Phase I Home Page
The Language of
Bioethics (Glossary)
Objectives
Goals
Required
Reading
Concept of
Justice
Principle
of Formal Justice
Material
Principles of Justice
Theories
of Distributive Justice
Fair-Opportunity
Rule
Choosing
Between Person Competing for Basic Health Care Services
Allocation
of Health Care Resources
Rules of
Exclusion
Physician
as Gatekeeper: A Dubious Moral Role
Economics
of Health Care
Major
Health Care System Changes Under Consideration
Clinical
Vignette
Topical
Questions
References
& Resources
|
|
Resource Allocation
The Physician's Obligation to Society: Management and
Allocation of Medical Resources in Relation to Clinical Decisions
Objectives
Explore informing principles and the physician's
responsibility regarding the efficient and just use of limited clinical
resources. Help the student understand the various interests involved, the areas
of controversy and conflict and what is expected of the student in preparation
for his/her role as a physician.
Goals
- Discuss how the physician can be an advocate for the care
that best serves the interests of his/her patients in a resource limited
environment.
- Discuss where health care stands in contrast to other
competing societal goods. How do you prioritize resource allocation?
- Examine the different conceptual models of the
doctor-patient relationship and how these are sustained or challenged in a
resource-conscious healthcare system.
Required Reading
- Introduction to Clinical Ethics by Fletcher, Hite,
Lombardo and Marshall. Second Edition.
"Economics, Case Management, and Patient Advocacy,"
p. 239-54.
- Ethics
Manual, Fourth Edition, American College of Physicians
"Resource Allocation"
- Code of Medical Ethics, American Medical
Association "Allocation of Limited Medical Resources,"
2.03
"The Provision of Adequate Health Care," 2.095
"Caring for the Poor," 9.065
Note: Many of these AMA statements are in Doctor's
Dilemma
Concept of Justice
- Fair, equitable and appropriate distribution in society
determined by justified norms that structure the terms of social cooperation
- Problems arise under conditions of society and competition
- Weighing alternatives—
- Aggregate risks
- Costs
- Benefits of various alternatives
- Distribution through society
Principle of Formal
Justice
- Equals must be treated equally and unequals must be treated
unequally
- Problems with above: who is equal and who is unequal?
Material
Principles of Justice
1. Those that specify the relevant characteristics for equal
treatment
2. Need versus free-market distribution
3. Valid material principles of distributive justice—
- to each person an equal share
- to each person according to need
- to each person according to effort
- to each person according to contribution
- to each person according to merit
- to each person according to free market exchanges
4. Relevant properties that persons must possess to qualify
for a particular distribution
- Established by tradition, moral, legal principles
- Changing relevancy: i.e., what was considered relevant is
now considered irrelevant and visa-versa
Theories of
Distributive Justice
- Utilitarian: criteria that maximize public utility.
- Libertarian: emphasize rights to social and economic
liberty (invoking fair procedures rather than substantive outcomes).
- Communitarian: stresses principles and practices of justice
that evolve through tradition in a community.
- Egalitarian: equal access to goods in life that every
rational person values.
Fair-Opportunity Rule
No person granted social benefits as basis of underserved
advantageous properties (because no persons are responsible for having these
properties) and no person denied social benefits on basis of underserved
disadvantageous properties (because they are also not responsible for these
properties.
Choosing
Between Person Competing for Basic Health Care Services
1. What moral calculus exists to tip the scale in favor of one
person over another?
2. How do we weigh competing claims to life or health?
A. Consequentialist principles—
- Priority given to those for whom treatment has highest
probability of medical success
- Principle of immediate usefulness: priority given to most
useful under the immediate circumstances
- Principle of conservation: priority given to those who
require proportionately smaller amounts of resources
- Principle of parental role: priority given to those who
have largest responsibilities to dependents.
- Principle of general social value: priority given to
those believed to have the greatest social worth (prior, current, and
potential).
B. Egalitarian principles—
- Principle of saving no one: none should be saved if not
all can be saved.
- Principle of medical neediness: priority given to the
medically neediest.
- Principle of general neediness: priority given to the
most helpless or the generally neediest.
- Principle of queuing: priority given in first-come,
first-served manner.
- Principle of random selection: priority given to those
selected by chance.
Allocation of
Health Care Resources
- Rationing of health care: allocation of scarce health care
resources among competing individuals. Occurs when not all care expected to
be beneficial is provided to all patients.
- No ultimately correct theoretical approach: use story of
St. Martin of Tours
- Allocation decisions rest on following tenets:
- What kinds of health care services will exist in a
society?
- Who will receive them and on what basis?
- Who will deliver them?
- How will the power and control of those services be
distributed?
Rules of Exclusion
- Constituency Factor: sets patient-centered boundaries,
e.g., geographic region, age group, ability to pay
- Progress of Science Factor: may exclude or admit patients
in experimental trials based on such contingencies as disease process, sex,
age.
- Prospect of Success Factor: exclude those with least chance
of successful outcome.
Physician
as Gatekeeper: A Dubious Moral Role
Physician must use the patient's and society's resources
optimally Physician uses only those measures appropriate to the cure of the
patient or alleviation of the patient's suffering. What the physician recommends
must be effective and beneficial. Physicians must use their knowledge to
practice competent, scientifically rational medicine using the right degree of
economy of means of diagnosis and providing just those treatments that are
demonstrably beneficial and effective.
Economics of Health Care
Causes of continually increasing health care costs:
- General inflation based on overall increase in Consumer
Price Index
- Population increase
- Medical inflation
- New technologies, new procedures, personnel and other
resources (intensity)
Major
Health Care System Changes Under Consideration
- Single payor system
- Fee-for-service system with reform of bureaucracy and
insurance reform
- Managed care contractual model of payment for medical care
- Health care insurers or groups of patients contract with
individual or groups of health care "providers"to provide a
specified level of health care services.
- Preferred provider refers to a participating health care
provider listed with the plan to whom the plan member can receive care.
- Capitation: the provider receives a yearly fee for each
managed care patient
- Provider is guaranteed a specified number of patients in
return for a discounted fee.
- Primary care physicians serve as "gatekeeper":
all care provided by the particular managed care plan must be approved by
the "provider" (i.e., all diagnostic test including x-rays and
all referrals to medical specialists).
Clinical Vignette
Patient A
A 25 year-old unemployed man with a history of
migraine consulted his general practitioner with a specific request that he
should be prescribed the drug Imigran®, having it recommended to him by a
relative. The general practitioner, working to an evidence-based practice
protocol for the management of migraine, told the patient that his present
medication was the right approach for his problem. The patient became angry,
demanded the drug and maintained that he was entitled to the best regardless
of cost. The doctor persisted with the clinical decision even though she found
the intervention difficult to handle. The patient invoked the Government's
Patient's Charter and told the doctor he would be making a formal complaint.
Patient B
A 76 year-old retired mine worker, recently widowed, had
end-stage renal failure and was being maintained on hospital dialysis. He had
been asked to become the head of a major new community program to help
unemployed young people. He also wanted to marry again. He sought an
appointment with the Consultant Physician who was supervising his care to ask
that he might be considered for renal transplant. The Consultant's renal
replacement program was cash-limited to a certain number of transplants a
year; moreover, there were problems with limited availability of donor organs.
The patient's request was denied on the grounds of his age.
Topical Questions
- How is the traditional role of the physician as patient
advocate being challenged by societal decisions of resource allocation?
- What responsibility does the physician have in use of all
health-related resources?
- How do decisions on resource allocation differ from the
traditional context of the individual patient-physician encounter?
- How does the physician safeguard the interests of patients
when decisions regarding resource allocations are made at the societal
level?
- Within the context of limited medical resources, how does
the physician deal with such issues as aging, rationing, futility therapy
and caring for the poor and still maintain the fundamental elements of the
patient-physician relationship?
|