Allocating Scarce Medical Allocating Scarce Medical ResourcesResources

Some medical resources are Some medical resources are bothboth valuablevaluable and (potentially) and (potentially) scarcescarce..

When a resource is When a resource is scarcescarce, the , the demand for it exceeds the available demand for it exceeds the available supply and decisions have to be supply and decisions have to be made about who will receive it.made about who will receive it.

ExamplesExamples

Machinery (dialysis, respirator, etc.)Machinery (dialysis, respirator, etc.) DrugsDrugs Resources from the human body Resources from the human body

(blood, bone marrow, organs)(blood, bone marrow, organs) Space in an ICUSpace in an ICU Slot in an experimentSlot in an experiment Time of HCPs (situations of triage)Time of HCPs (situations of triage)

Key IssuesKey Issues

1.1. Who will receive the resources?Who will receive the resources?

2.2. What criteria will be used to make What criteria will be used to make these decisions?these decisions?

This is an issue of distributive justice.This is an issue of distributive justice. Principle of JusticePrinciple of Justice: burdens and : burdens and

benefits in society should be benefits in society should be distributed fairly among all distributed fairly among all membersmembers..

The issue is how to understand The issue is how to understand “fairness.”“fairness.”

Competing CriteriaCompeting Criteria

MedicalMedical: Here the focus is on who : Here the focus is on who can benefit medically from the can benefit medically from the receipt of the resource. But even receipt of the resource. But even here, there are different senses of here, there are different senses of “medically benefit.”“medically benefit.”

ImmediateImmediate needneed (“rescue rule”) (“rescue rule”) Long-termLong-term survivabilitysurvivability (who will live (who will live

longest if given the resource?)longest if given the resource?)

Competing CriteriaCompeting Criteria

Social UtilitySocial Utility: Here the focus is on : Here the focus is on trying to determine who will trying to determine who will contribute the most to society. contribute the most to society. DeliberateDeliberate human decisions will be human decisions will be made among the candidates.made among the candidates.

LotteryLottery: Everyone is given an equal : Everyone is given an equal chance; who is selected depends on chance; who is selected depends on luckluck. This should not be a deliberate . This should not be a deliberate human decision.human decision.

Example: Swedish Hospital, Seattle, Example: Swedish Hospital, Seattle, Washington, 1960s.Washington, 1960s.

Dialysis becomes available for pts Dialysis becomes available for pts suffering from kidney failure.suffering from kidney failure.

The demand for access to dialysis The demand for access to dialysis exceeds the available supply.exceeds the available supply.

Dialysis is expensive. It was not Dialysis is expensive. It was not routinely paid for by insurance until routinely paid for by insurance until the ‘70s.the ‘70s.

Swedish Hospital formed a Swedish Hospital formed a committee to select the final committee to select the final recipients.recipients.

Advisory group of physicians Advisory group of physicians screened applicants for medical screened applicants for medical suitability.suitability.

Committee makeup was a cross Committee makeup was a cross section – lawyer, banker, labor section – lawyer, banker, labor leader, house wife, minister.leader, house wife, minister.

Dr. Scribner (key player) sought Dr. Scribner (key player) sought publicity for dialysis with the hope publicity for dialysis with the hope that it would become more readily that it would become more readily available for pts.available for pts.

The press focused on how pts were The press focused on how pts were selected.selected.

The committee was referred to as The committee was referred to as “the God squad.”“the God squad.”

Factors considered by Committee:Factors considered by Committee: Residents of Washington were given Residents of Washington were given

priority..priority.. Very young and old were eliminated Very young and old were eliminated

because of the rigors of dialysis.because of the rigors of dialysis.

Favorable Factors as Favorable Factors as Committee Saw ItCommittee Saw It

Having dependents (family support)Having dependents (family support) EducationEducation AchievementsAchievements Church and civic activitiesChurch and civic activities IncomeIncome Ability to tolerate anxietyAbility to tolerate anxiety

Committee seemed to be operating Committee seemed to be operating with social utility/worth criterion.with social utility/worth criterion.

Criticisms of Committee:Criticisms of Committee:

1.1. Case for each pt was made by his or Case for each pt was made by his or her physician.her physician.

2.2. Committee selected as “worthy” Committee selected as “worthy” those most like themselves.those most like themselves.

3.3. This is “playing God.”This is “playing God.”

Social Utility ViewSocial Utility View

One attempt to defend the “social One attempt to defend the “social utility” (worth) view is the work of utility” (worth) view is the work of ethicist Nicholas Rescher. This is an ethicist Nicholas Rescher. This is an attempt to defend the attempt to defend the approachapproach used used by the Seattle committee.by the Seattle committee.

Rescher’s assumption: the number of Rescher’s assumption: the number of applicants will applicants will greatlygreatly exceed the exceed the supply.supply.

This approach advocates This approach advocates twotwo stages in stages in the decision-making process:the decision-making process:

1.1. This stage will This stage will narrownarrow the field to a the field to a workable number. Here workable number. Here criteria of criteria of inclusioninclusion are used. are used.

2.2. ActualActual recipientsrecipients will be chosen at will be chosen at this stage from those who made it this stage from those who made it through 1 based on through 1 based on criteria of criteria of comparisoncomparison..

About the “social utility” view:About the “social utility” view:The goal is to allocate resources so The goal is to allocate resources so that society as a whole will benefit the that society as a whole will benefit the most.most.Society is Society is investinginvesting a scarce resource; a scarce resource; it should get a it should get a returnreturn..Two ways to get a return: Two ways to get a return: life years life years gainedgained and and number benefitednumber benefited..

Stage 1 (criteria of inclusion):Stage 1 (criteria of inclusion):

1.1.Constituency factorConstituency factor

2.2.Prospect of success factorProspect of success factor

3.3.Progress in science factorProgress in science factorCriteria 2 and 3 promote Criteria 2 and 3 promote life years life years gainedgained (directly or indirectly) (directly or indirectly)Criterion 1 promotes, indirectly, the Criterion 1 promotes, indirectly, the number of people benefitednumber of people benefited

Stage 2 (criteria of comparison)Stage 2 (criteria of comparison)

1.1.Relative likelihood of successRelative likelihood of success

2.2.Life expectancyLife expectancy

3.3.Family roleFamily role

4.4.Future contributionsFuture contributions

5.5.Past contributionsPast contributions

Criterion 1 (relative likelihood of Criterion 1 (relative likelihood of success) and criterion 2 (life success) and criterion 2 (life expectancy) promote the value of expectancy) promote the value of life years gainedlife years gained..

Criterion 3 (family role), criterion 4 Criterion 3 (family role), criterion 4 (future contributions), and criterion 5 (future contributions), and criterion 5 (past contributions) promote the (past contributions) promote the number of people benefitednumber of people benefited..

Those who defend the “social utility” Those who defend the “social utility” view are committed to:view are committed to:Society ought to benefit as many Society ought to benefit as many people as possible.people as possible.Society ought to extend the years of Society ought to extend the years of living as long as possible.living as long as possible.It is justifiable to select some pts over It is justifiable to select some pts over others to achieve these ends.others to achieve these ends.

Lottery MethodLottery Method

Defenders of the Defenders of the lottery methodlottery method deny the last bullet point (ends deny the last bullet point (ends justify the means).justify the means).

This view says that This view says that luckluck, not , not deliberate choice, should determine deliberate choice, should determine who gets scarce resources.who gets scarce resources.

Two ways to institute this: i) using a Two ways to institute this: i) using a literal lottery, or ii) a policy of “first literal lottery, or ii) a policy of “first come, first served.”come, first served.”

Defenders of lottery method Defenders of lottery method recommend a two-stage process:recommend a two-stage process:

1.1.Reduce the field by considering only Reduce the field by considering only medicalmedical factors. If the person has a factors. If the person has a reasonable chance to benefit, he/she reasonable chance to benefit, he/she should be included.should be included.

2.2.Among those who Among those who cancan benefit, give benefit, give each an equal chance and let each an equal chance and let luckluck be be the determinant.the determinant.

Defenders of the lottery method make Defenders of the lottery method make the following the following criticismscriticisms of the social of the social utility view:utility view:It violates our belief in equality.It violates our belief in equality.We are not good judges of social We are not good judges of social worth or of who contributes the most worth or of who contributes the most to society.to society.

PositivePositive values promoted by the lottery values promoted by the lottery method:method:expresses a belief in equalityexpresses a belief in equalitywill better promote trust between pts will better promote trust between pts and HCPsand HCPsattitudes of those not selected will be attitudes of those not selected will be better better

CriticismsCriticisms of the lottery method: of the lottery method:

1.1.In some circumstances, it is irrational In some circumstances, it is irrational not to make deliberate choices: a) “life not to make deliberate choices: a) “life boat” situations, and b) situations of boat” situations, and b) situations of triage.triage.

2.2.In some cases, “merit” is relevant: a) In some cases, “merit” is relevant: a) when criminals are candidates; b) self-when criminals are candidates; b) self-induced problems; and c) citizen v. induced problems; and c) citizen v. non-citizennon-citizen