3 articles summary
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USHealthcareSystemRationing2.pptETHICS AND RATIONING
Diana M. Tisnado, PhD
Associate Professor, Health Science
California State University Fullerton
HESC 402
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Introduction to Medical Ethics
4 principles of medical ethics
- Beneficence: duty help those in need
- Non-maleficence: do no harm
- Autonomy: patient has right to make informed choice, and to refuse treatment
- Justice: equitable treatment
Also, distributive justice: how do we allocate benefits and burdens in society? Who gets what, and on what basis? (to each according to need?) Who pays? (from each according to ability?)
The duty to help must be balanced against the duty to do no harm. This is why we talk so much about balance benefits and risks. All health interventions come with a balance of benefits and risks: the healthcare provider has to make a judgement about the chances that the benefits will outweigh the risks for the patient. The provider might not prescribe medicine to help her insomnia if the elderly patient is put at higher risk of harm from a fall.
The patient also has autonomy, and the right to be informed and make a choice to refuse the treatment that is offered.
Justice means treating people in a fair manner. Refusing to treat or giving worse treatment to someone of a different race would be a violation of justice. Some people feel that treating people according to income rather than medical need is a violation of the principle of justice.
Distributive justice extends this principle to the societal level and looks at, in a society, how are benefits and burdens allocated – who gets the good stuff, and who has to pay for it? How do we decide?
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When ethical principles of care come into conflict
- Some dilemmas pit one ethical principle against another in decisions for a particular patient or type of patient situation.
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What ethnical principles are in conflict?
- A patient needs a blood transfusion but patient refuses on religious grounds.
- A patient’s adult son asks doctor not to tell the patient his diagnosis of terminal cancer because telling bad news about death violates cultural norms.
- A family demands to continue life support for a child whom doctors determined is brain dead and the treatment is futile.
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Other Conflicts of Principles?
- Other dilemmas involve broader society:
questions of distributive justice
questions of individual autonomy against societal claims
Also, questions about broader bio-ethical issues such as the technological developments
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Rationing?
What Do We Mean By
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Case 1
- Dr. E works in an HMO where patient Betty Ailes is seen for a headache. Betty wants an MRI. After a complete history and physical Dr. E determines the MRI is unnecessary and prescribes medications.
- Betty writes to the medical director complaining that the HMO is rationing services
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Case 2
- Mr. Hiler arrives at Vacant Hospital with a fever and severe cough. A chest x-ray is suspicious for either pneumonia or a tumor.
- The hospital has empty beds, but because he has no health insurance, Mr. Hiler is transferred to the County.
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Case 3
- Jim is a 50 year old man with terminal cardiomyopathy, and he is referred to a transplant center since his best chance of survival is with a heart transplant.
- Because the number of patients needing hearts is larger than the supply of donor hearts available, he is placed on a waiting list. After 6 weeks Jim dies.
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Case 4
- Dr. Intensivo oversees the intensive care unit, where all 8 beds are full. He gets a call from the emergency department that another patient needs ICU care.
- Now there are 9 patients all in need of ICU beds but only 8 beds: who will have to do without? Dr. Intensivo will need to make a quick decision about what to do.
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Rationing in Health Care: 2 Definitions
- Popular (general) use of the term “rationing” in health care
A limitation of medical care such that not all care expected to be beneficial is provided to all patients
Commodity scarcity: during wartime, resources such as gasoline (also rubber, materials used for fabrics, even foods) were limited due to limitations in getting the raw materials and limitations in manufacturing capacity; since these were limited in availability, a priority system used: military first, then civilian use, with rationing.
A more specific or precise definition means a conscious policy of equitably distributing needed resources that are in limited supply
So which of our cases was this kind of rationing?
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Rationing in Health Care: 2 Definitions
- A more precise definition of the term “rationing” in health care
A limitation of resources (including $$) going into medical care such that not all care expected to be beneficial is provided to all patients; distribution of these resources in a fair manner
In the US we generally have an adequate supply of hospital beds, and physicians in most communities. Some communities don’t have enough primary care, or enough mental health care, and organ shortages are a real problem as well.
But another type of scarcity which is starting to become a problem is funding. Most of the discussions about rationing when we talk about healthcare systems are talking about limited funding and questions of how we will reduce costs without sacrificing quality. This is a more immediate reality in systems with a set total budget. People often think of Canada or the UK when they think of rationing since they operate under pre-set total budgets.
But in the US we have these situations too – within the VA system for example.
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Examples: Oregon Medicaid plan
In 1987, case of leukemia and bone marrow transplant sparked controversy and debate
Legislators argued that it was impossible to cover every service for every person
In 1994 instituted a prioritization system to determine what services would be covered
Over 700 treatments rated on net benefit (based on combination of public preferences and cost-benefit analysis) and ranked on a list
Each year the state budget would dictate where the line would be drawn
Another example came up in Oregon’s Medicaid program.
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“NICE” Health Services Coverage in UK System
- UK funds NHS care under a set budget
- National Institute of Clinical Excellence analyzes cost-effectiveness of services
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