Rationing

Question 1

A scenario is presented, you have 3 patients in life threatening conditions. How should the resource be allocated?

State arguments against each point?

Answer 1

QALYS; quality adjusted life years
EBM; evidence based medicine
Maximising lives saved

1. Treat all of them
   - Resources are finite, funds not available like that
   - Taxes will have to be increased to treat more people - people wont be happy
2. There is no answer
   - They all need life sustaining treatment - based on the human rights principle of ‘discriminate not’, they are all entitled to treatment.
3. Who has a Right
   - They all have a right to be treated
   - Where life sustaining treatment is not required, this argument is not valid.
4. Need basis; Who will be worse off
   - Treat those who will be worse off; i.e. ambulance at crash scene treating emergencies 1st.
   - This is not valid in preventative medicine.

Question 2

Case; Alf is a newborn, he has serious disability and needs intensive care to live. Treatment will give him moderate chance of living into his 20s but he will be seriously disabled still.

Give reasons for and against his receiving treatment.

Answer 2

For;

• He has a human right to receive treatment as he has a right to life.
• It is discrimination if he doesnt receive based on his disability.
• It is in his best interest to receive treatment because otherwise he will die.
• Equality of treatment; everyone should have an equal claim to treatment (John Harris)

Against;
QALYs; He will still be seriously disabled after treatment meaning even if he lives his qalys score will be very low. others may have a better qalys score with treatment.

Question 3

Explain the QALYS scoring system

Answer 3

A score of 1 means; 1 year of perfect health
0 is if ; the person dies
-1: if person left in a state worse than death.

Question 4

What else must be considered in QALYs?

Answer 4

The cost of treatment!

A large number of qalys given for a low cost is preferred over a low number of qalys for a high cost.

Compare the cost PER qaly.

Question 5

Benefits of QALYs?

Answer 5

Considers quality of time a person gains not just the length.
Gives a unit that those at POLICY levels can use to compare different TREATMENTS….
and also to compare different CONDITIONS as to which to fund.

Question 6

What does NHS deem as a cost effective treatment?

Answer 6

One that costs less than £20,000 per QALY

Question 7

Name some arguments against the use of QALY?

Answer 7

1. How does one assess the quality of someone’s life?
   - difficult to calculate a qaly
   - what gives our lives quality differs between individuals. i.e. a musician will suffer worse from losing a finger than another person per say.
2. QALY can produce unacceptable conditions;
   - It places no weight on concepts i.e. dignity
   - someones dignity can be impniged by refusal of treatment based on qaly.
3. QALY is ageist
   - older people nearing life expectancy, will most certainly not have a qaly as high.
   - The lives of older people have as much Value as younger people. They are both precious.
4. Discriminates those with disability
   - Because those without disability will be restored to FULL health - better qaly.
5. QALY is individualistic and does not consider the impact of the treatment on people downstream of the patient i.e. carers. (dont want to complicate allocations)
6. QALY causes us to compare peoples worth inevitably. (but we are comparing treatments though!)

Question 8

What is an argument in support of ageism in the use of qalys?

Answer 8

1. The loss of a short period of life for an 80 year old is LESS than the loss of many years of life for a 10 years old.

Question 9

Is QALY really ageist?

Answer 9

1. It doesnt really look at age in deciding treatment to give but rather looks at the number of years of life the treatment will give to the person.

Question 10

What is Daniel Callhan’s argument about Rationing?

Answer 10

1. That; Everyone needs to get a Fair rationing of healthcare resources across their lifespan, so;

We need to help the young become old and not to help the old become older.

2. Acceptable death; around the age of late 70s and 80s, death should be considered as an acceptable event and thus there should be no use of life prolonging treatment.
   A similar argument to this is ‘FAIR INNNINGS’.

Question 11

State some arguments against Daniel callahans reasoning.

Answer 11

1. Ageist; considers older people of little worth
2. A person’s lifespan could depend on healthcare resources available so your withholding it could impinge on their life expectancy.
3. Savings made from witholding treatment from that age group will be very small and wont solve resource allocation problems.
4. Not in the best interest of women as they live far longer.

Question 12

What is John Harris’ argument in resource allocation?

What are arguments against this?

Answer 12

Equality of treatment; each person should have an equal claim to treatment.
Where there are finite resources, allocation should be by lottery.

Arguments against;
1. This can lead to wasted resources as that can lead to those who treatment will not benefit receiving treatment.

Question 13

What is the Rawlsian approach?

Some arguments against it?

Answer 13

John Rawls says for us to distribute resources on fair principles we must imagine ourselves in the the ORIGINAL POSITION;

1. Self interested rational people
2. Standing behind the veil of ignorance

So basically people who will not consider age race sex etc because they would allocate resources how they would like to receive/be treated if they were in that position.

Arguments against;
1. How can this group decide if money is better spent on choosing a condition when they have never experienced it.

Question 14

List all the principles used to argue resource allocation

Answer 14

1. QALY
2. Fair innings (Daniel callahan)
3. Equality of treatment (John Harris)
4. Rawlsian approach (John rawls)
5. Public opinion
6. Patient choice
7. Evidence based medicine

Question 15

Name some controversies over rationing?

Answer 15

1. Treatment should be given for ill-health and not lifestyle enhancement
2. Rationing impinges on good clinical judgement
3. Some conditions are the patients fault thus the shouldnt be considered first line for treatment.
4. Using age as a category - qalys - discriminates women.
5. Is maximising benefit really ethically sound as an argument?

Question 16

1 woman needs a £500,000 treatment without which she will die. Should the money be spent on her or on prevention campaigns for 10,000 people?

Answer 16

Spent on her;

• NHS there to meet clinical need. Prevention is not yet a clinical need. This lady has a need that must be met - she has a right to treatment.
• Her life is just as precious as those whose lives would be saved with prevention.
• Large sums of money are also used in rescue missions for i.e. people lost at sea.

Spent on others;
- qalys maximisation, etc