MODULE 12 - RESOURCE ALLOCATION IN HEALTH CARE
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There are several ethical issues related to allocating scarce health care resources. Different ethical frameworks provide approaches for prioritizing patients, such as maximizing health benefits for the greatest number, or allocating based on principles of fairness and medical need. While it is difficult to satisfy all expectations, transparent use of ethical tools and frameworks can help clinicians and committees make reasoned and justifiable decisions about resource allocation.
MODULE 12 - RESOURCE ALLOCATION IN HEALTH CARE
- 1. 145 MODULE 12 - RESOURCE ALLOCATION IN HEALTH CARE
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- 3. 147 By the end of this module, the resident will be able to: 1. Identify the ethical issues related to resource allocation in public health 2. Present at least one ethical framework for resource allocation 3. Utilize an ethical framework to outline an approach to allocate resources What are the ethical issues and principles in resource allocation? It is almost a fact in health care that there are never enough resources for everyone. This is true even in the richest countries. There are always health needs; some health care needs are basic, while other needs can be considered secondary or tertiary. For example, there is a growing need for body organs, which makes waiting lists longer and longer for patients with liver or kidney failure, and for patients who may even need lungs or hearts. Resource allocation is not only about money; it also includes time allocation to patients, and allocation of beds or drugs. Issues related to allocation of resources are faced at both the higher level of policy setting (the Ministry of Health) and at the bedside level. We will mainly focus on the latter. The following are examples of the main ethical principles that are relevant to this issue: The principle of (distributive) justice Patients and the community in general expect the health care system, represented mainly by clinicians, to be fair. However, the standard of fairness is usually measured against the patient‟s expectations of the system, which might be idiosyncratic, rather than realistic. In addition, the health care service should be provided regardless of gender, race, socioeconomic status, or any other non-clinical factors. The principles of non-maleficence and beneficence Doctors should not do anything that would harm their patients. This includes providing them with the care needed to avoid this harm (non-maleficence) and extending their well-being (beneficence). However, these principles do not tell doctors which patients‟ interests should be given priority when there is more than one patient in need of a resource. The patient‟s autonomy The principle of autonomy indicates that individuals have a right to make decisions that are related to their own health and bodies, though this right is
- 4. 148 bound by similar limits given to other individual members of the community. It could logically be expected that patients (or their families) might want to “have everything done” to cure their disease. Different approaches to allocation of resources in health care There have been many attempts to decide who should get what, i.e., how to allocate health care resources. These approaches may not (and will not) arrive at the same conclusions, or the expected “right” answer. Some of these approaches are presented here, to help you decide which ones to utilize when facing similar problems related to allocation of scarce resources. Consequentialist and utility principle approach The utility principle is about acting to produce the greatest good. Consequentialism (utilitarianism) considers the right action to be that which produces the greatest sum of pleasure in the relevant population. This suggests that the resources available in a health care setting should be used to provide the greatest good for the greatest number. Deontological (duty-based) approach Deontology is duty-based, and suggests that people should act to fulfill their duties to others, and that acts should always follow a set of maxims (e.g., “Do not lie”). This approach focuses less on the act‟s consequences. Cost-effectiveness, quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs) In addition to being just (fair), distribution of resources needs to be cost- effective. This means that the allocation maximizes health benefits for the population served. A cost-effectiveness analysis (CEA) compares the respective costs and benefits of alternative health intervention measures to determine their relative efficiency in the production of health. Costs are measured in monetary terms; benefits are measured in health improvements. By dividing costs by benefits, one can obtain a cost-to-effectiveness ratio for each health intervention, and interventions can be ranked by these ratios. Quality-adjusted life-years (QALYs) are used to combine the two main benefits of health care: (a) protecting or improving health or health-related quality of life, and (b) preserving life. Disability-adjusted life-years (DALYs) are a variant of QALYs in that they measure the losses from disability or premature death; a CEA will determine which interventions will maximize QALYs or minimize DALYs (Brock & Wikler, 2006). Principle-based approach (Principlism) Principlism is one way of approaching professional deontology. Put simply, it is based on stating one or more principles from which stem duties. Some
- 5. 149 examples of these principles include Hippocrates‟ oath (“First, do no harm” or “Primum non nocere”), the Belmont Report, produced in 1978 (three principles) and the four principles of beneficence, non-maleficence, respect for persons, and justice by Beauchamp and Childress. (Beauchamp & Childress, 2008) Fair process approach (Accountability for reasonableness) This approach is focused more on the process of allocating resources, rather than the principles used. In other words, if we cannot agree on what is a fair distribution, let us at least agree on procedural justice (fair process). For a “fair process” of resource allocation, Norman Daniels suggested a set of principles that should be followed in decision making: Transparency/publicity: information about the processes and bases of decisions should be made available to the affected population. Participation: the stakeholders should be involved in the processes of formulating the objectives and adopting the policies. Effectiveness/Relevance: states that there must be ways to translate the other principles into practice relevant to meeting population health needs fairly. Appeal: Stakeholders should have a way to appeal policies after they have been adopted, and processes should be in place that allow policies and plans to be reviewed and revised. Resources are not only about medications or equipment, but also include aspects of time and care. Their importance is tied in with the difficulty of reaching a definite decision on who should be given what. In turn, this may lead to a level of dissatisfaction among patients and medical staff. Therefore, there should be an ethical basis on which you can base your decision about who should receive what. There are many ways to achieve a fair allocation of resources, which are based on a number of ethical considerations, summarized in the following list: 1. CEA: (Effectiveness) - priority given to those most likely to achieve a good outcome, i.e., medical success 2. Medical Need - priority given to those most in need of medical intervention, or those considered most helpless or generally neediest in society (vulnerable groups) 3. Utility - achieving the least morbidity/mortality possible, given the resources available (maximizing good health/survival with the available resources)
- 6. 150 4. Immediate Usefulness - priority given to those with special skills that could be used to serve the common good in the immediate circumstance 5. General Social Value - priority given to those who are considered by society to have the greatest social worth (past or future) 6. Principle of Conservation - priority given to those who use proportionally less resources 7. Responsibility for Dependents - priority given to those who have primary responsibilities to dependents (parents, nursing home attendants, etc.) 8. None if not all - no one should be saved if all cannot be saved 9. Queue - priority given on a first-come, first-served basis 10. Random Selection - allocation determined by chance (a lottery, for example) 11. Ability to Pay - priority given to those who can pay for the resources 12. Merit based - priority given to those who have earned it due to past actions The main goal of this module is to help you approach such issues; it provides different approaches and references that will help you reach decisions on these issues, and justify those decisions to your colleagues and patients, if needed. This is an important issue because some clinical staff may experience moral reservations and frustration. This can happen if they feel they have failed, and let a patient down by allocating an intervention to a different patient. Ethically, we have moral obligations of fairness, utility, and beneficence towards our patients, who expect us to work in their best interests. In addition, the resource decisions that sectors make might negatively affect some patients by delaying or denying their access to a given medication or intervention. Therefore, it is important to find a way by which clinicians and other health care providers can justify these decisions, at least ethically. At the policy level, we might expect significant differences between institutions that have guidance on how their resources should be allocated and those who do not. This includes policies related to, for example, organ donation, admission to ICU, and end-of-life care.
- 7. 151 The Islamic approach to these issues is similar to the Islamic approach to other ethical issues. It aims at achieving the five main goals of the Sharia, which is to preserve people‟s religion/faith, souls/bodies, mind, wealth, and progeny. See Module 2 for more details. As a clinician or member of an ethics committee, you can use more than one framework. These frameworks are based on a set of questions that, when answered, will hopefully help you take the most suitable decisions about allocating a given resource. We will present two examples: The American College of Healthcare Executives (ACHE) framework It has suggested an 8-step approach: Step One: Clarify the ethical conflict Step Two: Identify all of the affected stakeholders and their values Step Three: Understand the circumstances surrounding the ethical conflict Step Four: Identify the ethical perspectives relevant to the conflict Step Five: Identify different options for action Step Six: Select among the options Step Seven: Share and implement the decision Step Eight: Review the decision to ensure it achieved the desired goal The Hamilton Health Sciences (ISSUES) framework 1. Identify issue and decision-making process 2. Study the facts 3. Select reasonable options 4. Understand values & duties 5. Evaluate and justify options 6. Sustain and review the plan
- 8. 152 Figure 0.1 ISSUES Framework (http://hamiltonhealthsciences.ca/workfiles/CLINICAL_ETHICS/HHSEthicsFramework.pdf) There are rarely enough health care resources for everyone. At some point, there will be a need to prioritize the beneficiaries of the service that you provide in a fair way that fulfills your professional commitments. 1. Different people have different expectations of what the health care system ought to provide, thus it is hard to make decisions that satisfy everyone. 2. There are moral and professional commitments related to these decisions. 3. There are ethical frameworks and tools based on ethical principles that, if used in a transparent way, may help clinicians and ethics committees to provide fair resource allocation. 1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th edition. 2008 2. Brock D, Wikler D. Ethical Issues in Resource Allocation, Research, and New Products Development. In: Disease Control Priorities in Developing Countries. 2nd edition. Jamison D, Breman J, Measham A,
- 9. 153 et al., (eds). Washington (DC): World Bank; 2006. Chapter 14. Available from: http://www.ncbi.nlm.nih.gov/books/NBK11739/?report=reader 3. Crippen D, Whetstine L. ICU resource allocation: life in the fast lane. Critical Care 1999;3(4):R47-R51 available from: http://ccforum.com 4. Lasry A, Carter M, Zaric G. S4HARA: System for HIV/AIDS resource allocation. Cost Effectiveness and Resource Allocation 2008;6(1):7 available from: http://www.resource-allocation.com/content/6/1/7 5. Lippert-Rasmussen K, Lauridsen S. Justice and the allocation of healthcare resources: should indirect, non-health effects count? Medicine, Health Care and Philosophy 2010;13(3):237-246 available from: http://dx.doi.org/10.1007/s11019-010-9240-9