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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