Health Care Ethics The Ethics of Distribution Ch. 4

Health Care EthicsHealth Care EthicsThe Ethics of Distribution Ch. 4The Ethics of Distribution Ch. 4

Defining Health and Defining Health and DiseaseDisease

Part of figuring out how to fairly distribute a scarce Part of figuring out how to fairly distribute a scarce commodity, healthcare in this instance, involves commodity, healthcare in this instance, involves identifying who the recipient are.identifying who the recipient are.

Who is diseased, and therefore, a potential recipient of Who is diseased, and therefore, a potential recipient of health care?health care?

Is a biological definition of disease enough?Is a biological definition of disease enough?


The judgment that a person has a disease or requires The judgment that a person has a disease or requires healthcare may differ according to the individual and healthcare may differ according to the individual and society.society.

FibromyalgiaFibromyalgia Chronic Fatigue SyndromeChronic Fatigue Syndrome-examples where patients have had to argue that their -examples where patients have had to argue that their

condition constitutes disease and therefore justifies condition constitutes disease and therefore justifies expending scarce resources on their treatment expending scarce resources on their treatment


On the other hand, On the other hand,

Alcoholism Alcoholism

is perhaps an example of the medical community is perhaps an example of the medical community identifying a disease where individuals, for a time at identifying a disease where individuals, for a time at least, resisted that classification.least, resisted that classification.

Since individuals are able to conduct their daily lives Since individuals are able to conduct their daily lives under varying levels of biological functioning, the under varying levels of biological functioning, the book offers a definition of disease relative to that book offers a definition of disease relative to that standard, and to the two competing interests in its standard, and to the two competing interests in its definition…definition…


Book definition of disease:Book definition of disease:Any deficit in the physical form or the physiological or Any deficit in the physical form or the physiological or

psychological functioning of the individual in terms psychological functioning of the individual in terms ofof

what society wants or expects from that individual, what society wants or expects from that individual, oror

in terms of what the individual wants or expects for in terms of what the individual wants or expects for himselfhimself


Health, then, is defined as a lack of any such deficit.Health, then, is defined as a lack of any such deficit.Note that there is great opportunity for disagreement Note that there is great opportunity for disagreement

between what an individual considers “being between what an individual considers “being diseased” and what society considers that state to diseased” and what society considers that state to be.be.

With society’s interest in decreasing the cost of With society’s interest in decreasing the cost of healthcare, we can expect tension to arise between healthcare, we can expect tension to arise between individuals and society on this question, especially: individuals and society on this question, especially:

in nursing homesin nursing homes for the homelessfor the homeless parental concern for childrenparental concern for children

Goals of HealthcareGoals of Healthcare

In defining the goals of healthcare … is the main idea In defining the goals of healthcare … is the main idea ……

1.1. trying to live forever?trying to live forever? ¼ of all Medicare funds are spent in the last year ¼ of all Medicare funds are spent in the last year

of life, and more than ½ of that spent in the last of life, and more than ½ of that spent in the last monthmonth

2.2. trying to alleviate suffering?trying to alleviate suffering? trying to eliminate the pain, or trying to eliminate the pain, or trying to eliminate the cause of the paintrying to eliminate the cause of the pain


If healthcare is the effort to protect and preserve the If healthcare is the effort to protect and preserve the dignity of patients, then some efforts in prolonging dignity of patients, then some efforts in prolonging life and alleviating suffering may not always be goodlife and alleviating suffering may not always be good

3.3. trying to optimize happiness?trying to optimize happiness? what does it cost to relieve all anxiety of what does it cost to relieve all anxiety of

patients?patients? how much money should be spent, how how much money should be spent, how

many resources consumed in trying to many resources consumed in trying to ensure full mental health and happiness to ensure full mental health and happiness to only some individuals?only some individuals?


On p89, the book suggests there is value in trying to On p89, the book suggests there is value in trying to decrease expectations in American society of just decrease expectations in American society of just what medicine can do for you. The line of reasoning what medicine can do for you. The line of reasoning seems to be …seems to be …

Lower expectationsLower expectations

Less demand for healthcareLess demand for healthcare

Eases burden on providersEases burden on providers

Lowers costs for everyoneLowers costs for everyone


Ultimately, the individual’s desire for a certain level of Ultimately, the individual’s desire for a certain level of functioning cannot control the definition of adequate functioning cannot control the definition of adequate care.care.

With the expense and scarcity of care, society will With the expense and scarcity of care, society will have to have a say in what is reasonable have to have a say in what is reasonable accommodation of patient desire.accommodation of patient desire.

This leads us to consideration of the components that This leads us to consideration of the components that form the basis of that accommodation…form the basis of that accommodation…

Basis of DistributionBasis of Distribution

The 2 main components that form the basis of The 2 main components that form the basis of distribution:distribution:

1.1. NeedNeed2.2. ContributionContribution

The fascinating part of the discussion is how the book The fascinating part of the discussion is how the book manages to never say in concrete terms how manages to never say in concrete terms how contribution figures in the just distribution of contribution figures in the just distribution of healthcare.healthcare.


The book mentions the failure of communist societies The book mentions the failure of communist societies in which distribution of scarce goods was governed in which distribution of scarce goods was governed by the dictum of Carl Marx:by the dictum of Carl Marx:

““to each according to his need, from each according to to each according to his need, from each according to his ability”his ability”

Americans, capitalists specifically, typically reject the Americans, capitalists specifically, typically reject the dictum because it leaves out considerations of merit dictum because it leaves out considerations of merit and or desert, both of which are subsumed under and or desert, both of which are subsumed under the term “contribution” in the book.the term “contribution” in the book.


Merit = having the qualities that justify awarding Merit = having the qualities that justify awarding something to someonesomething to someone

Desert = having put forth the effort that justifies Desert = having put forth the effort that justifies awarding something to someoneawarding something to someone

LeBron James LeBron James meritsmerits playing on the US Olympic playing on the US Olympic team in that he is best able to help the team win team in that he is best able to help the team win among eligible playersamong eligible players

LeBron James LeBron James deservesdeserves playing on the US playing on the US Olympic team only if he puts in his time practicing Olympic team only if he puts in his time practicing (he may still merit playing, even if he does not (he may still merit playing, even if he does not deserve to)deserve to)


Note that the book’s discussion of contribution is Note that the book’s discussion of contribution is purely utilitarian:purely utilitarian:

““The contributions of individuals to society must be The contributions of individuals to society must be acknowledged in practice. Failure to do so acknowledged in practice. Failure to do so undermines a powerful motive for producing goods undermines a powerful motive for producing goods and leaves the society with less to distribute.” p94and leaves the society with less to distribute.” p94

Note: Note: there is no reference to whether contributors there is no reference to whether contributors deserve healthcare deserve healthcare

they are a means, only, to the good of they are a means, only, to the good of healthcare distributed to everyone based on healthcare distributed to everyone based on needneed

their desert as contributors, if any, the book their desert as contributors, if any, the book leaves unexploredleaves unexplored


Health Care v Public Health:Health Care v Public Health:

In general, there is a competition for resources In general, there is a competition for resources between preventive measures like public health and between preventive measures like public health and health education, on one hand, and disease/injury health education, on one hand, and disease/injury care or hospitalization on the other.care or hospitalization on the other.

On p97 the book introduces the distinction between On p97 the book introduces the distinction between statistical lives and identified lives; note there is a statistical lives and identified lives; note there is a more emotional effect on our decision making when more emotional effect on our decision making when we see whose lives are saved by money spent than we see whose lives are saved by money spent than when we don’t.when we don’t.

MicroallocationMicroallocation

We’ve been talking about macroallocation in the We’ve been talking about macroallocation in the preceding slides; microallocation happens at the preceding slides; microallocation happens at the level of hospitals, nursing homes, and clinics. level of hospitals, nursing homes, and clinics.

Microallocation decisions about distribution are made Microallocation decisions about distribution are made by individuals likeby individuals like

DoctorsDoctors PatientsPatients HospitalsHospitals


Triage rules, p98, differ according to situation:Triage rules, p98, differ according to situation:

In a disaster situation:In a disaster situation: Those who need treatment to surviveThose who need treatment to survive Those who will survive without treatmentThose who will survive without treatment Those who will not survive even with treatmentThose who will not survive even with treatment

On the battlefield:On the battlefield: Those with minor injuries (so they can return to battle)Those with minor injuries (so they can return to battle) Those seriously wounded who need immediate careThose seriously wounded who need immediate care Those hopelessly wounded are lastThose hopelessly wounded are last


Dangers of Social Power (p99):Dangers of Social Power (p99):

Labeling or categorizing people for the public good can Labeling or categorizing people for the public good can lead to trampling the dignity of individuals when lead to trampling the dignity of individuals when resources are scarce, esp.resources are scarce, esp.

Calling patients “diseased” for quarantine purposes?Calling patients “diseased” for quarantine purposes?

Okay for tuberculosis patientsOkay for tuberculosis patients Not okay for AIDS patientsNot okay for AIDS patients

Why is the first okay, but not the second?Why is the first okay, but not the second?

Microallocation At Microallocation At InstitutionsInstitutions

For-Profit Hospitals:For-Profit Hospitals:

The book suggests turning away those who cannot The book suggests turning away those who cannot pay is permissible for hospitals and clinics that pay is permissible for hospitals and clinics that receive no federal monies and no federal tax receive no federal monies and no federal tax breaks.breaks.

Their classification is…Their classification is…

EthicalEthical But not admirableBut not admirable


Government Owned and Operated Hospitals…Government Owned and Operated Hospitals… 1.1. Should be open to allShould be open to all2.2. Should give priority to those unable to payShould give priority to those unable to pay

Because those who can pay can go elsewhere, Because those who can pay can go elsewhere, while those who cannot pay cannot go while those who cannot pay cannot go elsewhereelsewhere

3.3. Should limit care to those that match their Should limit care to those that match their specializations when resources are scarcespecializations when resources are scarce

Veterans Hospitals should limit care to Veterans Hospitals should limit care to veteransveterans


Voluntary, Not-For-Profit Hospitals…Voluntary, Not-For-Profit Hospitals…

The book suggests they are burdened with the public The book suggests they are burdened with the public interest (they have a duty to provide care to at least interest (they have a duty to provide care to at least some who cannot pay)some who cannot pay)

Why?Why? They receive no government funding, but do receive They receive no government funding, but do receive

tax-exempt statustax-exempt status They also receive much of their income from They also receive much of their income from

government programs such as Medicaregovernment programs such as Medicare And from tax-exempt nonprofits like Blue Cross and And from tax-exempt nonprofits like Blue Cross and

Blue ShieldBlue Shield


Questions for points on previous slide…Questions for points on previous slide…

They receive no government funding, but do receive tax-They receive no government funding, but do receive tax-exempt statusexempt status

But are they exempt because it makes no sense to tax no But are they exempt because it makes no sense to tax no profit?profit?

They also receive much of their income from government They also receive much of their income from government programs such as Medicareprograms such as Medicare

But Medicare is money owed to patients, not the hospital … But Medicare is money owed to patients, not the hospital … why does it impose a burden on a not-for-profit hospital?why does it impose a burden on a not-for-profit hospital?

And from tax-exempt nonprofits like Blue Cross and Blue And from tax-exempt nonprofits like Blue Cross and Blue ShieldShield

Why should money from BCBS create a duty to treat the Why should money from BCBS create a duty to treat the poor or unable to pay when basis for taxing them is poor or unable to pay when basis for taxing them is missing, rather than a case of generosity of government?missing, rather than a case of generosity of government?

Microallocation Within Microallocation Within InstitutionsInstitutions

How do we decide within a hospital or clinic whom to How do we decide within a hospital or clinic whom to treat?treat?

By Lottery or “First Come, First Served”?By Lottery or “First Come, First Served”?Book rejects a principle of strict equality or Book rejects a principle of strict equality or

“Egalitarianism”:“Egalitarianism”:

Equality of distribution neglects to consider need, Equality of distribution neglects to consider need, and need must be considered to respect the dignity and need must be considered to respect the dignity of individualsof individuals

Read this on p102Read this on p102


How do we decide within a hospital or clinic who to How do we decide within a hospital or clinic who to treat?treat?

By committee made up of a cross-section of the By committee made up of a cross-section of the community?community?

Virtues:Virtues: No one person has too much powerNo one person has too much power No one can easily maintain a biasNo one can easily maintain a bias

Vices:Vices: Scarcity can lead to trading and back-scratching among Scarcity can lead to trading and back-scratching among

committee memberscommittee members


How do we decide within a hospital or clinic who to How do we decide within a hospital or clinic who to treat?treat?

Rationing (p103):Rationing (p103):

Rationing is required whenever resources are Rationing is required whenever resources are scarcescarce

Rationing is guided by need and contributionRationing is guided by need and contribution


The book offers these rules to guide rationing:The book offers these rules to guide rationing:

1.1. Basic needs such as preservation of a meaningful Basic needs such as preservation of a meaningful life take precedence over mere wants, desires, and life take precedence over mere wants, desires, and acquired needs (p91 & 92)acquired needs (p91 & 92)

2.2. Priority to individuals who can resume functioning Priority to individuals who can resume functioning over those with no chance to resume functioning or over those with no chance to resume functioning or those terminalthose terminal

#2 is a consideration of contribution in what sense?#2 is a consideration of contribution in what sense?

DistributionDistribution

Read the Mechanisms of Distribution and Ideology on Read the Mechanisms of Distribution and Ideology on p105p105

Documents

Health Care Ethics The Ethics of Distribution Ch. 4