Determining how scare medical resources are distributed amongst a healthcare system is a vital question that must be addressed in order to ensure a hospital is operating at its full efficient.  As the state of Oregon has shown, ranking the value of medical procedures subject to great scrutiny, as many will disagree on the specific of the methodologies used for the ranking.  Rather than asses procedures on “importance,” healthcare systems should analyze their capacity to withstand demand shocks and develop a system of patient triage that maximized positive health outcomes.

Patients who require organ transplants are likely aware of scarcity in healthcare, as there are a limited number of hospitals equipped to perform such surgeries.  Also, there is a perpetual shortages of available organs, demonstrating how some components of medical care are already vastly outstripped by demand.  Consequently, when the demand for a common medication or vaccine increases beyond predicted levels, the US healthcare system can increase the production of a desired compound and take emergency action to provide increased access to care.¹  While scarcity will increase, scaling up production of common medications and vaccines demonstrates is an example of how a healthcare system can successfully deal with instances of shortage and avoid excessive rationing. 

However, the availability of most medical care falls somewhere between these two examples.  Additionally, more nuanced factors like age and ability to pay for treatment influence how the medical care is allocated.  Setting aside these other factors, a purely utilitarian ethical model would promote treating patients who:

          1. Require immediate care

          2. Present a high chance of recovery. 

That is, if two patients require immediate care, the patient more likely to have a positive health outcome (or have a lower associated cost relative to improvement) is prioritized.  For sake of argument and simplicity, I’ll assume that these two conditions are independent of each other; though in reality, there is likely a direct relationship between how long a patient can wait to be treated and the chance of having a good medical outcome. 

Though this may appear to be contradictory to the principle of justice, a healthcare system should focus on operating in a utilitarian manner to promote justice through efficiency and positive health outcomes.  By prioritizing patients who are more likely to recover, aggregate-level utility (positive health outcome vs. negative health outcome) is maximized by the utilitarian triage system.  Under this framework, patient justice is not secondary to the quantifiable medical outcomes, but rather an extension of the healthcare system operating at its greatest possible efficiency.  Justice at the aggregate-level is not about selecting people who are “deserving” of medical care in a social sense, but rather ensuring that a hospital can cause as many good health outcomes as possible.²  In any healthcare system that does not operate efficiently, there will be patients who are untreated or under treated as a result of operation inefficiency.  Consequently, hospitals can promote healthcare justice by reducing the number of patients who fall victim to an inefficient healthcare system.

1) Lorenzoni, G. 2006. Theory of Demand Shocks. National Bureau of Economic Research.

2) Gatter, RA; Moskop, JC. 1995. From Futility to Triage. Journal of Medicine and Philosophy. 20: 194.

Do immunization mandates sacrifice patient autonomy for the benefit of public health, and if so, is this a justifiable tradeoff?  Responsible governing bodies and healthcare providers are obligated to maximize a patient’s ability to make an informed, autonomous decision, while also promoting beneficence for both the individual patient and the group (i.e. overall population).  Immunization — generally achieved through vaccination — presents a challenging case for balancing autonomy with individual and group benefit.  This is further challenged by the fact that overall immunization efficacy is partly dependent on the percentage of the population inoculated, or herd immunity.  The benefits of immunization are not solely confined to the individual and thus it is in the interest of the government and healthcare providers to act on behalf of the collective group.  

In the past, immunization was mandatory by using it as a requirement for participation public education.  The mandating of certain childhood vaccinations reduces parental autonomy by creating an undesirable alternative to non-compliance.  Though this policy was once effective as making vaccination a de facto requirement for American children, state exemptions have made it relatively ineffective. 

Some states view vaccination as a procedure that conflicts with certain ideologies.  As a potential violation of religious freedom and patient autonomy, religious and personal belief (philosophical) vaccine exemptions were adopted in many states.  In fact, California, West Virginia, and Mississippi are the only states that do not have at least one of these exemptions for school enrollment (1).  These three states do however provide medical exemptions for rare instances of patients who have been deemed unfit for receiving vaccination.  While the religious and personal belief exemptions are designed to return greater autonomy to the patient, these laws have subsequently undermined immunization efficacy and the overall population safety.

After decades of effort to eradicate lethal communicable diseases, the government has seemingly abandoned its ability to enforce universal medical policy, rather choosing to prioritize maximizing patient autonomy.  The effects have been noticeable; measles, once thought to have been eradicated from the United States, has returned with the liberalization of patient autonomy policies regarding immunization (2).  Yet despite the return of some diseases, opponents to mandatory vaccination have been willing to challenge the underlying safety of vaccines as defense of their position.

These vaccination debates have persuaded some — with or without factually justifiable arguments — to utilize the vaccine exemptions for their children.  Past failures in vaccine synthesis and storage, along with egregious errors in administration protocol (i.e. Egypt’s Hepatitis C needle sharing and subsequent Hep C outbreaks) provide precedents for vaccine-skeptics to justify their stances (3).  While many of these arguments rely on straw man and falsely-equivalency fallacies, plenty of people are willing to disregard logical coherence for emotionally persuasive arguments.  While rhetorical strategy is not of direct relation to the dilemma of balancing autonomy with beneficence, the dissemination of such fallacious arguments poses as a threat to maintaining vaccine compliance when broad exemptions are available.  Safe levels of preservatives likes thimerosal will continue to be investigated, along with risk-benefit analyses of vaccination being included to challenge exemptions by demonstrating the collective risk induced from marginal gains in patient autonomy.  Sadly, absurd straw man arguments like “vaccines cause autism” detract from legitimate discussion regarding the government’s role in minimizing disease risk through compulsory immunization.  Vaccine exemptions as they currently exist have been abused and demonstrate the need for a revitalized focus on population health.

While I agree that it is the role of the government to enforce public health policies that seek to reduce and eradicate diseases from the population, the slippery slope of government involvement in healthcare continues to be of legitimate concern for many.  There are examples of medical procedures that have been deemed illegal on moral grounds, like abortion.  As popular opinion changes and politicians react to constituent demands, it does not appear to be unrealistic that hysteria regarding certain medical procedures could be used to defend either strict mandates or inappropriate exemptions that greatly sacrifice autonomy and beneficence, respectively.    

If there has ever been an example where a measured amount of individual autonomy can be curbed for the group benefit, mandatory immunization is certainly a defensible policy.  However, discourse indicates growing skepticism towards the pharmaceutical industry and the government’s intentions.  Growing resentment towards political lobbying — particularly against the villainized pharmaceutical industry — along with increased immunization exemptions present an unsettling trend in the government’s abdication of its authority over public heath policies.   

With extensive peer-reviewed research, FDA trials, and concrete examples of the risk imposed by non-medical immunization exemptions, the government should not feel compelled to expand parental autonomy over childhood vaccination.  Empirical evidence supports strict immunization laws; hysteria and fallacious arguments promote exemptions. With solid empirical support and clear examples of risks, it is the responsibility of our political leaders to stay informed and act in accordance with the best policies for their constituents. We can only hope that the many such cases of empiricism and reason lead our discussion, and not fear-promoting, fallacious arguments.

https://twitter.com/realdonaldtrump/status/449525268529815552

Sources

1.States with Religious and Philosophical Exemptions from School. NCSL. Online. Accessed 22 March 2017 <http://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx>

2. Mnookin, S. The Return of Measles. Boston Globe. Sept 29 2013.

3. Miller, FD. Elzalabany MS, Hassani S. Cadres D. Epidemiology of hepatitis C virus exposure in Egypt: Opportunities for prevention and evaluation.World Journal of Hepatology. 2015. 28: 2849-2858.

Arguments regarding proper ethical actions in medicine tend to focus on preserving life and working towards improving the health of a patient. In many cases, the ethical decisions regarding an individual’s health may appear – at least superficially – to be linked with the volume or sophistication of medical care. However, these are inaccurate replacements for the primary focus of truly caring for an individual. The patient’s quality of life is the most ethically significant factor to both the physician and patient, and therefore should always be preserved or improved over the long run. Of course, many medical treatments reduce a patient’s quality of life in the short term while long-term benefits heavily outweigh these negatives. Unfortunately, there are extraordinary cases where the quality of life will likely never improve, only becoming worse with time. When the patient’s forecasted quality of life is not typical, the patient should not be treated or assessed as a typical patient.

Such is the case of Sue Rodriguez, whose quality of life had deteriorated substantially with the progression of amyotrophic lateral sclerosis (ALS). While Sue had made her intentions clear — to continue living as long as she could enjoy life — this presented the issue of requiring physician-assisted suicide if her condition progressed beyond what she could tolerate. This was in violation of Canadian law, where a physician could face up to 14 years in prison from assisting in suicide. While in violation of the Canadian legal code, the Charter of Rights and Freedoms ensured she would not “be subjected to any cruel and unusual treatment or punishment.”

When sanctity of life conflicts with individual autonomy, the decision of the individual must take precedent over the sanctity if the decision was made logically. It is worth noting that anyone in this condition will be unable to act with full rationality, as the extreme degenerative state of the disease compromises an individual’s ability to comply by normal standards. Essentially, the degenerative state is a highly coercive influence over the patient’s wellbeing and should be recognized as having an impact. The patient can, however, act logically considering the realities and possibility of their predicament. The possibilities of improvement, in Sue’s case, were merely hypothetical while the impending deterioration was inevitable by all realistic assumptions. It is reasonable of Sue to assume that her condition would only deteriorate and that assisted suicide would be the only viable option in that case. Such an assumption, even by a person with diminished mental and reasoning capacity, should be treated as a valid decision, as the rational behind the decision is of sound logic and respects the realistic outcomes regarding the future of her quality of life.

As long as the autonomy of the individual is respected, allowing for physician-assisted suicide does not present a threat of progressing into more malicious uses of euthanasia or eugenics, as detractors often propose. The decision ultimately remains with the patient, not the physicians, hospitals, or legislature. There are rigid cultural and social taboos regarding this as well, with numerous organizations existing to prevent physician-assisted suicide from being further adopted legally (Physician Assisted Suicide). However, trends in medicine and law indicate an easing of the laws prohibiting this, allowing for more nuanced ethical and moral discussions to take place regarding end-of-life care and patient autonomy. Also, once adopted by Oregon in the United States, patients can cross state lines if their resident state does not allow for this procedure (Battin). This renders the local bans useless and goes to demonstrate that systems respecting the autonomy of the patient will be popular amongst the target demographic (i.e. deteriorating quality of life patients).

Sources

1. Physician Assisted Suicide Violates ADA, accessed 26 Feb 2017. <http://www.adapt.org/newsletter/1997v31n1/22ndy>
2. Battin MP, Heide A, Ganzini L. Legal physician assisted dying in Oregon and Netherlands: evidence concerning the impact on patients in “vulnerable” groups. Journal of Medical Ethics. 2007. 33(10) 591-597.

https://xkcd.com/1526/

One of the most pertinent questions in medical ethics is balancing physician autonomy with patient trust.  Giving physicians full authority over all action at the expense of the patient’s autonomy and trust is a unsettling notion for most patients.  The use of placebo as a treatment may act to break this trust.

Using placebos is an absolutely essential part of the medical research process, as controlling patient test groups under varying conditions is a requirement set forth by the Food and Drug Administration (Clinical Trials and Human Subject Protection).  In this circumstance, a placebo treatment is legally required for determining the efficacy of a drug or procedure.  However, placebos may offer their own therapeutic benefits in some circumstances (Daniel E Moerman, 472).  Because placebos can result in real symptom improvement, prescribing a patient a placebo is now considered by some to be a viable option.

However, when the placebo becomes a possible treatment option remains uncertain.  There are a few requirements that govern the discretionary usage of a placebo as treatment.  First, the physician must be acting in the best interest of the patient.  In cases of moderate pain treatment, placebo may be seen as a good medical decision, especially if the pain is not indicative of more severe physical problems.  In fact, using placebo over opioid pain relievers offers reduced side effects, albeit at the expense of euphoria and sedation.  Second, the patient must be consistently monitored so that standard treatment can be administered if there is no improvement.  Third, the physician must be honest if the patient decides to inquire about the specifics of treatment.  While those in favor of placebo usage argue that physicians do not have to initially disclosure it, they concede that physicians must guarantee a basic level of trust in the patient relationship.

The article’s second case presents a dilemma that extrapolates on the third point made above: Is the physician’s initial deception of the patient unethical?  While certain benefits — or lack of problems — make placebo a viable option, choosing this treatment runs the risk of diminishing trust in the patient-physician relationship.  In cases that do not absolutely require negative-control patient groups, I see the use of undisclosed placebo as a violation of trust by the physician.  Patients seek out medical professionals to receive the best advice and treatment.  Therefore, it is my opinion that medical professionals should not use placebo treatments, as doing so undermines the trust between the two parties.    

While placebo should not be rejected as an outright useless treatment, the patient’s trust in their physician relies on knowing that the doctor is acting honestly, transparently, and in their best interest.  Knowing this allows patients to put more confidence in the actions of their doctor, thereby strengthening the relationship and improving health outcomes (Lynda A Anderson).  Despite this, there is little room for arguing against use placebos in clinical trials, especially phases II and III.  Unless a patient is being studied and compared to groups with different variables — like authentic treatment or placebo — physicians should not consider using placebos and must value honesty with their patients.

Citations

Clinical Trials and Human Subject Protection, accessed 3 Feb 2017, http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/

Daniel E Moerman, Wayne B Jonas. “Deconstructing the Placebo Effect and Finding the Meaning of Response,” Annals of Internal Medicine 136 (2002): 471-476.

Lynda A Anderson, Robert F Dedrick. “Development of Trust in Physician Scale: A Measure to Assess Interpersonal Trust in Patient-Physician Relationships,” Sage Journal 67 (1990).