Resources are limited in healthcare. Although the goal is to treat and save as many people as possible, in some cases it may not be economically feasible to do so. Resource scarcity leads to budgets on how much money can be allocated to certain programs, such as preventative care or research. Although the concept of allocation is accepted within health economics, problems can arise when people are competing for the same amount of resources and only some will be able to receive them. This leads into my question: is allocation ethical?
First, to help put allocation into context, let us create a scenario. Suppose two people are both in need of a heart transplant. One patient is a middle-aged man who damaged his arteries by consuming foods high in saturated fats and being inactive in his youth, while the other patient is a young old boy who was born with a rare condition at birth, causing his heart to fail. Also, let’s assume that the surgery has a high chance of a favorable outcome, meaning it will most likely be successful and the organ will not be rejected by the body’s immune system. The decision that we now need to make is who will receive the surgery.
There are several issues with using allocation in this case. For one, who is to make the decision on who gets the surgery? Is there a policy in place, or an ethics review board that addresses cases of this matter? If there is no stable ground as to who should make the decision of allocation, then a nonpartisan decision may be difficult to achieve. Secondly, how is someone to measure effectively who gets the heart transplant over the other? In the Beauchamp and Childress reading, they present a case for cost-utility analysis (CUA). The objective of CUA is to come to a decision the creates the biggest possible health gains given the resources provided (Beauchamp 282). However, this way of coming to a conclusion is unethical in some cases, because it discriminates against those who are older and favors the youth, since they are predicted to live longer. Due to their youth, they have more to gain in life years from a life-saving treatment than someone who is older (Beauchamp 282). Also, who is to say that the life years gained will be of an acceptable quality? Even if the young boy receives the heart transplant and his life years are extended, that is not to say his Quality of Life (QOL), will improve, and in some cases, may get worse.
On the other hand, there is a benefit to using the concept of allocation in healthcare. By making decisions that are based on who will receive the greatest benefit, the decision is free of pathos, which helps to eliminate potential bias in the decision. Another benefit of allocation is that is allows the hospital to save money, which may be put towards helping other patients. Also, since allocation can help health care professionals to make decisions, it can be used where it would be unethical to make a decision otherwise.
In conclusion, while I believe that there are several benefits to using allocation, I do not believe the benefits of using such a system overcome the potential harms. Groups such as the elderly will be discriminated against due to their low anticipated health gains from such a surgery. Also, using a standardized measure of health assumes that everyone’s ideal QOL would be similar. Everyone does not have the same mindset when it comes to their quality of health, and health care professionals should take note of that. If allocation is to be used in the future, it should be in situations where physicians and patients are aware of the possible benefits and risks involved, and are willing to accept the decision that is made by the appropriate health care professionals.
Sources:
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009, 2013. Print.
Healthcare Rationing. Digital image. Cartoonstock.com. N.p., n.d. Web. 14 Apr. 2017.
Hello Kenquavius,
This is a great post and the scenario you used certainly brings up great points about the use of allocation in the medical field. These are difficult decisions to make, especially when it comes to deciding who lives or who dies. However, allocation is absolutely necessary because unfortunately, resources are not unlimited and sometimes doctors are put into these positions.
I believe that making these choices under the premise of “quality of life” is helpful for instance. This allows the doctor to determine who would get the best use out of treatment. However, this can also be controversial because a person’s evaluation of quality of life can be subjective as many students have brought up in class. Beauchamp and Childress bring up the use of Quality of Life Adjusted Years or QALY’s which uses a standardized system to determine who would gain the most from treatment (Beauchamp & Childress 2013). I believe a standardized system must be used to avoid bias as you have brought up.
Beauchamp, T. L., & Childress, J. F. (2013). The value and quality of life. In Principles of
biomedical ethics (pp. 238-239).
Hi Kenquavius,
Your blog post complements our in-class debate very well. I think that the decision of who should receive the treatment is a difficult one because you want the patient who will have the greatest benefit to receive it, but you also don’t want to discriminate against certain groups of individuals.
In class we debated over the situation in which two individuals, one an alcoholic and one a non-alcoholic, need a liver transplant, but there is only one liver available. In this situation I would choose to give the liver to the non-alcoholic individual for many reasons. First, there is no guarantee that the alcoholic is committed to changing their habits and could therefore continue drinking with the new liver causing them to waste the fresh start they were given. If the individual showed that they were trying to help themselves, through something like rehab, I would reconsider my decision. Second, alcoholism can result in several other organ problems in addition to the liver, including “high blood pressure, stroke, and other heart-related diseases; permanent damage to the brain, and cancer of the mouth and throat” (Drug Free World). As a result, even if the alcoholic individual got the liver transplant, they could have several other organ issues impeding their quality of life that the non-alcoholic individual would not have.
All in all, I think that choosing who should get a life-saving organ over another individual is a very difficult decision. In every choice, someone will live and someone will die. This is why I think having a clean-cut plan for doctors and physicians to follow when presented with this issue is important to minimize bias and expedite the process since I am sure they are usually in a time-crunch. Having a set of guidelines, while difficult to come up with, would benefit the health care profession greatly.
Morgan
Works Cited:
Drug Free World. “Watch Truth About Drugs Documentary Video & Learn About Substance Addiction. Get The Facts About Painkillers, Marijuana, Cocaine, Meth & Other Illegal Drugs.” Foundation for a Drug-Free World. Drug Free World, 2006. Web. 15 Apr. 2017.
Hello Kenquavius,
Thanks for this post — it was a great addition to the in-class discussion yesterday. I argued during for the “con” side of the argument in class yesterday, and at first did not agree the stance of the debate. Through the discussion and debate, though, I slowly began to recognize the true complexity of resource allocation in healthcare and that the factors that we would consider “fair” when making those decisions are not always so. I agree that allocation is a tricky system and possibly not the best way to determine healthcare simply because of individuality and the scale of fairness, I think that some sort of system is necessary in today’s world.
A concept that might support your argument is that of triage situations, in which typically the most injured are given the most resources in emergency situations. One could argue that any instance in which allocation must be determined is an emergency situation requiring triage, and subsequent issues do then arise concerning the quality and value of people’s lives. What are your thoughts on situations of triage, and do you think they can be applied to other instances of resource allocation?
Thanks,
Elisabeth Crusey
Jonsen, Albert R., PhD, and Kelly A. Edwards, MA. “Resource Allocation.” Resource Allocation: Ethical Topic in Medicine. University of Washington School of Medicine, 18 Feb. 2016. Web. 15 Apr. 2017.
Hello Kenquavius,
I enjoyed this post, it highlighted the issues involved when using allocation, and the fairness in question with such a practice. Although I agree with your point that allocation is not always ethical, I feel it is a necessary practice in medicine. There are limits to the resources available to provide. Sometimes, not everyone can receive the best quality healthcare, simply because of external circumstances. In cases such as the one you described, one must realize that in times of limited resources, someone will always get the short end of the stick. Not all patients can always be saved. “In the Aristotelian conception of distributive justice, the unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit.” (McKneally et al.)
References
McKneally, M. F., B. M. Dickens, E. M. Meslin, and P. A. Singer. “Bioethics for Clinicians: 13. Resource Allocation.” CMAJ: Canadian Medical Association Journal. U.S. National Library of Medicine, 15 July 1997. Web. 16 Apr. 2017.
Kenquavius,
In the case of liver transplants, there is more demand than supply. At times like these, medical professionals need to determine the basis on which they allocate scarce resources. It will be important to allocate resources efficiently based on the patients’ lives and the hospital’s amount of resources. One option to is make impersonal mechanisms. This means that the hospital can make their decision based on a system of randomization. Some examples include a lottery or ‘first come first serve’ system. However, this system is insensitive to those patients who will suffer in the short-term without the transplant. The best system to determine the personal, medical needs of all patients and then determine how to allocate resources. I agree with your conclusion that it is not ethical to use QOL to determine the system of allocation. It is discriminating against the elderly who have a low amount of years left. I believe an individual assessment of all the cases is necessary to determine the system of allocation.
Sylvie
Hi Kenquavius,
This was a great post, as it highlighted inherent issues present within allocation. I appreciated the fact that you discussed age as a criteria for allocation. In my opinion, age is an interesting principal for allocation, as it is a non-medical criteria that may discriminate against elderly individuals. However, at the same time, age may play into the efficacy of treatments. In my opinion, it is justified to consider age when allocating scare resources, as doctors/hospital personnel should be administering these resources to individuals that will receive the most benefit.
Hi Kenquavius,
I think this is a really good post, and it brings up many issues concerning allocation. I too think that resource allocation can be source of a slippery slope into discrimination against vulnerable populations in healthcare.
And I agree with the point you made about allocation being a necessary tool as there are scarce resources and an ample amount of people that can use them.Specifically, in the case of transplants I think having an ethical method of allocation is very important. In my opinion, I think having transplant organs go to the best qualified recipient is the right way to go. For instance, in our debate in class about the liver donor, I think that history should be evaluated just as a last-effort determinant. What I mean is that, people who suffered or are suffering from alcoholism should be candidates for liver transplants. But in a case or severe scarcity, these resources should go to the person that it can benefit the most. So, in the scenario you posed I would agree with people who wanted to give the heart to the young boy. Simply because he would get the most utility out of it, and his recovery does not include severe lifestyle modifications like the man who would need to change his eating habits. Which is not that easy.
-Best,
Arianna
Hi Kenquavius,
I do agree with you that allocation should not be the system used to distribute resources but what can we replace with it? What system or method would be better than allocation?
Considering the case you brought up in your post, I had different thoughts come into my head:
1. Is there a time crunch for both patients on the need for a heart transplant? If not, can one patient be placed on a wait list and the other who needs it immediately be given the heart transplant?
2. About the age thing, I am not sure if age is the sole factor for choosing because heart transplant patients do get screened to determine whether they can get a heart transplant. Regardless of the age, if one has a higher outcome, then they would be chosen. If a younger person is chosen simply because it is predicted they would live longer, then the possibility of the body rejecting the new heart should be considered.