles
1. transparency
2. Equality
3. Impartiality
4. Defend the poor and vulnerable

27. Wyatt’s Idealism
Idealistic and in reality not everyone can be treated.
Shouldn’t be selfish in the demand they put on the NHS
Remember that Jesus accepted suffering.
Shouldn’t fear death as they believe in the after life.

28. Divine Command - stewardship
Use limited resources wisely
Give treatment only when it is genuinely needed.
Avoid giving unnecessary treatment
Needs v’s wants

29. Situation Ethics
Apply Agapeic calculus: look at individual cases on the basis of Christian LOVE (AGAPE) – involves equality, impartiality, justice and compassion.

30. Justice Justice – fairness and equality Fairness
Give people what they deserve
Does it mean giving priority to those who have a disease or accident rather than those who deliberately put themselves at risk?
God treats everyone equally
God acts unconditionally out of love and compassion.

31. Equality Avoid discrimination Treat people equally
Jesus respected all people regardless
Doctors should not let discrimination cloud their judgement

32. Equity People have different needs
Inequity is when differences in care are not morally justified
Equity involves weighing up what is best for the individual with what is fair, equal and just.

33. Micro-allocation deciding between individuals
Decisions to treat individuals may not only be dependent on resources factors:
Patient autonomy
Availability of non-resource materials, such as organs
Some decisions may seem instinctive
Treat the person who is in the greatest pain?
Treat the person who can realistically be saved
These decisions may pass judgement on the perceived Quality of Life of the ‘untreated’ person.

34. Assessment of Need as a quantum…
One definition of need is “when an individual has an illness or disability for which there is an effective and acceptable treatment”
But need may be qualified further by asking who ‘needs’ a treatment more:
The urgency, intensity and importance of the need
The amount of what is needed
The capacity of the person to benefit from what is needed

35. Treatment Outcomes Who will live longest with treatment?
Will discriminate against the older person.
May discriminate against those who have underlying conditions that are nothing to do with the condition being considered for treatment –double jeopardy.
Does the fact that both patients stand to lose the same thing (i.e. their lives mean that in fact they should be treated equally).
Who will respond best to treatment?
What about resource allocation where there is no real ‘treatment’ being proposed?

36. Social cost-benefit analysis …
Who will contribute the most to society…?
How do we measure ‘contribution’?

37. Who ‘deserves’ to be treated…?
Rewarding hospitals that do well at harvesting organs with first-choice when organs come up for transplantation…
Numbers of children
Those who contribute to their own downfall
e.g. smokers & CABG
Doctors as dealers in punishment?
Do the virtuous get a double reward under schemes such as this
Moral quality of the patient
“Good innings” arguments
Idea that you have lived “long enough”
But does a lifetime of paying taxes warrant better treatment?

38. توصيه هاي كمك كننده در تخصيص منابع در سطح خرد
1- انتخاب روش هاي درماني سودمند و استاندارد
2- به حداقل رساندن استفاده از آزمايشات و درمان هاي حاشيه اي و غير ضروري
3- يافتن روش هاي تشخيصي و درماني كه با كمترين هزينه بهترين نتيجه را بدهند
4- حمايت كامل بيمار و ندادن مزيت هاي غيرعادلانه به بيماران در تصميم گيري

39. 5- حل عادلانه مشكلات منابع محدود براساس معيارهاي اخلاقي مانند توجه به نياز ، سوددهي و رعايت عدالت
6- درجريان قرار دادن بيمار در خصوص كمبود هاي موجود با روش منطقي
7- يافتن راه حل براي كمبود هاي غيرقابل قبول در سطح كلان، مياني و خرد