Rational and Just Distribution of Healthcare Resources

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Rational and Just Distribution of Healthcare
Resources

• Martin McKneally and Josh Mayich
• Department of Surgery and
• Joint Centre for BioethicsUniversity of Toronto
• Principles of Surgery
• November 6, 2012

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Plan of Talk

• Cases ICU bed, transplant, emergency,
• uninsured patient, others
• Rationing resources
• Allocating resources
• Setting priorities
• Fair procedures
• Coping strategies

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ICU Case 63 y.o. Mr. E is brought to the
emergency room with severe but potentially
reversible brain injury after an MVA. You
consider going through the charts of each patient
in the intensive care unit in the hope of finding
one whose need for intensive care is less than
that of Mr. E. You also consider sending Mr. E
to the floor, but know that this will overtax the
capabilities of the floor staff, who are not
prepared to manage the patients elevated
intracranial pressure and seizures. Because of
recent hospital closures in the region, no other
facility is available to share responsibility for
the care of patients with neurosurgical problems
of this magnitude.
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Rationing

• Is rationing wrong? Unjust?
• Unethical?
• Indefensible politically?

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Systematic distribution of goods to specific
individuals in conditions of scarcity
Rationing
rations on the raft
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Rationing

• The reasoned and justifiable distribution of
  goods to specific individuals in conditions of
  scarcity.
• When all beneficial health care cannot be
  provided to all who might want it, implicit or
  explicit rationing occurs.

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• Though devoted to the medical ethic of
  rendering to each patient a full measure of
  service and devotion, physicians who have many
  patients have traditionally rationed their
  services
• Mark Siegler
• University of Chicago

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No beds again can he solve the rationing
problem alone?
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Resource Allocation
Systematic distribution of resources to programs

• Macro-Allocation
• Highways, Education, Healthcare
• Meso-Allocation
• Hospital care
• cancer, trauma, cardiac, neuro, etc.
• Home care
• Micro-Allocation
• Who gets the bed

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Determining Just Distribution by Setting
Priorities

• To each an equal share
• To each according to effort
• To each according to need
• To each according to contribution
• To each according to merit
• To each according to free-market exchange
  procedures and rules

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Priority Setting

• Current politically correct term for rationing /
  resource allocation
• Rational allocation of resources based on the
  priorities set by appropriate decision makers

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Suggested Priority List for Decisions about ICU
Care

• Reasonable chance in ICU - would die outside ICU
• High risk of life-threatening complications, need
  rapid response
• 3. Lower priority
• Comatose with a poor expected outcome
• Care is unlikely to result in a good outcome
• Low risk for life-threatening complications

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Transplant Case Chris D, a 21 y.o. programmer
with CF, is a candidate for retransplantation.
Chronic rejection and fungal infections are
destroying the double lung transplant he received
15 months ago. He has intermittently required
ventilation during flareups of infection or
rejection. The presence of infection and the
risks associated with repeat transplants predict
a survival rate of 65 at one month, and 38 at
24 months. Mrs. J, a 42 y.o. schoolteacher and
mother of 3, is a candidate for double lung
transplantation because of rapidly progressing
pulmonary hypertension associated with hemoptysis
and hypoxemia. She is unable to manage at home
because of decompensated right heart failure
unresponsive to maximal therapy. As a first time
candidate free of infection, her predicted
survival at one month is 82, and 62 at 2
years. Dr. K has ONE donor for these two
patients. He knows that the best result can be
achieved by transplanting both lungs of the donor
into one of his patients.
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Fair Procedures for Decision Making
Reasonable Transparent
Appealable Enforceable
Norm Daniels, Boston
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UNOS Headlines

• Multiple-Organ Allocation Policy approved for
  public comment
• Public Comment sought on pediatric renal
  allocation
• Blood Type O Liver Allocation sent for public
  comment
• Heart Allocation for Domino Transplants approved
  for public comment

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Ortho case You are a busy foot ankle surgeon
with a two year waiting list a patient cancels

• Pt 1 has subtalar arthritis following a calcaneus
  fracture. He is a smoker. He has been unable to
  find work since his arthritis advanced clinically
  3 years ago (which is how long he has been
  waiting for the OR).
• Pt 2 is a very pleasant, affluent 69 year old
  retiree from a financial investment company. He
  is very disabled by his ankle arthritis. He has
  been waiting 1.5 years.

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Strategies to Cope with the Shortage of
Resources

• Use the tests treatments that work
• Choose the least costly ones
• Minimize marginally beneficial ones
• Use the natural queue
• modify by need/benefit
• Rank current patients ahead of imagined future
  patients

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Strategies

• Address shortages at the level of the
  institution/government
• Support conservation of health resources
• Avoid gaming, but keep modifying the system
• Avoid frightening vulnerable patients

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Emergency case As the elective schedule winds
down, Mr. M, the third patient listed for an
elective cancer resection, is cancelled because
of insufficient time to complete the operation
within the day shift. What is the fair thing
to do Put him on the emergency schedule? For
tonight? This weekend? Displace tomorrows
first elective patient? Send him home and
readmit?
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Uninsured case Mrs. C, a Guyanese woman with
complications from cancer, was refused complex
elective surgical treatment at an Ontario
hospital.The resource allocation decision, had
to be made after she had been admitted and a
caregiver-patient relationship established.
Caregivers and administrators struggled with the
moral anguish of choosing between protecting
limited resources for Canadian patients and their
desire to provide care for a hospitalized visitor
in need of complex and expensive care.
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• You are making these decisions now

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You will make more and larger decisions You are
the future
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Coping strategies to eliminate or reduce
rationing include

• Choose interventions known to be beneficial on
  the basis of evidence of effectiveness.
• 2. Minimize the use of marginally beneficial
  tests, such as the diagnostic zebra-hunt.
• 3. Minimize the use of marginally beneficial
  interventions, such as the latest generations of
  antimicrobials for common infections.
• 4. Seek the least costly tests or treatments that
  will accomplish the diagnostic or therapeutic
  goal.
• 5. Use the natural queue, treating patients in
  order of appearance unless morally relevant
  considerations of need and benefit require
  modification of this approach.

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• Rank patients with whom you have an established
  patient-doctor relationship ahead of unknown or
  future patients.
• Support rather than oppose reasonable efforts to
  conserve health care resources.
• Avoid manipulation of the rules of the health
  care system to give unfair advantage to your
  particular patients.
• Resolve conflicting claims for scarce resources
  justly, on the basis of morally relevant criteria
  of need and benefit.
• Employ fair and publicly defensible procedures
  for resolution of conflicting or competing
  claims.

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1. Seek resolution of unacceptable shortages at the
   level of hospital management (meso allocation) or
   through political action at the level government
   (macro allocation).
2. Inform your patients of the impact of cost
   constraints on care in a humanistic way, as a
   matter of respect for all concerned.
3. Embittered blaming of administrative or
   governmental systems during discussions with the
   patient at the point of treatment should be
   avoided.
4. Develop guidelines for individualization in the
   face of uncertainty in order to promote a
   reasonable balance between individual choice and
   systemic cost control.

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Summary

• Keep Mr. E in ER
• Transplant Mrs. J
• Move Mr. M to the next available morning slot
• Discharge Mrs. C
• Ration/Allocate justly
• benefit and need
• Use Fair Procedures
• reasonable
• transparent
• appealable
• Share the problem

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• Acknowledgements

Paintings by Robert Pope and Joe Wilder Deborah
McKneally, The Ravine Research and Education
Centre
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martin.mckneally_at_utoronto.ca