What are the three main steps to resource allocation?
- Background - setting the outlines of the debate
2 ethical approaches - to resource allocation at macro/meso level
3 Examples of priority-setting - for resource allocation in health care
What are the two ethical approaches?
1 The maximising approach - QALYs
2 The Distributive justice approach
What are the levels of resource allocation? and what do they entail?
Macro-govt level -allocating federal health budget Meso - mid-level - Eg a hospital deciding what it should pend money on Micro - individual level - priority on waiting list & eligibility
Is resource allocation a real ethical issue in health care?
Yes
Whose values should be taken into account?
- impact values of economics
- social values
- ethical values
What is the maximizing approach to resource allocation?
- the most bang for your buck
- based on moral theory of utilitarianism
- disregards justice as inherently important concept
- aims is to maximize good consequences in terms of health (not to produce fairness)
What is QALY? and how is it used?
- used in maximising approach
Questions to ask:
1. How many patients will each one treat per year?
2. What will be the health outcomes – how many QALYs?
1. How many life-years gained?
2. How much improvement in health (ie what quality of life
is produced)?
3. How much does each program cost?
4. Which program produces the most health for the
money?
What are some factors that are not considered in basic maximizing approach?
- The pattern of distribution (doesn’t take into account disadvantaged)
- the level of need of suffering
What are some implications of the maximising approach?
- Elderly systematically (though not intentionally) lose out,
since they have less years left to live. - The young are systematically (though not intentionally)
favoured, since they have the greatest number of years
still to live. - Favours preventive programs over acute health services –
treatment in the last few months of life does not
produce many QALYs. (ie those whose death is
inevitable in short term systematically miss out) - It is argued that those with disabilities systematically lose
out, since there is limit to their gain in health (it will
never be 100%) – but this is disputed
What is the ‘fairness’ approach: Distributive justice?
Consider:
- need
- contribution
- merit(desert)
- equal shares (egalitarianism)
What is distributive justice? & the material principles?
how to share out a limited resource in a fair manner
-differs from criminal (how to respond to a person who has committed a crime), procedural (fair justice procedure) & material (people who get the resource ‘deserve is the most)
- need
- contribution
- merit(desert)
- equal shares (egalitarianism)
What is the right way to allocate scarce resources according to the distributive justice approach?
Give it to the people who:
- need it most
- have the greatest contribution to the group
- deserve it the most just to their actions/character
OR - give it to everyone equally
- BUT depends what it is and how it’s used
What counts as ‘need’ in the criteria for allocation?
- subjective (‘desires’, demand)
- Objective (basic requirements of life)
- > nearly impossible to judge
- severity
- suffering
- can get the best out of treatment
What are the implications of using ‘need’ as a criteria for allocating health care resources?
- Concentrates resources on acute care, where the
strongest needs are (preventing imminent death) - Leaves out preventive health approaches, since there is no current need, at least in the straightforward
sense - Some who receive resources will not survive – so does not produce best outcomes
- Makes cause of medical need irrelevant (important for later in our discussion)
What are the possible criteria for allocation?
- need
- merit
- equal shares
What is the explanation for using ‘merit’ as a criteria? And who is considered of higher & lower priority?
Basic idea is that some people deserve higher or lower priority for health care, because of some feature of themselves or their illness.
- higher priory: the young, those willing to help their community, public service
- lower priority: elderly, smokers, substance abusers, convicted criminals, second attempt organ transplant
What are the two contentious principles? related to merit as a criteria
“Fair innings” / ”natural lifespan”
– a reason not to spend money on increasing the
length of life of those 70+
“Self-caused need” / ”personal responsibility”
– a reason to give lower priority who choose to
act in ways that put their health at risk (smoking,
using drugs….)
-> widely disputed
What is the explanation for using ‘equal shares’ as a criteria?
Giving everyone an equal share of health care services does not make good sense
Aiming that everyone has an equal amount of health
does make good sense
Who’s principle is the egalitarian criteria based on?
On Rawls’ maximin principle
- Aim to improve the situation of those who are least well off, before improving the situation of those who are better off
What are some implications to using the maximin principle?
- Do not focus on aggregate health outcomes per se (level
of health for whole community); focus instead on minimising inequality in health between sub-groups of
the population - suggests money should be spent on providing equality, not just on producing health
- Priority would be given to improving the health of people who has the lowest health status, to bring them up to the
level of the most healthy (eg indigenous health & remote areas)
