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ETHICAL DILEMMAS IN THE INTERFACE BETWEEN PERSONAL AND SOCIETAL NEEDS Manfred Maier

ETHICAL DILEMMAS IN THE INTERFACE BETWEEN PERSONAL AND SOCIETAL NEEDS Manfred Maier. OBJECTIVES. Participants should be able to identify various reasons which cause ethical dilemmas discuss the rational of different approaches when faced with ethical dilemmas

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ETHICAL DILEMMAS IN THE INTERFACE BETWEEN PERSONAL AND SOCIETAL NEEDS Manfred Maier

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  1. ETHICAL DILEMMAS IN THE INTERFACE BETWEEN PERSONAL AND SOCIETAL NEEDSManfred Maier Abtg. Allgemeinmedizin Medizinische Universität Wien

  2. OBJECTIVES Participants should be able to • identify various reasons which cause ethical dilemmas • discuss the rational of different approaches when faced with ethical dilemmas • compare arguments for individual and public health priorities Abtg. Allgemeinmedizin Medizinische Universität Wien

  3. ETHICAL DILEMMAS • demanding patients • patients in need • guideline requirements • genetic diagnostics • screening procedures – prevention – medicalisation • palliative care • defensive medicine • to many duties in GP / FM – time limited • public health care – private insurance • economic forces – ethical principles • overuse – misuse – underuse of resources • inpatient – outpatient interface Abtg. Allgemeinmedizin Medizinische Universität Wien

  4. Abtg. Allgemeinmedizin Medizinische Universität Wien

  5. ALLOCATION OF RESOURCES – RAISING NEEDS IN HEALTH CARE • demographic developments • increased life expectancy • increased elderly population • increase in chronic diseases • new diseases • increase in multi - morbid patients • new epidemics • reduction in birth rate • increased risks due to leisure time activities Abtg. Allgemeinmedizin Medizinische Universität Wien

  6. RAISING NEEDS • biomedical developments • technical developments (PET,…) • diagnostic / therapeutic improvements • Increased requirement for resources • new medications • screening – prevention – health promotion • palliative care • guidelines • quality improvement measures • information technology • individualized treatment (pharmacogenomics) Abtg. Allgemeinmedizin Medizinische Universität Wien

  7. LIMITED RESOURCES • financial resources • reimbursement system • structural resources • Health insurance, HC - systems, group practices, facilities • personnel resources • imbalance of health care professionals, • generalists - specialists, • health care teams not all goals can be reached at the same time Abtg. Allgemeinmedizin Medizinische Universität Wien

  8. NEW DEVELOPMENTS • health insurance companies have the right to look into individual medical data • physicians are obliged to provide documentation • the health insurance system system has the right to collect and process individual data • patient management has to follow guidelines established by public health authorities – sanctions ? Abtg. Allgemeinmedizin Medizinische Universität Wien

  9. EXAMPLE: PATIENT • Chol > 300, LDL > 200, hypertension • Bezafibrate medication no effect • Simvastatin sample effective • Prescription not accepted by insurance company (high risk, PVAD, CAD, diabetes, ...) • Pharmacist: indication ? • Private prescription not possible for patient • How would you react ? Abtg. Allgemeinmedizin Medizinische Universität Wien

  10. ETHICAL PRINCIPLES • Primacy of patient welfare • Patient autonomy • Social justice Hippocrates (460-380 bc) Abtg. Allgemeinmedizin Medizinische Universität Wien

  11. PUBLIC VERSUS PERSONAL INTEREST • cost effectivness – individual health data - control mechanisms - steering instruments • legislation – privileges of physician - loss of autonomy • electronic records and data processing - negative outcome for vulnerable populations • confidentiality = right of privacy - exemptions restricted to defined epidemic diseases - sanctions for physicians violating this code of ethics Abtg. Allgemeinmedizin Medizinische Universität Wien

  12. ECONOMIC RESOURCES Education Health Care Environment Safety Prevention Curative Medicine Rehabilitation nursing continued payment of wages accidents diagnostics medical inpatient sickness immunization therapy social advising handicapped health checks emergency care occupational psychosocial Patient – oriented health care Abtg. Allgemeinmedizin Medizinische Universität Wien

  13. HEALTH PROMOTION AND HEALTH CARE SPENDING • NEJM 2003;349:1048 • goal: to estimate the relation of health status to life expectancy and cumulative health care expenditures • methods: - assessment of functional status and health - calculation of life expectancy - annual health care expenditures Abtg. Allgemeinmedizin Medizinische Universität Wien

  14. HEALTH PROMOTION AND HEALTH CARE SPENDING • results: • life expectancy longer for people in good health • similar cumulative health expenditures until death • institutionalization increases costs • interpretation: health promotion may improve health and longevity without increasing health expenditures Abtg. Allgemeinmedizin Medizinische Universität Wien

  15. QUESTIONS • individual or public health priorities ? • economic savings for patient or society ? • management for patients or society / system ? • vulnerable populations ? • confidentiality ? • who is sanctioned ? Abtg. Allgemeinmedizin Medizinische Universität Wien

  16. Abtg. Allgemeinmedizin Medizinische Universität Wien

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