Allocation of Medical Resources
Who decides who gets what?
How is the decision to be made?
Key Issues
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Medical resources are expensive.
How are they to be allocated?
Who decides who gets what?
How do doctors, hospital managers and society make
decisions between patients with competing medical
needs?
Key questions
 Should treatment be to everyone regardless of
whether their illness is self-inflicted?
Smokers, drinkers, drug users, drink drivers, selfharmers?
 Should it be regardless of cost? E.g. 1 liver
transplant v’s 100 hip replacements?
 Should it be regardless of age? E.g. 25 week
premature baby v’s 70 yr old pensioner?
 Should it b regardless of the patient’s place in
society - rich or poor, law-abiding or criminal,
post code lottery?
Medical Method
 QALYs: Quality Adjusted life Years.
 Ask question: how many years of good quality life will
patient have as a result of treatment?
 Doctors use this method when allocating drugs,
surgery and technological treatments to competing
patients – look at the long-term prognosis of each
case.
NICE
 Natural Institute of Clinical Excellence decides which
treatments and technologies – from drugs to artificial
hips – should or should not be available on the NHS in
England and Wales.
 Set up to remove ‘postcode lottery’ of health care
and to ensure parity throughout the NHS.
 Has to balance clinical effectiveness and cost
effectiveness.
How does NICE make its decisions?
Weighs up:
 The benefits on any treatment v’s the benefits of
note.
 Any undesirable side effects
 The effects of removing NHS availability
 The impact of any treatment on length and
quality of life
 The net cost to the NHS
 The impact of the treatment on NHS resources
Examples of NICE decisions
 Many expensive new drugs such as betainterferon do not ‘cure’ a disease but ameliorate
(ease) the symptoms of chronic disease such as
MS.
Hence NICE rules against its use – money would
be better spent on actual cures and effective
treatment.
 Man who paid £8000 for cryotherapy which has
98% success rate yet not approved by NICE as too
expensive for use throughout NHS.
Utilitarianism - Bentham
 Teleological approach
 Greatest good for the greatest number
 Motives are unimportant consequences are what
matters.
 The end justifies the means
 Utilitarianism and justice do not always correspond
 Minority count less than the majority – hard on some
individuals.
Examples
 Greatest good for the greatest number – mirrors NICE
principles e.g. 100 hip replacements rather than 1 liver
transplant, several people on kidney dialysis rather
than 1 kidney transplant, inoculating all babies against
childhood diseases rather than expensive intensive
care treatment for very premature babies.
Hedonic Calculus
 Applying HC is similar to applying QALYs
 Provides a flexible and intelligible guide to solving the
complex issue of resource allocation
Hedonic Calculus
 Apply IDCERRP – try to give examples of at least 3
criteria.
e.g. Intensity of pain, duration of pain/disability,
remoteness of effect of non-treatment, extent of
people affected in person treated or not.
 Should doctors look at age, sex, marital status,
number of dependents, income, emotional stability,
education, occupation, future potential.
Utilitarian views against unfair allocation
of resources
 Bentham – no one’s happiness is to be counted as
more important than anyone else’s .
 “everybody is to count for one, nobody for more
than one.”
 Supported by Peter Singer – a politician should
not count more than a murderer, a mother more
than her child, a disabled person more than a
scientist with a cure for cancer, a pensioner more
than a premature baby – decisions should only be
made on clinical medical reasons.
Mill
 Rule utilitarian – law as a set of principles developed
and tested by history to normally ensure the greatest
happiness of the greatest number.
 Idea of justice & community.
 One group shouldn’t count more than others.
 Quality rather than quantity - would look to QALYs
too.
 Higher pleasures
Kant
 Apply to 2nd formulation of CI
 Treat people as ends not means
 Example – decide between a young smoker and
an older non-smoker. Using QALYs doctor will
choose non-smoker even though older.
 Kant – use reason with non-smoker to give up
then s/he would have more QALYs, involving
patient in decision.
 Doctor has duty to preserve life – this doesn’t
help decide which person gets the treatment.
Christian views - Wyatt
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“Matters of life and death”
4 Principles
1. transparency
2. Equality
3. Impartiality
4. Defend the poor and vulnerable
Wyatt’s Idealism
 Idealistic and in reality not everyone can be treated.
 Shouldn’t be selfish in the demand they put on the
NHS
 Remember that Jesus accepted suffering.
 Shouldn’t fear death as they believe in the after life.
Divine Command
 Not an issue in 1st C. Have to try to apply and extract
principles
 Parable of the Talents Matt 25:14-30
Divine Command - stewardship
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Stewardship Gen1 26:30
Use limited resources wisely
Give treatment only when it is genuinely needed.
Avoid giving unnecessary treatment
Needs v’s wants
Sanctity of life
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All created in God’s image Gen1:27
Treat people with care and reverence
Body as a temple 1 Cor6:19
Everyone created equal therefore equal access to
medical care.
Situation Ethics
 Apply Agapeic calculus: look at individual cases on
the basis of Christian LOVE (AGAPE) – involves
equality, impartiality, justice and compassion.
Web site articles
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www.ethicsforschool.org
CMF
Katie Wasson 2002 principles for decision making
Tom Hale 1999 Time and Money developing world
ethics
Katie Wasson – resource allocation
 Refers to concept of stewardship, sanctity of life,
parable of the talents and applies them to resource
allocation.
 Individuals as needs v’s wants
 Look at medical needs
 Rights and duties
Justice
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Justice – fairness and equality
Fairness
Give people what they deserve
Does it mean giving priority to those who have a
disease or accident rather than those who
deliberately put themselves at risk?
 God treats everyone equally
 God acts unconditionally out of love and compassion.
Equality
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Avoid discrimination
Treat people equally
Jesus respected all people regardless
Doctors should not let discrimination cloud their
judgement
Equity
 People have different needs
 Inequity is when differences in care are not morally
justified
 Equity involves weighing up what is best for the
individual with what is fair, equal and just.
More than we deserve
 Points out Jesus healed the sick in mind, body and
spirit – irrespective of the cause of the illness.
 Parable of the Sheep and the Goats
 Look to God to provide resources
 Christians look forward to a time when ill-health and
suffering will be a thing of the past when God’s
kingdom arrives on earth – Revelation 21:1-5
Wasson - Conclusion
 Christians have a difficult task making decisions about
resource allocation.
 Balance individual needs against the Christians
principles of justice, equality and equity.
 Look forward to a time of not suffering
 In the meantime decisions will be made that reflect
God’s love, justice and concern for the individual and
the disadvantaged.
Questions
 Outline the key features of a utilitarian approach to
the allocation of resources in medicine
 Explain how the key ideas of the religion you have
studied could be applied to the issue of resource
allocation in medicine