The role of ethics committees and ethics consultation in priority

setting.

An evidence-based analysis

Daniel Strech, MD, PhD (Hannover Medical School, Germany)

Samia Hurst, MD (University of Geneva, Switzerland)

Marion Danis, MD (National Institutes of Health, USA)

Priorities 2010Boston, April 2010

Definitions

Rationing Withholding of a medical technique that has

net additional benefit for the patient for reasons of cost

Rationalization aims to reduce excessive or faulty treatment

and inefficiency without reducing net additional benefit

Presuppositions

Rationing is in fact unavoidable in clinics

Often rationing is implicitly and thus non-transparently Bedside decisions are limited by budgets and

prospective compensation (DRGs) Affects quality but also fairness of medical

care.

Current state of research

Normative frameworks1-3 ethically appropriate implementation of unavoidable

rationing

Qualitative research Conflicts that arise when doctors make decisions under

implicit limits

Synthesis (objective of this presentation) Specifying the role of ethics consultation and ethics

committees in allocation decisions at the hospital level

1. Emanuel EJ (2000) Justice and managed care. Hastings Cent Rep 2. Daniels N and Sabin JE (2002) Setting limits fairly OUP3. Hurst SA and Danis M (2007) A framework for rationing by clinical judgment. Kennedy Inst

Ethics J.

The (indirect) need for ethics consultation in rationing questions Data on bedside rationing1-3

Italy, Great Britain, Norway, Switzerland: 56 % of doctors reported rationing clinical interventions1

Logical argument: no health care system can provide all patients with all possibly beneficial treatments4,5

1. Hurst SA et al. (2006) Prevalence and Determinants of Physician Bedside Rationing J Gen Intern Med

2. Ward NS et al. (2008) Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units Crit Care Med

3. Strech D et al. (2009) [Extent and impact of bedside rationing in German hospitals: results of a representative survey among physicians]. Dtsch Med Wochenschr

4. Kent D (2010) Just-as-good Medicine American Scientist5. Shrank WH et al (2006) Physicians' perceptions of relevant prescription drug costs Am J

Manag Care

The (indirect) need for ethics consultation in rationing questions Doctors’ rationing decisions are inevitabley a

function of the particularities of individual cases patient characteristics and clinical context “those that shout the loudest get the most”1

Leeway in interpretation of „hard“ criteria such as medical benefit or cost-effectiveness2

Non-patient factors that play a role clinic’s general financial situation the pressure of competition

1. Berney L et al. (2005) Ethical principles and the rationing of health care Br J Gen Pract2. Strech D et al. (2009) [Challenges of explicit rationing by cost-conscious guidelines]

Gesundheitsökon. & Qualitätssich.

Study of direct need: Should ethics consultants help clinicians face scarcity in their practice1

Types of support professional reassurance that the decision

was correct (48%) someone capable of providing specific advice

(41%) help in weighing outcomes (36%) clarification of the issues (36%) help in talking things through with the patient

(33%) mediation of conflict (33%)

1. Hurst, S.A., et al. (2008) Should ethics consultants help clinicians face scarcity in their practice? J Med Ethics

Four-stage approach for ethics consultation in rationing questions1

1. Training

2. Identifying actual scarcity-related problems at clinics

3. Supporting decision-making

4. Evaluation

1. Strech D, Hurst M, Danis M [accepted for publication] The role of ethics committees and ethics consultation in priority setting. Medical Care.

Didactic and practical goals

Didactic goals foster understanding of the theories of justice and

their continued application-based development

Practical goals1. encourage an awareness and understanding 2. encourage rationalization before rationing3. reinforce consistency 4. facilitate explicit reflection and justification 5. improve transparency 6. prevent the misuse of consulting structures

1. Training

Essential reasons for scarcity of means

Physician’s responsibility and patient trust focus on the possibility that rationing, when carried out fairly under scarcity

conditions, can be in the best interest of patients (regarded from an inter-personal, public health standpoint)

Rationing versus rationalizing clarification (discussion) of whether certain actions are to be considered

rationing or rationalization

Justice clarify the fact that the application of alternative theories of justice or

methods of economic analysis could lead to different results in rationing decisions

Prioritization criteria broad consensus: extent of the benefit, cost-effectiveness, severity availability

of an alternative intervention Controversial: Patient age, “rule of rescue”

Material and procedural conditions of a just allocation

2. Identification of resource constraints in the clinical setting Awareness and understanding of the constraints of the

specific clinical environment

Survey among the clinic personnel not limited to health care providers identify the spectrum of actual problems Identify clinic employees’ expectations towards ethics

consultation. provide an initial orientation concerning the distribution of

problems among the individual departments.

Examining the relevant contextual variables routine processes, informal agreements, guidelines for

rationing decisions, etc.

Material and procedural conditions of a just allocation

Support in decision-making processes Classical functions of ethics consultation

Facilitation of discussion joint appraisal of relevant information work out the available alternatives

Alleviate psychic burdens of rationing? Responsibility for consultants of explicitly introducing

well-justified criteria for rationing? Draw attention to circumstances when ethically

problematic rationing criteria are being used?

Should ethics consultants intervene in decision-making?

Material and procedural conditions of a just allocation

Evaluation

Subjective satisfaction with the consultation by those who request consultative advice

Objective (results and process) evaluation through documentation 1. basic question and processes that determined the question2. information taken into consideration and its interpretation 3. principles and normative criteria taken into account4. Final decision and compromises

Assessment of evaluation results includes (among other things) the comparison with similar cases and thus a review of decision-making consistency

Material and procedural conditions of a just allocation

Conclusion

Legitimate ethics consultation needs to be embedded into a broader framework addressing material and procedural conditions of just allocation

Need for further translational research E.g. different implementation strategies

Readiness of clinical managers1

to utilize ethics frameworks to involve stakeholders

Resource allocation happens at multiple levels (community, institution) organizational ethics committees.

1. Foglia MB et al. (2009) Ethical challenges within Veterans Administration healthcare facilities Am J Bioeth

The role of ethics committees and ethics consultation in priority

setting.

An evidence-based analysis

Daniel Strech, MD, PhD (Hannover Medical School, Germany)

Samia Hurst, MD (University of Geneva, Switzerland)

Marion Danis, MD (National Institutes of Health, USA)

Priorities 2010Boston, April 2010