Budgetary constraints and
healthcare in hospitals : an ethical
point of view
Sadek Beloucif, M.D, Ph.D.
Paris 13 University & Avicenne Hospital, AP-HP
Le Monde, Apr 1, 2009
Land Area (worldmapper.org)
Often Preventable Deaths (worldmapper.org)
Physicians Working (worldmapper.org)
Lessons from developing nations on improving health care Berwick, BMJ 2004
1.
Simplify.
- Complexity is waste
2.
Teamwork
- Uncoperativeness is waste
3.
Be pragmatic for the evaluation
- Too much counting is waste
4.
Limit organisational aspects
- Dependency is waste
5.
Consider political aspects
- Naivety is waste
6.
Empower patients
- Keeping patients silent is waste
7.
Start now
- Delay is waste
8.
Continuously expand
- Isolation is waste
9.
And don’t complain !
- Complaint is waste
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NBC News, Aug 7, 2009
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NBC News, Aug 9, 2009
Why We Must Ration Health Care
By PETER SINGER
Rationing health care means getting value for the billions we
are spending by setting limits on which treatments should be
paid for from the public purse.
If we ration we won’t be writing blank checks to pharmaceutical
companies for their patented drugs, nor paying for whatever
procedures doctors choose to recommend.
When public funds subsidize health care or provide it directly, it
is crazy not to try to get value for money. The debate over health
care reform in the United States should start from the premise
that some form of health care rationing is both inescapable and
desirable.
Then we can ask, What is the best way to do it?.
“France's woes provide grist to critics of Mr. Obama and the
Democrats' vision of a new public health plan to compete with
private health insurers. Republicans argue that tens of millions
of Americans would leave their employer-provided coverage for
the cheaper, public option, bankrupting the federal
government.”
August 12, 2007
EDITORIAL
World’s Best Medical Care?
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Insurance coverage.
Access.
Fairness.
Healthy lives.
Quality.
Life and death.
Patient satisfaction.
Use of information technology.
Top-of-the-line care.
“With health care emerging as a major issue in the presidential
campaign and in Congress, it will be important to get beyond
empty boasts that this country has “the best health care system
in the world” and turn instead to fixing its very real defects.”
4
Neither of the Above
The health systems in the UK and the US have different virtues and different vices
In the battle over which country, the UK or the US, has the better health system, it is a shame
that either side has to win. The answer to the question is probably France.
There is no doubt that the healthcare system that is being so vigorously defended at town hall meetings across
America has glaring flaws. America spends 16 per cent of its national income, more than any country in the
world, on health. To spend $2.2 trillion per annum and still fail to insure more than 40 million citizens is quite
something. Administrative costs are a third of the bill, hospital costs are high and employer-provided insurance
is a serious reduction of labour market flexibility. President Obama has a point when he suggests that the NHS
provides universal cover for half the cost.
That said, the American critics of the NHS have a point too. The deficiencies of what the Americans call
“socialised medicine” are amply exhibited by the NHS. Four-month waits for treatment and limited patient
choice are no great cause for British patriotism. The problems with the NHS are all the more stark when they
are contrasted with the best of American healthcare. The better insurance plans provide an unmatched rapidity
of response and quality of care. The teaching hospitals at American universities lead the world in research and
development.
The sophisticated question is not which one of these two flawed systems is the better but is it feasible to
combine the virtues of both, without busting the bank? France has a system of universal healthcare financed
by compulsory national insurance. Premiums are charged as a percentage of income and paid to insurers that
are non-government, non-profit agencies. The French have a choice of doctor whose fee they usually pay and
then claim back 75-80 per cent of the cost. The poor are exempt from payment. All patients, whether exempt
from co-payments or not, may go directly to a specialist.
CCNE Opinion #101: Health, ethics and money:
ethical issues as a result of budgetary constraints
on public health expenditure in hospitals
http://www.ccne-ethique.fr
• What criteria should be used to arrive at an equitable
decision when a choice has to be made between two
frequently contradictory imperatives: preserving the health
of an individual versus the responsible management of a
community's health care?
– Decisions must lead to rationalisation of expenditure to avoid what
in effect would be rationing of care.
• A balance in pure accounting terms,
– taking only into consideration the liabilities (the cost of services)
– without relating them to the assets which are their counterpart (the
benefits for the community or those that can reasonably be
expected from the adoption of a new system of calculation)
would not be acceptable.
Further, there are 2 possible responses:
“utilitarian” (“distributive justice”)
vs. “equalitarian” (so-called "deontological") ethics
• In practice, existing tension between person-centred
ethics and utilitarian ethics leads to choosing between two
contradictory demands:
– on the one hand achieving effectiveness in a competitive
environment,
– on the other accepting a public service mission assigned
specifically to hospitals by the code of public health.
• The ethical and economic constraints of the hospital
system —which is also true for the more general context
of democracy— in fact reside in the opposition between
two apparently mutually exclusive concepts: the
"unconditional value" of an individual and "satisfying the
greatest number".
Therefore,
• The limited nature of financial resources allocated to the hospital
system requires ethical choices to be made by the community which
should be made public.
• The ethical dimension of these decision-making processes should be
clearly identified and integrated in the evaluation methods. Evaluation
methods including only quantifiable criteria but neither qualitative
criteria nor the ethical dimension would put hospitals in grave danger
of dehumanisation and furthermore would lead in practice to
increased costs.
• Clinically speaking, the notion of sober medicine, as opposed to
redundant medicine should be given prominence. Redundancy
disguised as precaution is only too often a mask for intellectual
laziness and for reluctance to shoulder the responsibility of difficult
decisions.
In conclusion, guaranteeing fair access to quality health care
is not incompatible with economic orthodoxy.
• The constant need to adjust health care to demographic
requirements, epidemiological changes and technological advances
is ample justification, more so than for any other human activity, for
clear and courageous choices, which must be explicit in the eyes of
citizens. Such decisions must be kept under constant review without
ever losing sight of the central core objective: helping the most
vulnerable.
• The ethical issue raised by an examination of the economic
dimensions of health care is an exploration of the tension between
autonomy and solidarity, between individual liberty and the public
good. Such tension can only be relieved by seeking equity, in other
words, justice.