Healthcare Allocation for Limited Budgets
By Joshua Parker and Ben Davies
Like many public services, the UK’s National Health Service (NHS) is under increasing resource pressure across the service. Acute services are under strain, with every stage between dialling 999 and getting into a hospital bed taking longer. Waiting times are also up for non-urgent care: 7 million people are on a waiting list in England, while General Practitioners (GPs, the UK’s primary care physicians) are exceeding safety limits and still not managing to meet demand. These measures are only proxies; the underlying concern is that failures in these metrics betray failures of quality and safety.
In part this is due to chronic under-investment made worse by a range of factors: greater demand generated by Covid and lockdowns; increasing complexity with an ageing patient population; more medical ability due to developments in medical technologies; and staff shortages that are in part a result of the UK’s departure from the European Union. However, some may argue that the pressure is also a sign that the NHS is trying to do too much in straitened times, and perhaps even that the scope of what a health system is responsible for has been expanded too far.
The New Relevance of Rationing
By Ben Davies
Decisions about how to allocate healthcare resources can be divided, somewhat crudely, into macro– and micro-level choices. Roughly speaking, macro-choices are policy choices, often made outside any clinical setting, e.g., by government. For instance, it is a macro-level choice which treatments to fund to what degree, and how large the health budget should be as a whole. Micro-choices are the choices people make with a particular budget, generally in clinical settings. For instance, it is a micro-level choice which patients to admit to intensive care, and how to prioritise individuals for organ transplants.
Cross Post: Pandemic Ethics: Vaccine Distribution Ethics: Monotheism or Polytheism?
Written by Alberto Giubilini, Julian Savulescu, Dominic Wilkinson
(Oxford Uehiro Centre for Practical Ethics)
(Cross-posted with the Journal of Medical Ethics blog)
Pfizer has reported preliminary results that their mRNA COVID vaccine is 90% effective during phase III trials. The hope is to have the first doses available for distribution by the end of the year. Discussion has quickly moved to how the vaccine should be distributed in the first months, given very limited initial availability. This is, in large part, an ethical question and one in which ethical issues and values are either hidden or presented as medical decisions. The language adopted in this discussion often assumes and takes for granted ethical values that would need to be made explicit and interrogated. For example, the UK Government’s JCVI report for priority groups for COVID-19 vaccination reads: “Mathematical modelling indicates that as long as an available vaccine is both safe and effective in older adults, they should be a high priority for vaccination”. This is ethical language disguised as scientific. Whether older adults ‘should’ be high priority depends on what we want to achieve through a vaccination policy. And that involves value choices. Distribution of COVID-19 vaccines will need to maximize the public health benefits of the limited availability, or reduce the burden on the NHS, or save as many lives as possible from COVID-19. These are not necessarily the same thing and a choice among them is an ethical choice. Continue reading
Video Series: Why Parental Status Matters When Allocating Scarce Medical Resources
Which patients should we treat, if we can’t treat them all? The Covid-19 pandemic has brought questions about how to allocate scarce medical resources to the forefront. In this Thinking Out Loud interview with Katrien Devolder, Philosopher Moti Gorin (Colorado State University) argues that parents (or primary caregivers) of a dependent child should (sometimes) get priority. A controversial position that nevertheless has some intuitive appeal!
Should PREDICTED Smokers Get Transplants?
By Tom Douglas
Jack has smoked a packet a day since he was 22. Now, at 52, he needs a heart and lung transplant.
Should he be refused a transplant to allow a non-smoker with a similar medical need to receive one? More generally: does his history of smoking reduce his claim to scarce medical resources?
If it does, then what should we say about Jill, who has never touched a cigarette, but is predicted to become a smoker in the future? Perhaps Jill is 20 years old and from an ethnic group with very high rates of smoking uptake in their 20s. Or perhaps a machine-learning tool has analysed her past facebook posts and google searches and identified her as a ‘high risk’ for taking up smoking—she has an appetite for risk, an unusual susceptibility to peer pressure, and a large number of smokers among her friends. Should Jill’s predicted smoking count against her, were she to need a transplant? Intuitively, it shouldn’t. But why not?
Podcast: Genetic Parenthood, Assisted Reproduction, and the Values of Parental Love
On the evening of Thursday 28 December, Prof. Justin Oakley, Deputy Director of the Centre for Human Bioethics at Monash University, gave a fascinating and suggestive lecture on whether there is reason for the state to broaden access to IVF treatment for childless people as well as facilitating adoption. Continue reading
Nudge Drugs: should the social side-effects of medications weigh into public health?
You are a public health official responsible for the purchasing of medications for the hospitals within your catchment area in the NHS. Your policies significantly affect which, out of the serpentine lists of heart disease medications, for example, are available to your patients. Today, you must choose between purchasing one of three heart disease medications: Drug A, Drug B, and Drug C. They are pretty similar in efficacy, and all three have been being used for many years. Drug B is slightly less expensive than Drug A and Drug C, but there is emerging evidence that it increases the likelihood that patients will take “bad bets,” i.e. make large gambles when the chance of winning is low (and thus might contribute to large social costs). Drug C costs a tiny bit more than Drug A, but there is some evidence that Drug C may help decrease implicit racial bias. You have been briefed on the research suggesting that implicit racial bias can lead to people making choices that consistently and unintentionally limit the opportunities of certain groups, even when all the involved parties show explicit commitments to social equality. Finally, there is emerging evidence that drug A both helps people abstain from alcohol and dissociates negative emotional content from memories.
Which drug should you purchase?
Let us begin to think about this question through the lens of the idea of the “Nudge,” which has exploded onto the public sphere (and blogosphere) since Thaler and Sunstein’s published their book, “Nudge: improving decisions about health, wealth, and happiness.” (see the blog here). I briefly and incompletely introduce nudges here, in hopes that we may soon move on to discuss the kind of “nudge drugs” our thought experiment considers.
The cost of living and the cost of dying
X, a patient with reliably diagnosed PVS, lies in a hospital bed for years, fed via a nasogastric tube. He has not, and by definition never will have, any capacity for pain, pleasure or any sort of sensation. Devoted family members come each day to sit by his bedside, but he has no idea that they are devoted, or that they exist.
It is expensive to keep him alive. He occupies a bed and consumes a good deal of nursing time.
The NHS Trust responsible for his care has a limited budget. It decides that the money spent on maintaining his merely biological life would be better spent on dialysis machines. It can, and does, justify its decision in purely utilitarian terms. It writes in the minutes of the relevant committee meeting: ‘For the money we spend keeping X alive, we can save the lives of 10 kidney patients, each of whom will have a good quality of life for many years. The QALY arithmetic makes X’s continued existence nonsensical.’ Continue reading
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