Rationing and Futility

Question 1

Categories of allocation principles

Answer 1

• Equal treatment
• Favor of worst off
• Maximizing total benefits (utilitarianism)
• Promoting and rewarding social usefulness

Question 2

Scarce medical goods, with the exception of physician or nursing time, tend to be ___.

Answer 2

Scarce medical goods, with the exception of physician or nursing time, tend to be indivisible.

Question 3

Lottery

Answer 3

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.

Question 4

Treating people equally often fails to treat them . . .

Answer 4

Treating people equally often fails to treat them as equals

See “separate but equal”

Question 5

First-come-first-served

Answer 5

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

Question 6

Two dominant forms of prioritarianism

Answer 6

1) Youngest first
2) Sickest first

Question 7

Sickest first

Answer 7

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.

Question 8

Youngest first

Answer 8

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

Question 9

Number of lives saved

Answer 9

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.

Question 10

Prognosis or life-years saved

Answer 10

Form of utilitarianism.

Maximises life-years produced.

Ignores distributive principles and disability.

Question 11

Instrumental value

Answer 11

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

Question 12

Reciprocity

Answer 12

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

Question 13

“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”.

Answer 13

Franklin Delano Roosevelt

Question 14

United Network for Organ Sharing’s point calculation

Answer 14

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.

Question 15

QALYs

Answer 15

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

Question 16

DALYs

Answer 16

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.

Question 17

Complete Lives System

Answer 17

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

Question 18

Murphy et al’s Seven futile conditions, 1990

Answer 18

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.”

Question 19

Schneiderman’s definition of futility

Answer 19

“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”

Question 20

“qualitative” futility

Answer 20

Futility in restoring quality of life

Question 21

“quantitative” futility

Answer 21

Judgement about probability of operation success

Question 22

“physiological” futility

Answer 22

treatments are considered futile only if they are unable to achieve their physiologic goals

Question 23

Case of Helga Wanglie

Answer 23

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.”

Question 24

“Generations” of futility struggle

Answer 24

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

Question 25

BCH Futility Policy

Answer 25

If the physician decides continued treatment is futile, he forwards the case to the Committee. If the Committee agrees, the hospital has four options:

1. Having the physicians negotiate terms with the family
2. Attempt to transfer the patient to an institution willing to comply with the family’s wishes
3. File a case in court in order to have an alternate court-appointed decision maker who supercedes the family
4. 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.

Question 26

Problem with procedural policies, according to Burns

Answer 26

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?”

Question 27

Futility policies should never be invoked as a method of ___.

Answer 27

Futility policies should never be invoked as a method of cost control.

Question 28

Principled negotiation approach

Answer 28

Rests on four conditions:

1. Separate the people from the problem
2. Focus on interests rather than positions
3. Generate a variety of options before settling on an agreement
4. Insist that the agreement be based on objective criteria

Question 29

Pyramid approach to resolving futility disputes

Answer 29

Question 30

The argument in favor of futile CPR

Answer 30

“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”