Ethical Issues in Public Healthcare ?????????

1
Ethical Issues in Public Healthcare?????????

• Dr Derrick Au (?????)
• Head of Human Resources
• Hong Kong Hospital Authority

Ethics in Public Health and Health Care
Management (EDB 07.6.2012)
2
Ethical principles for clinical cases????????

• Commonly taught ethical principles
• Respect of autonomy??????
• Beneficence ????
• Nonmaleficence ?????
• Justice ????

3
Clinical ethics in practice?????????

• Patient rights ????
• Doctor-patient relationship????
• Health care decision-making ???????

4
Clinical ethics in practice???????????

• Patient rights ????
• Doctor-patient relationship????
• Health care decision-making ???????

5
Common clinical ethical issues ??????????? (??)

• Informed consent ????
• ??autonomy,information on risk and benefit,duty
  of care
• Patient privacy ????
• ??autonomy,confidentiality
• Life-sustaining treatments ?????????
• ??autonomy, information on risk and
  benefit,patients best interests

6
Clinical Ethics

• Clinical ethics A structured approach to assist
  health care professionals in identifying,
  analyzing, and resolving ethical issues in
  clinical medicine.
• Some clinical issues of importance
• Informed consent autonomy vs. benevolence
• Truth telling autonomy vs. nonmaleficence
• Confidentiality autonomy and privacy
• End-of-life care autonomy and risk-benefit
• Patient rights autonomy vs. justice
• Risk-benefit benevolence vs. nonmaleficence

7
Four-Quadrant method of clinical ethics
evaluation???????????????
A clinical case with ethical problem can be
analyzed by considering four aspects of the case
Clinical Indications ?????? Patient Preference ?????
Quality of Life ???????? Contextual Features ???????
Source Sliwa JA et al. Am J of PMR, Vol 81(9),
Sep 2002, pp 708-717.
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Patients Charter (????)

• In year 2000, the Hong Kong Hospital Authority
  produced a Patients Charter to outline patient
  rights and responsibilities in public hospital
• Read more
• http//www.ha.org.hk/tmh/patient_charter/index.htm
  l

9
HA Patients Charter Patients rights

• Right to Medical Treatment (???)
• Right to Information (???)
• Right to Choices (??? )
• Right to Privacy (??? )
• Right to Complaint (???)

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Issues Life sustaining treatment at end of life
stage

• ???????????????????,2002?4?,2012????????
• Ethical considerations involved
• Medical view on what is in patients best
  interests (risk and benefit, quality of life,
  suffering)
• Patients informed decision (risk and benefit,
  values, quality of life, suffering, dignity)
• Role of close family members (consensus and
  conflict management)
• Advance directives and Do-not-attempt-resuscitatio
  n decisions
• Special considerations in decisions related to
  withdrawing artificial means of nutrition and
  hydration

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Public Health (??????)

• Public health practice and policy concerns with
  issues of illness and disease of populations
  (???????????????????????)
• Some ethical issues are unique to public health
  conflict between overall health of the public and
  autonomy of the individual
• Immunization (????)
• Mandatory medical reporting and treatment of
  communicable diseases (??????????)

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Public Healthcare (??????)

• Publicly funded health care is responsible for
  delivering health service to a population
• Many issues are in clinical ethics but some
  ethical issues are at policy level e.g.
  allocation of resources (????????????)
• In health care management ethical issues may be
  related to health care workers (????????????)
  e.g. immunization, medical reporting,
  conscientious objection

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Questions raised in case of HIV Doctor

• The ethical issues
• Privacy/confidentiality vs. Right to know of
  the public (??? vs.?????)
• Mandatory medical reporting (??????)
• Restriction of duties (?????????)
• Discussion

14
Anti-Drug Driving Law AE Doctors Role
(?????????????)

• The new law in effect from Mar 2012 allows a
  doctor to, if he thinks fit, assist police by
  taking blood (to check drug/alcohol levels) from
  patients who are incapable of giving consent at
  time of presentation to AE Department
• The ethical issues
• Privacy in doctor-patient relationship vs. public
  interest (????)
• HA policy neutral or positively facilitate?
• Conscientious objection (???????????)

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Resource allocation Brothers with Pompe Disease
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Allocation of Resources new treatment for Pompe
Disease

• In 2010, two brothers with Pompe Disease pleaded
  for use of a new enzyme replacement therapy. The
  new drugs are not yet in HA formulary and the
  evidence for its benefit is not yet strong enough
  for inclusion
• The ethical issues
• Potential benefit vs. cost-effectiveness in
  treatment of rare conditions with poor prognosis
• Compassionate treatment and its implication on
  equity

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Challenges of prioritization
??????????????
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Applying ethical theories to prioritization (I)

• Prioritization to promote personal choice
• This is a Libertarian (????)principle.
• Advocates a system which can maximize personal
  liberty, including allowing individuals free
  choice to decide what levels of health care they
  would prefer.
• The society may aid those without sufficient
  resources to pay for health care needs on
  humanitarian (????)grounds, but it is not
  demanded on the basis of social justice.

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Applying ethical theories to prioritization (II)

• Prioritization emphasizing equity and equal
  access
• The underlying ethical theory is Egalitarianism
  (????).
• Most ethicists would interpret this to mean equal
  opportunity (????).
• In healthcare, equal opportunity translates into
  equal chance to be assessed or triaged, not
  actually equal sharing of scarce services

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Applying ethical theories to prioritization (III)

• Prioritization by cost-effectiveness(??????)
• Justified by the intention to maximize health
  gain for a population.
• This is a Utilitarian principle (????).
• Not all utilitarian theories advocate a
  maximizing principle.
• A moderate approach is to adopt the Principle of
  Proportionality(??????), which implies that some
  health care will always be allocated to those
  with lesser needs, even though the more needy
  will receive more

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Applying ethical theories to prioritization (IV)

• Prioritization to reflect societal values
• The underlying ethical theory is
  Communitarianism(????).
• Stresses the importance of local context and
  societal values (??????,??????????????????????????
  )..
• Does not favour automatic adoption of
  universalistic principles (e.g. International
  guidelines).
• Societal values are often implicitly reflected in
  Macro allocation levels, e.g. the proportion of
  resources to be allocated to take care of the
  elderly, the mentally ill, sick children.
• Challenge Not easy to find appropriate
  mechanisms to involve the community in the
  complex subject of health care resource
  allocation.
• Caution Professional consensus and community
  views may be different.

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Applying ethical theories to prioritization (V)

• Prioritization according to health
  needs(????????????)
• Needs as determined by assessment
• Patient choice weighs little in this approach, as
  the underlying value is that of Beneficence and
  Non-maleficence
• Aims to be neutral to other value judgments
  (??????e.g. social economic background,
  life-styles)
• Limitation Comparing medical benefits across
  different patient groups (e.g. CABG????????vs
  renal dialysis????). is difficult
• Caution Professional consensus does not
  automatically translate into publicly acceptable
  policy

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Waiting list Health service prioritization in
practice (????????)

• ??????????????????(scarce healthcare resources)
• ???????(triage),???????,???????????
• ?????triage ??????,???????????,??????????????????
  ?????????????(maximize benefit),??????????????????
  ???
• ????????????(cost-effectiveness)
  ,????????????????,???????????????????(proportional
  ity??)?

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Health service prioritization in practice

• In practice, some criteria of prioritization are
  less controversial and more acceptable than
  others.
• It is generally considered acceptable to
  prioritize according to patient needs and
  risk-benefit.
• It is usually not acceptable to adopt moral
  criteria (???????????????? e.g. unhealthy life
  styles is irresponsible there for should not get
  as much health care.)
• Age-based prioritization is usually not
  justifiable, except where there is evidence that
  it is a good proxy to predicting care need or
  medical outcome. (?????????????????)
• Completely random allocation is usually not
  adopted unless resource constraint is not an
  issue. (???????????????,??????????)

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Selected references

• Medical ethics http//en.wikipedia.org/wiki/Medic
  al_ethics
• ????/???? http//baike.baidu.com/view/34513.htm
• ????http//uk.oneworld.net/article/view/122604/1/
  562
• Public Health Ethicshttp//depts.washington.edu/b
  ioethx/topics/public.html
• ?????????. ??????????? http//www.hkjc.com/chines
  e/news/images/Audience_Handout_May2010.pdf
• (???)??????????????,???????,2003?

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Thank you for your attention