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Rational and Just Distribution of Healthcare Resources


Joint Centre for Bioethics. University of Toronto. Principles of Surgery. November 11, 2008 ... You also consider sending Mr. E to the floor, but know that ... – PowerPoint PPT presentation

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Title: Rational and Just Distribution of Healthcare Resources

Rational and Just Distribution of Healthcare
  • Martin McKneally Department of Surgery and
  • Joint Centre for Bioethics University of Toronto
  • Principles of Surgery
  • November 11, 2008

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

ICU Case When 63 y.o. Mr. E is brought to the
emergency room with severe but potentially
reversible brain injury after a motor vehicle
accident, 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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  • Is rationing wrong? Unjust?
  • Unethical?
  • Indefensible politically?

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

  • 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
  • Mark Siegler
  • University of Chicago

No beds again can he solve the rationing
problem alone?
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

Determining Just Distribution by Setting
  • 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

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

Suggested Priority List for Decisions about ICU
  • 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

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
Norm Daniels, Boston
UNOS Headlines
  • Multiple-Organ Allocation Policy approved for
    public comment
  • Public Comment sought on pediatric renal
  • Blood Type O Liver Allocation sent for public
  • Heart Allocation for Domino Transplants approved
    for public comment

Strategies to Cope with the Shortage of
  • 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

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

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? Send him home and
Uninsured case Mrs. C, a Guyanese woman with
complications from cancer, was refused complex
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.
  • You are making these decisions now

You will make more and larger decisions You are
the future
  • 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

  • Acknowledgements

Paintings by Robert Pope and Joe Wilder Deborah
McKneally, The Ravine Research and Education
martin.mckneally_at_utoronto.ca pager
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
  • 5. Use the natural queue, treating patients in
    order of appearance unless morally relevant
    considerations of need and benefit require
    modification of this approach.

  • 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

  • Seek resolution of unacceptable shortages at the
    level of hospital management (meso allocation) or
    through political action at the level government
    (macro allocation).
  • Inform your patients of the impact of cost
    constraints on care in a humanistic way, as a
    matter of respect for persons. Embittered
    blaming of administrative or governmental systems
    during discussions with the patient at the point
    of treatment should be avoided.
  • 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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