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 society’s 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 individual’s 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 book’s 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 don’t.

16. Microallocation We’ve 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