Health Care Ethics

1
Health Care Ethics

• The Ethics of Distribution Ch. 4

2
Defining Health and Disease

• Part of figuring out how to fairly distribute a
  scarce commodity, healthcare in this instance,
  involves identifying who the recipient are.
• Who is diseased, and therefore, a potential
  recipient of health care?
• Is a biological definition of disease enough?

3
Defining Health and Disease

• The judgment that a person has a disease or
  requires healthcare may differ according to the
  individual and society.
• Fibromyalgia
• Chronic Fatigue Syndrome
• -examples where patients have had to argue that
  their condition constitutes disease and therefore
  justifies expending scarce resources on their
  treatment

4
Defining Health and Disease

• On the other hand,
• Alcoholism
• is perhaps an example of the medical community
  identifying a disease where individuals, for a
  time at least, resisted that classification.
• Since individuals are able to conduct their daily
  lives under varying levels of biological
  functioning, the book offers a definition of
  disease relative to that standard, and to the two
  competing interests in its definition

5
Defining Health and Disease

• Book definition of disease
• Any deficit in the physical form or the
  physiological or psychological functioning of the
  individual in terms of
• what society wants or expects from that
  individual, or
• in terms of what the individual wants or expects
  for himself

6
Defining Health and Disease

• Health, then, is defined as a lack of any such
  deficit.
• Note that there is great opportunity for
  disagreement between what an individual considers
  being diseased and what society considers that
  state to be.
• With societys interest in decreasing the cost of
  healthcare, we can expect tension to arise
  between individuals and society on this question,
  especially
• in nursing homes
• for the homeless
• parental concern for children

7
Goals of Healthcare

• In defining the goals of healthcare is the main
  idea
• trying to live forever?
• ¼ of all Medicare funds are spent in the last
  year of life, and more than ½ of that spent in
  the last month
• trying to alleviate suffering?
• trying to eliminate the pain, or
• trying to eliminate the cause of the pain

8
Goals of Healthcare

• If healthcare is the effort to protect and
  preserve the dignity of patients, then some
  efforts in prolonging life and alleviating
  suffering may not always be good
• trying to optimize happiness?
• what does it cost to relieve all anxiety of
  patients?
• how much money should be spent, how many
  resources consumed in trying to ensure full
  mental health and happiness to only some
  individuals?

9
Goals of Healthcare

• On p89, the book suggests there is value in
  trying to decrease expectations in American
  society of just what medicine can do for you. The
  line of reasoning seems to be
• Lower expectations
• Less demand for healthcare
• Eases burden on providers
• Lowers costs for everyone

10
Goals of Healthcare

• Ultimately, the individuals desire for a certain
  level of functioning cannot control the
  definition of adequate care.
• With the expense and scarcity of care, society
  will have to have a say in what is reasonable
  accommodation of patient desire.
• This leads us to consideration of the components
  that form the basis of that accommodation

11
Basis of Distribution

• The 2 main components that form the basis of
  distribution
• Need
• Contribution
• The fascinating part of the discussion is how the
  book manages to never say in concrete terms how
  contribution figures in the just distribution of
  healthcare.

12
Basis of Distribution

• The book mentions the failure of communist
  societies in which distribution of scarce goods
  was governed by the dictum of Carl Marx
• to each according to his need, from each
  according to his ability
• Americans, capitalists specifically, typically
  reject the dictum because it leaves out
  considerations of merit and or desert, both of
  which are subsumed under the term contribution
  in the book.

13
Basis of Distribution

• Merit having the qualities that justify
  awarding something to someone
• Desert having put forth the effort that
  justifies awarding something to someone
• LeBron James merits playing on the US Olympic
  team in that he is best able to help the team win
  among eligible players
• LeBron James deserves playing on the US Olympic
  team only if he puts in his time practicing (he
  may still merit playing, even if he does not
  deserve to)

14
Basis of Distribution

• Note that the books discussion of contribution
  is purely utilitarian
• The contributions of individuals to society must
  be acknowledged in practice. Failure to do so
  undermines a powerful motive for producing goods
  and leaves the society with less to distribute.
  p94
• Note
• there is no reference to whether contributors
  deserve healthcare
• they are a means, only, to the good of healthcare
  distributed to everyone based on need
• their desert as contributors, if any, the book
  leaves unexplored

15
Basis of Distribution

• Health Care v Public Health
• In general, there is a competition for resources
  between preventive measures like public health
  and health education, on one hand, and
  disease/injury care or hospitalization on the
  other.
• On p97 the book introduces the distinction
  between statistical lives and identified lives
  note there is a more emotional effect on our
  decision making when we see whose lives are saved
  by money spent than when we dont.

16
Microallocation

• Weve been talking about macroallocation in the
  preceding slides microallocation happens at the
  level of hospitals, nursing homes, and clinics.
• Microallocation decisions about distribution are
  made by individuals like
• Doctors
• Patients
• Hospitals

17
Microallocation

• Triage rules, p98, differ according to situation
• In a disaster situation
• Those who need treatment to survive
• Those who will survive without treatment
• Those who will not survive even with treatment
• On the battlefield
• Those with minor injuries (so they can return to
  battle)
• Those seriously wounded who need immediate care
• Those hopelessly wounded are last

18
Microallocation

• Dangers of Social Power (p99)
• Labeling or categorizing people for the public
  good can lead to trampling the dignity of
  individuals when resources are scarce, esp.
• Calling patients diseased for quarantine
  purposes?
• Okay for tuberculosis patients
• Not okay for AIDS patients
• Why is the first okay, but not the second?

19
Microallocation At Institutions

• For-Profit Hospitals
• The book suggests turning away those who cannot
  pay is permissible for hospitals and clinics that
  receive no federal monies and no federal tax
  breaks.
• Their classification is
• Ethical
• But not admirable

20
Microallocation At Institutions

• Government Owned and Operated Hospitals
• Should be open to all
• Should give priority to those unable to pay
• Because those who can pay can go elsewhere, while
  those who cannot pay cannot go elsewhere
• Should limit care to those that match their
  specializations when resources are scarce
• Veterans Hospitals should limit care to veterans

21
Microallocation At Institutions

• Voluntary, Not-For-Profit Hospitals
• The book suggests they are burdened with the
  public interest (they have a duty to provide care
  to at least some who cannot pay)
• Why?
• They receive no government funding, but do
  receive tax-exempt status
• They also receive much of their income from
  government programs such as Medicare
• And from tax-exempt nonprofits like Blue Cross
  and Blue Shield

22
Microallocation At Institutions

• Questions for points on previous slide
• They receive no government funding, but do
  receive tax-exempt status
• But are they exempt because it makes no sense to
  tax no profit?
• They also receive much of their income from
  government programs such as Medicare
• But Medicare is money owed to patients, not the
  hospital why does it impose a burden on a
  not-for-profit hospital?
• And from tax-exempt nonprofits like Blue Cross
  and Blue Shield
• Why should money from BCBS create a duty to treat
  the poor or unable to pay when basis for taxing
  them is missing, rather than a case of generosity
  of government?

23
Microallocation Within Institutions

• How do we decide within a hospital or clinic whom
  to treat?
• By Lottery or First Come, First Served?
• Book rejects a principle of strict equality or
  Egalitarianism
• Equality of distribution neglects to consider
  need, and need must be considered to respect the
  dignity of individuals
• Read this on p102

24
Microallocation Within Institutions

• How do we decide within a hospital or clinic who
  to treat?
• By committee made up of a cross-section of the
  community?
• Virtues
• No one person has too much power
• No one can easily maintain a bias
• Vices
• Scarcity can lead to trading and back-scratching
  among committee members

25
Microallocation Within Institutions

• How do we decide within a hospital or clinic who
  to treat?
• Rationing (p103)
• Rationing is required whenever resources are
  scarce
• Rationing is guided by need and contribution

26
Microallocation Within Institutions

• The book offers these rules to guide rationing
• Basic needs such as preservation of a meaningful
  life take precedence over mere wants, desires,
  and acquired needs (p91 92)
• Priority to individuals who can resume
  functioning over those with no chance to resume
  functioning or those terminal
• 2 is a consideration of contribution in what
  sense?

27
Distribution

• Read the Mechanisms of Distribution and Ideology
  on p105