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Rationing/ Resource Allocation

Focussing on diseases

Further to Julian’s article about Giving What We Can, an important part of helping people as much as possible is to find out which charities do the most good for a certain amount of money. This has been in the news recently with this article. It claims that we are missing out on doing a lot of good by focussing exclusively on certain high-profile diseases, while other diseases impose a greater burden and are much cheaper to treat. This raises the question of why some diseases get much more attention and support than others.

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Is professional integrity a futile argument?

by Dominic Wilkinson

In an earlier post this week I argued that there are only two substantive reasons for doctors not to provide treatment that they judge futile – either on the basis of a judgement that treatment would harm the patient (a form of paternalism), or on the basis that providing treatment would harm others (on the basis of distributive justice). I rejected the idea that professional integrity provided an additional reason to withhold or withdraw treatment.

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Break my bones, but don’t let me die! Should doctors provide ‘futile’ CPR?

by Dominic Wilkinson

Two recent cases in a Toronto hospital illustrate a dilemma that hospital doctors face all too frequently. What should they do if patients or their representatives insist on treatment that the doctor believes would be futile? Should they just go along with the patient despite their misgivings? Alternatively, should they unilaterally withhold treatment if they feel it would be inappropriate to provide it?

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Benefit cuts for large, workless families

The UK's culture secretary, Jeremy Hunt, has suggested that the state should limit the provision of social security benefits to large, unemployed families. Hunt said last week that

The number of children that you have is a choice and what we're saying is that if people are living on benefits, then they make choices but they also have to have responsibility for those choices . . . It's not going to be the role of the state to finance those choices.

Two quite different arguments might be offered in support of such a move.

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The NHS Should Make and Sell its own Homeopathic Remedies and Homeopaths Should be Paid the Minimum Wage

In March this year I blogged on the topic of NHS funding for homeopathic remedies. Even though I agreed with the critics of homeopathy, that there is no credible evidence for the efficacy of homeopathic remedies and that it is irrational to use these in preference to medical treatments that have actually been proven to work, I argued that the NHS should continue to subsidise the cost of homeopathic remedies. My basic line of argument was anti-paternalist. People should have the choice to be irrational if they want. What is important is that people are provided with all information relevant to their decision making. However, if they go ahead and choose to behave irrationally, then, provided that they are not harming others, their actions should not be interfered with. It is not the State’s role to prevent people from making such choices.

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A costly separation between withdrawing and withholding treatment

by Dominic Wilkinson

Television child star Gary Coleman died recently following a severe brain haemorrhage. He was taken to an intensive care unit, but the next day was taken off life support because of the severity of his brain injury.

Decisions like the one made by Gary Coleman’s doctors are common in intensive care. Many deaths follow decisions to stop intensive treatment because it is believed to have no chance of succeeding or because of the burden of illness even if the treatment does work. One question raised about cases like these is about the importance (or risks) of living wills. A separate question (and one that was raised during the critical care grand round earlier today) is about the difference between stopping treatment and failing to start treatment.

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Critical Care ethics grand round

by Dominic Wilkinson

Today I gave a talk at the John Radcliffe Medical Grand Round on Advance Directives and treatment withdrawal decisions in intensive care – based on a case I was involved in last year.

A middle-aged patient presents with acute respiratory failure, and is intubated and transferred to the intensive care unit. After admission he improves, but it transpires that he has a progressive neurodegenerative disorder and has previously expressed a wish not to have intensive life support measures provided.

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Mining your past to justify your terminal care: the idea of a ‘retrospective QALY’

There is no end to human suffering. There is a distinct end to the amount of money that governments will spend on reducing it. Someone has to make decisions about healthcare resource allocation. I am very glad it’s not me.

Many tools are used in the decision-making process. Not many emerge well from a viva with a philosopher.

Individual clinicians use intuition, experience, NICE
guidelines, the fear of hospital accountants and, no doubt, prejudice and the
tossed coin. But policy makers do not have the luxury of being able to account
only to their consciences and the local man in a suit. They have to say something in the minutes about the
reason for funding procedure X but not procedure Y. The real reason might be:
‘My grandma, whom I loved very much, had procedure X, and it did her good’, but
they can’t say that.

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For Sale: Body Parts?

The Nuffield Council on Bioethics has recently published a consultation paper entitled Give and Take? Human Bodies in Medicine and Research: https://consultation.nuffieldbioethics.org/fileLibrary/pdf/Human_bodies_in_medicine_and_research_consultation_paper.pdf The paper seeks responses from individuals or groups on a wide range of issues relating to the use of human bodies or body parts in medical treatment and research. Section 6 is on… Read More »For Sale: Body Parts?

The worth of a life and a life worth living

There has been a lot of discussion about health care rationing in the North American media over the last year, much of it hysterical and barely coherent. A number of respected ethicists have tried to make the case for rationing, including Peter Singer in the New York Times last year, and recently John Freeman.

This week Newsweek Science Editor Sharon Begley asked ‘What is a Life Worth?’ drawing on a recent study presented at the American Society for Maternal-Fetal Medicine meeting. Begley noted

“This is the kind of news that unleashes hysteria about "death panels" and "health-care rationing," but here goes: an analysis of genetic screening for an incurable, untreatable disease called spinal muscular atrophy shows that it would cost $4.7 million to catch and avert one case, compared with $260,000 to provide lifetime care for a child born with it. So here's the question: do we say, "Damn the cost; it is worth any price to spare a single child the misery of being unable to crawl, walk, swallow, or move his head and neck"—or do we, as a society, put on the green eyeshades and say, "No, sorry, we can't afford routine screening"?”

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