Principles of Allocation of Scarce Medical Resources

Reading:

London in Steinbock, “Case Study”, pp. 233-240.

Cappelen and Norheim in Steinbock, “Responsibility in Health Care,” pp. 247-253.

Daniels and Sabin in Steinbock, “Last Chance Therapies and Managed Care,” pp. 254-265.

Persad et al. in Steinbock, “Principles for Allocation of Scarce Medical Interventions,” pp. 265-275.

Overview

This module begins with the case study of Christine Demeures, a 32-year-old schoolteacher and married mother of two. Mrs. Demeures was diagnosed with Stage IV metastatic breast cancer. When standard treatment proved unsuccessful, her physician, Dr. Glaspy, informed her of a new aggressive therapy with unproven therapeutic benefits. The new therapy came with a price tag of $100,000-$200,000.

The core question in this module is posed by Alex John London:

Should we, should the government or insurance companies, pay for people’s access to procedures of this nature? Should we pay for costly medical procedures of unknown therapeutic benefit when there are people struggling to get access to a host of genuinely effective therapies? (p. 237)

This question brings up one of the most frequently avoided terms in biomedical ethics: Rationing. We do not have unlimited health care budgets. Which procedures will be deemed “too expensive” or “of unproven therapeutic benefit”? How much of your household budget are you willing to spend on healthcare premiums? How much of the federal budget should be allocated to healthcare? Should taxpayers be placed on the hook for aggressive new therapies of unproven benefit that cost hundreds of thousands of dollars? Where do we draw the line between routine care and aggressive new therapies?

In the next reading for this module Cappelen and Norheim raise an important question: to what extent should taxpayers be on the hook for diseases caused by poor lifestyle choices—choices such as smoking, drug use, unsafe sex, obesity. Note that under the Health Care Act insurance companies cannot exclude people for pre-existing conditions, even if those pre-existing conditions are the result of poor lifestyle choices. Also note that under the new legislation, Medicaid will be expanded significantly. People who are successful and make good lifestyle choices will be forced under the law to subsidize health care of people who have made poor lifestyle choices. Cappelen and Norheim argue that people who make poor lifestyle choices, for example, people who choose to remain obese, should be held accountable for their choice to remain obese.

In the next reading Daniels and Sabin analyze principles of allocation of scarce medical resources in terms of four competing values: (1) giving some priority to “last-chance” interventions such as the case of Mrs. Demeures (the question is, of course, how much priority); (2) providing stewardship of collective resources; (3) producing the public good of scientific knowledge; and (4) respecting patient autonomy.

In the next reading Persad et al. consider eight principles of allocation: (1) lottery, first-come, first-served, (3) sickest first, (4) youngest first, (5) number of lives saved, (6) prognosis, (7) instrumental value, and (8) reciprocity. They note that none of these allocation principles are sufficient taken individually.

Objectives

By the end of this unit, I will be able to:

· Understand the difference between routine medical care and experimental therapies of unproven benefit

· Assess the role of personal responsibility in the allocation of scarce medical resources

· Evaluate various allocation principles of scarce medical resources

Key Concepts

· Rationing

· Allocation Principles of Scarce Medical Resources

· Last chance “Experimental” Therapies

· Routine Medical Care

· Stewardship of Limited Collective Resources

· Expanding Scientific Knowledge

· Patient Autonomy

Review Questions

[1] State the central features of the case of Mrs. Demeures.

[2] Should taxpayers be forced to foot the bill for experimental new therapies with unproven therapeutic value?

[3] Cappelen and Norheim argue that individuals should be held accountable for their poor lifestyle choices. Explain the two arguments they advance for this position. Do you agree or disagree with their position?

[4] Cappelen and Norheim consider three objections based on normative considerations to their position: (1) the humanitarian objection, (2) the liberal objection, and (3) the fairness objection. Explain each of these objections. Do you find them convincing?

[5] Cappelen and Norheim consider two objections based on practical considerations: (1) the informational objection, and (2) the non-neutrality objection. Explain each of these objections. Do you find them convincing?

[6] How do Cappelen and Norheim respond to these objections? Do you find their responses convincing?