Unit Four: Allocation of Medical Resources
One of the perennial issues in bioethics is how to allocate scarce resources in health care. A question we should consider first perhaps should be: How did this become a problem in the first place? What I mean by this is that the issue doesn't seem to come up in other areas of our economic life such as groceries, electronics. Two factors seem to cause the difference; one economic and the other involving prevention. There are good reasons, perhaps for not letting the market dictate how medical resources are allocated but the consequences of doing this are some form of rationing. It is ironic that one of the cheapest forms of health care, prevention, is not more strongly promoted as it could eliminate many (certainly not all) of these allocation problems. However, failing that it seems that we are left, in the words of George Annas with a situation where we "must choose between using a conscious, value-laden, social worth selection criteria (including the committee to make the actual choice), or some type of random device."
The question of prevention becomes relevant when considering patients who need treatment because of a condition their behavior brought on (at least in part). In the Cohen & Benjamin article this question is addressed with regard to alcoholics in need of liver transplants. They conclude that there is no argument, either moral or medical, for categorically denying such patients a transplant. There may be good reasons on an individual case basis but they argue against denying all alcoholics treatment merely because they are alcoholics.
On a more philosophical note, Daniel Callahan's article raises some important questions regarding our view of what medicine should do for the aged and what value should be placed on a long life span. Thomas Browne once said that "the long habit of living indisposeth us to dying." Callahan argues for a more accepting attitude towards the aging (and dying) process. We ought to "understand that it is possible to live out a meaningful old age that is limited in time" and we "need a more supportive context for aging and death."
Callahan continuously counsels that "the elderly need to have a sense of the meaning and significance of their stage in life." In doing so, he is counseling in a similar fashion to Viktor Frankl, the psychiatrist and developer of logotherapy: "a psychotherapy which not only recognizes man's spirit, but actually starts from it." For Frankl the main challenge in life was to find meaning in the face of what he termed the "tragic triad:" pain, death, and guilt. Particularly relevant for our subject is Frankl's view that one can give meaning to pain and death by the attitude with which one faces these inevitabilities. As Frankl pointed out "conditions do not determine me, but I determine whether I yield to them or brave them."
In practical terms Callahan outlines a plan to "limit health care for the aged under public entitlement programs" by maintaining three points:
1. Government has a duty to help people live out a natural life span but not to extend it.
2. Government is only obliged to pay for treatment to help achieve this natural life span.
3. Beyond that point government should only provide treatment to relieve suffering not extend life.
For those who think this sounds very harsh your thoughts might turn to prevention; a not very exciting topic but one way of addressing many of the problems associated with old age. Of course, we cannot prevent death but there are many ways to prevent many painful, debilitating, and expensive diseases such as eating properly, not smoking, exercising regularly. In addition it is well known that preventative medicine such as regular check ups is far more inexpensive than major medical procedures. When prevention ceases to be effective many increasingly turn to palliative care such as that offered by Hospice.
Daniels Article
The question of prevention becomes relevant when considering patients who need treatment because of a condition their behavior brought on (at least in part). In the Cohen & Benjamin article this question is addressed with regard to alcoholics in need of liver transplants. They conclude that there is no argument, either moral or medical, for categorically denying such patients a transplant. There may be good reasons on an individual case basis but they argue against denying all alcoholics treatment merely because they are alcoholics.
On a more philosophical note, Daniel Callahan's article raises some important questions regarding our view of what medicine should do for the aged and what value should be placed on a long life span. Thomas Browne once said that "the long habit of living indisposeth us to dying." Callahan argues for a more accepting attitude towards the aging (and dying) process. We ought to "understand that it is possible to live out a meaningful old age that is limited in time" and we "need a more supportive context for aging and death."
Callahan continuously counsels that "the elderly need to have a sense of the meaning and significance of their stage in life." In doing so, he is counseling in a similar fashion to Viktor Frankl, the psychiatrist and developer of logotherapy: "a psychotherapy which not only recognizes man's spirit, but actually starts from it." For Frankl the main challenge in life was to find meaning in the face of what he termed the "tragic triad:" pain, death, and guilt. Particularly relevant for our subject is Frankl's view that one can give meaning to pain and death by the attitude with which one faces these inevitabilities. As Frankl pointed out "conditions do not determine me, but I determine whether I yield to them or brave them."
In practical terms Callahan outlines a plan to "limit health care for the aged under public entitlement programs" by maintaining three points:
1. Government has a duty to help people live out a natural life span but not to extend it.
2. Government is only obliged to pay for treatment to help achieve this natural life span.
3. Beyond that point government should only provide treatment to relieve suffering not extend life.
For those who think this sounds very harsh your thoughts might turn to prevention; a not very exciting topic but one way of addressing many of the problems associated with old age. Of course, we cannot prevent death but there are many ways to prevent many painful, debilitating, and expensive diseases such as eating properly, not smoking, exercising regularly. In addition it is well known that preventative medicine such as regular check ups is far more inexpensive than major medical procedures. When prevention ceases to be effective many increasingly turn to palliative care such as that offered by Hospice.
Daniels Article
- "No plausible principles of justice will entitle an individual patient to every potentially beneficial treatment."
- "No class of patients is entitled to whatever new procedure offers them some benefit."
- In the British system of health care "considerations of justice are explicit in its design and in decisions about the allocation of resources" whereas in the American system these considerations are not present.
- This does not imply that the British system is just whereas the American system is not.
- "Saying no to beneficial treatments or procedures in the United States is morally hard, because providers cannot appeal to the justice of their denial."