Rationing and Futility Flashcards
Categories of allocation principles
- Equal treatment
- Favor of worst off
- Maximizing total benefits (utilitarianism)
- Promoting and rewarding social usefulness
Scarce medical goods, with the exception of physician or nursing time, tend to be ___.
Scarce medical goods, with the exception of physician or nursing time, tend to be indivisible.
Lottery
One way to treat everyone equally when goods are indivisible. Everyone has an equal chance, from the outset, to receive the good.
Notably, well-run allocation lotteries resist corruption, another attractive feature.
Treating people equally often fails to treat them . . .
Treating people equally often fails to treat them as equals
See “separate but equal”
First-come-first-served
Method for equal allocation. In a way, it is another sort of “lottery,” but only if 1) rate at which different populations get sick is equal, and 2) there is equal access by different populations.
Favours wealthy, powerful, and well-connected; ignores other relevant principles
Two dominant forms of prioritarianism
1) Youngest first
2) Sickest first
Sickest first
Form of prioritarianism. Aids those who are suffering right now; appeals to “rule of rescue”; makes sense in temporary scarcity; proxy for being worst off overall
Ignores needs of those who will become sick in future; might falsely assume temporary scarcity; leads to people receiving interventions only after prognosis deteriorates.
Also, may disproportionately favor elderly, thus reducing DALYs rescued.
Youngest first
Form of prioritarianism. Benefi ts those who have had least life; prudent planners have an interest in living to old age
Undesirable priority to infants over adolescents and young adult
Maximizes DALYs rescued in many cases
Number of lives saved
Form of utilitarianism.
Saves more lives, benefi ting the greatest number; avoids need for comparative judgments about quality or other aspects of lives
Ignores quality of lives and disability. Not best approach for DALY reduction.
Prognosis or life-years saved
Form of utilitarianism.
Maximises life-years produced.
Ignores distributive principles and disability.
Instrumental value
Form of promoting/rewarding social usefulness
Helps promote other important values; future oriented
Vulnerable to abuse through choice of prioritised occupations or activities; can direct health resources away from health needs.
Recommended to Include only in some public health emergencies
Reciprocity
Form of promoting/rewarding social usefulness
Rewards those who implemented important values; past oriented
Vulnerable to abuse; can direct health resources away from health needs; intrusive assessment process
Include only irreplaceable people who have suff ered serious losses
“The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little”.
Franklin Delano Roosevelt
United Network for Organ Sharing’s point calculation
They combine three principles: sickest-first (current medical condition); first-come, first-served (waiting time); and prognosis (antigen, antibody, and blood type matching between recipient and donor). UNOS weights principles differently depending on the organ distributed. Historically, no UNOS system has emphasised prognosis.
QALYs
Allocation systems based on quality-adjusted life-years (QALY) have two parts:
1) an outcome measure that considers the quality of life-years (assigns a decimal ratio where 1 represents full-quality)
2) a maximizing assumption that justice requires total QALYs to be maximised without consideration of their distribution
DALYs
Disability-adjusted life years
Assigns a decimal ratio assigning a magnitude to disability (with 1 representing undisabled life years)
As with QALY allocation, DALY allocation does not consider interpersonal distribution.
Complete Lives System
Prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid
Youngest-first; prognosis; save the most lives; lottery; instrumental value, but only in public health emergency
Least prone to corruption
Murphy et al’s Seven futile conditions, 1990
List of seven conditions Murphy et al recommended physicians not attempt to treat, as the outcomes had all been abyssmal.
Included “HIV infection with more than two episodes of PCP pneumonia” and “coma lasting > 48 h.”
Schneiderman’s definition of futility
“when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile”
“qualitative” futility
Futility in restoring quality of life
“quantitative” futility
Judgement about probability of operation success
“physiological” futility
treatments are considered futile only if they are unable to achieve their physiologic goals
Case of Helga Wanglie
Elderly woman on life support in coma with extremely low odds of recovery. Physicians recommend cessation of support, family refuses.
The family’s reluctance to discontinue treatment was based on religious and personal grounds. Mr. Wanglie stated that only God can take life and that doctors should not “play God.”
“Generations” of futility struggle
1st: What is the definition of futility in a medical context?
2nd: How should we resolve disputes regarding futility?
3rd: Established models for provider-family negotiation
BCH Futility Policy
If the physician decides continued treatment is futile, he forwards the case to the Committee. If the Committee agrees, the hospital has four options:
- Having the physicians negotiate terms with the family
- Attempt to transfer the patient to an institution willing to comply with the family’s wishes
- File a case in court in order to have an alternate court-appointed decision maker who supercedes the family
- If all of the above fail, the hospital may, as an institution, endorse cessation of life support. Policy stipulates that such action should occur only after informing the patient or surrogate decision maker of the plan, and only after giving them sufficient opportunity to seek legal advice and possibly judicial involvement, if desired.
Problem with procedural policies, according to Burns
It may not adequately distinguish between futility and rationing. With regard to any diagnostic or therapeutic intervention, futility asks the question “will the intervention work?” whereas rationing concerns the question “is the intervention worth it?”
Futility policies should never be invoked as a method of ___.
Futility policies should never be invoked as a method of cost control.
Principled negotiation approach
Rests on four conditions:
- Separate the people from the problem
- Focus on interests rather than positions
- Generate a variety of options before settling on an agreement
- Insist that the agreement be based on objective criteria
Pyramid approach to resolving futility disputes
The argument in favor of futile CPR
“By sometimes agreeing to provide futile CPR, we send a message to our communities not that clinicians can be bullied into performing procedures that good medical judgment would oppose, but that our hospitals are invested in treating patients and families with respect and concern for their individual needs.”
“In a small number of cases, providing nonbeneficial CPR can be an act of sincere caring and compassion”
