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Rational and Just Distribution of Healthcare Resources
Martin McKneally and Josh MayichDepartment of Surgery and Joint Centre for Bioethics
University of Toronto
Principles of SurgeryNovember 6, 2012
Plan of Talk
Cases: ICU bed, transplant, emergency,
uninsured patient, others
Rationing resources
Allocating resources
Setting priorities
Fair procedures
Coping strategies
ICU Case: 63 y.o. Mr. E is brought to the emergency room with severe but potentially reversible brain injury after an MVA.
You consider going through the charts of each patient in the intensive care unit in the hope of finding one whose need for intensive care is less than that of Mr. E.
You also consider sending Mr. E to the floor, but know that this will overtax the capabilities of the floor staff, who are not prepared to manage the patient’s elevated intracranial pressure and seizures. Because of recent hospital closures in the region, no other facility is available to share responsibility for the care of patients with neurosurgical problems of this magnitude.
Rationing
Is rationing wrong? Unjust?
Unethical?
Indefensible politically?
Systematic distribution of goods to specific individuals in conditions of scarcity
Rationing
rations on the raft
Rationing
The reasoned and justifiable distribution of goods to specific individuals in conditions of scarcity.
When all beneficial health care cannot be provided to all who might want it, implicit or explicit rationing occurs.
“Though devoted to the medical ethic of ‘rendering to each patient a full measure of service and devotion’, physicians who have many patients have traditionally rationed their services…”
Mark Siegler
University of Chicago
No beds again – can he solve the rationing problem alone?
Resource Allocation
Macro-Allocation
Highways, Education, Healthcare
Meso-Allocation
Hospital care
cancer, trauma, cardiac, neuro, etc.
Home care
Micro-Allocation
Who gets the bed
Systematic distribution of resources to programs
Determining Just Distribution by Setting Priorities
To each an equal share
To each according to effort
To each according to need
To each according to contribution
To each according to merit
To each according to free-market exchange procedures and rules
Priority Setting
Current politically correct term for rationing / resource allocation
Rational allocation of resources based on the priorities set by appropriate decision makers
Suggested Priority List for Decisions about ICU Care
1. Reasonable chance in ICU - would die
outside ICU
2. High risk of life-threatening
complications, need rapid response
3. Lower priorityComatose with a poor expected outcomeCare is unlikely to result in a good
outcomeLow risk for life-threatening complications
Transplant Case: Chris D, a 21 y.o. programmer with CF, is a candidate for retransplantation. Chronic rejection and fungal infections are destroying the double lung transplant he received 15 months ago. He has intermittently required ventilation during flareups of infection or rejection. The presence of infection and the risks associated with repeat transplants predict a survival rate of 65% at one month, and 38% at 24 months.
Mrs. J, a 42 y.o. schoolteacher and mother of 3, is a candidate for double lung transplantation because of rapidly progressing pulmonary hypertension associated with hemoptysis and hypoxemia. She is unable to manage at home because of decompensated right heart failure unresponsive to maximal therapy. As a first time candidate free of infection, her predicted survival at one month is 82%, and 62% at 2 years.
Dr. K has ONE donor for these two patients. He knows that the best result can be achieved by transplanting both lungs of the donor into one of his patients.
Fair Procedures for Decision Making
Reasonable Transparent
Appealable Enforceable Norm Daniels,Boston
UNOS Headlines
“Multiple-Organ Allocation Policy approved for public comment”
“Public Comment sought on pediatric renal allocation”
“Blood Type O Liver Allocation sent for public comment”
“Heart Allocation for Domino Transplants approved for public comment”
Ortho case: You are a busy foot & ankle surgeon with a two year waiting list – a patient cancels…
Pt 1 has subtalar arthritis following a calcaneus fracture. He is a smoker. He has been unable to find work since his arthritis advanced clinically 3 years ago (which is how long he has been waiting for the OR).
Pt 2 is a very pleasant, affluent 69 year old retiree from a financial investment company. He is very disabled by his ankle arthritis. He has been waiting 1.5 years.
Strategies to Cope with the ‘Shortage’ of Resources
Use the tests & treatments that work
Choose the least costly ones
Minimize marginally beneficial ones
Use the natural queue
modify by need/benefit
Rank current patients ahead of imagined future patients
Strategies…
Address shortages at the level of the institution/government
Support conservation of health resources
Avoid gaming, but keep modifying the system
Avoid frightening vulnerable patients
‘Emergency’ case: As the elective schedule winds down, Mr. M, the third patient listed for an elective cancer resection, is cancelled because of insufficient time to complete the operation within the day shift.
What is the fair thing to do:Put him on the emergency schedule?For tonight? This weekend?Displace tomorrow’s first elective patient? Send him home and readmit?
Uninsured case: Mrs. C, a Guyanese woman with complications from cancer, was refused complex elective surgical treatment at an Ontario hospital.
The resource allocation decision, had to be made after she had been admitted and a caregiver-patient relationship established. Caregivers and administrators struggled with the moral anguish of choosing between protecting limited resources for Canadian patients and their desire to provide care for a hospitalized visitor in need of complex and expensive care.
You are making these decisions now
You will make more and larger decisionsYou are the future
Coping strategies to eliminate or reduce
rationing include: 1. Choose interventions known to be beneficial on the basis of
evidence of effectiveness.
2. Minimize the use of marginally beneficial tests, such as the diagnostic zebra-hunt.
3. Minimize the use of marginally beneficial interventions, such as the latest generations of antimicrobials for common infections.
4. Seek the least costly tests or treatments that will accomplish the diagnostic or therapeutic goal.
5. Use the natural queue, treating patients in order of appearance unless morally relevant considerations of need and benefit require modification of this approach.
6. Rank patients with whom you have an established patient-doctor relationship ahead of unknown or future patients.
7. Support rather than oppose reasonable efforts to conserve health care resources.
8. Avoid manipulation of the rules of the health care system to give unfair advantage to your particular patients.
9. Resolve conflicting claims for scarce resources justly, on the basis of morally relevant criteria of need and benefit.
10. Employ fair and publicly defensible procedures for resolution of conflicting or competing claims.
11. Seek resolution of unacceptable shortages at the level of hospital management (meso allocation) or through political action at the level government (macro allocation).
12. Inform your patients of the impact of cost constraints on care in a humanistic way, as a matter of respect for all concerned.
13. Embittered blaming of administrative or governmental systems during discussions with the patient at the point of treatment should be avoided.
14. Develop guidelines for individualization in the face of uncertainty in order to promote a reasonable balance between individual choice and systemic cost control.
SummaryKeep Mr. E in ERTransplant Mrs. JMove Mr. M to the next available
morning slotDischarge Mrs. CRation/Allocate justly
benefit and need
Use Fair Procedures reasonable transparent appealable
Share the problem
Acknowledgements
Paintings by Robert Pope and Joe Wilder
Deborah McKneally, The Ravine Research and Education Centre
