The cost of care: two troublesome cases in health care ethics. (Resource Allocation).

Key Concepts: Resource Allocation/Distributing Limited Resources/Ethics/Rationing Care/Distributive Justice

Robin Whitlock

With the cost of health care rising rapidly, both physicians and administrators regularly face resource allocation decisions. Under these conditions of relative scarcity, the equitable and appropriate distribution of limited resources becomes an ethical as well as a financial issue. Through ethical analysis, physician executives can assist their physician colleagues and fellow administrators to find rationally defensible answers to questions regarding the distribution of limited resources. Six criteria are frequently "weighed in the balance" by ethicists when analyzing whether justice is served in the distribution of a limited resource: need, equality, contribution, ability to pay, effort, and merit. The authors argue that, from an ethical standpoint, the best single criterion upon which one can base an allocation decision is that of merit, defined as the potential to benefit from the investment of additional resources.

WITH THE COST OF HEALTH CARE RISING RAPIDLY, third-party payers are increasingly less willing to underwrite the cost of various procedures. Both physicians and administrators regularly face resource allocation decisions that were unheard of only a few years ago. Under these conditions of relative scarcity. the equitable and appropriate distribution of limited resources becomes an issue--one of distributive justice. Ethics, the disciplined study of moral decision-making, provides tools, which physician executives can use to determine and justify the norms that structure the terms under which scarce medical resources are allocated.

Through ethical analysis, physician executives can assist their physician colleagues and fellow administrators to find rationally defensible answers to questions regarding the distribution of limited resources. The cases of Baby Boy-X and Baby Girl-Y are presented as examples of one approach to making this type of executive decision.

Traditionally in Western medicine, a physician's primary ethical obligation has been to protect and promote the best interests of his or her patients. This ethical principle of beneficence requires a physician to act in such a way that the consequences of his or her actions result in more good than harm. Over time, however, society has begun to question whether the ethical principle of respect for patient autonomy ought not to be given at least equal (if not greater) weight than beneficence where patient care decisions are concerned. For physicians, then, clinical decision-making has become a shared process--one of negotiating with patients in an effort to balance the demands of beneficence and respect for autonomy.

The ethical obligations imposed on health care administrators, however, vary considerably from those imposed on physicians. While physicians usually deal with individual patients, administrators deal with entire health systems. For an administrator, the ethical and equitable distribution of limited resources is no less critical than the financial solvency of the organization. Furthermore, the ethical principle of justice requires that, in an egalitarian society, all individuals have an equal opportunity to access scarce resources. This ideal requires health care organizations to render to each patient that which he or she is due. just how that obligation is calculated and met is the subject of this article.

The case of Baby Boy-X

Baby Boy-X is a patient in the neonatal intensive care unit (NICU). He was born to a 17-year-old woman at 34 weeks gestation. His mother has a history of cocaine abuse. She received no prenatal care and was pre-eclamptic on admission. Delivery was by emergency Cesarean section due to fetal distress. Baby Boy-X had Apgar scores of seven at one minute and nine at five minutes. He required ventilatory support and prostaglandin within two hours of birth. His medical problems include:

* Prematurity

* Low birth weight

* Hypoplastic left heart

* Patent ductus arteriosis

His condition Is stable, but guarded. A timely decision regarding his course of treatment must be made. Three treatment options are under consideration. If no action is taken and prostaglandin is discontinued, his ductus arteriosis will close and he will ultimately die. Heart transplantation is an option, but his prematurity makes him an unlikely candidate. If the Norwood procedure is performed to create a normal size aorta, a series of three operations will be required and his chances for survival will only increase to approximately 50 percent.

The case of Baby Girl-V

Baby Girl-Y is the third child born to a 42-year-old woman. The baby is 109 days old, but has yet to leave the NICU. Baby Girl-Y is currently recovering from surgery to correct an atrial septal defect. While she is listed in critical condition, she is not considered to be terminally ill. She is ventilator dependent and her medical history is significant for:

* Down's Syndrome

* Cerebral atrophy 

* Seizure disorder 

* Cardiothoracic surgery to repair an atrial septal defect

* Tracheostomy for tracheomalacia

* Gastrostomy 

* Chronic anemia

Baby Girl-Y is in critical, but stable condition. There are no "treatment options" comparable to those available to Baby Boy-X. What Baby Girl-Y requires is continuing, labor intensive, and, therefore, costly care. No immediate decision regarding the future course of her care is required at this time.

The question at distributive justice

Baby Boy-X and Baby Girl-Y are no different from most patients in at least one respect. A third party is paying for their care. The cost of their care may be covered under Medicaid or a fee-for-service insurance plan. Their parents may be members of a health maintenance organization (HMO) or their care may be being paid for out of the hospital's uncompensated care funds. The identity of the payer is not important unless the source of funding and/or history indicates less than free choice for the provider and patient when making treatment decisions.

Someone, somewhere will determine whether the providers who are caring for Baby Boy-X and Baby Girl-Y will be reimbursed for the cost of particular procedures and services. Someone, somewhere will be faced with the task of equitably distributing the limited resources available to pay for the care of Baby Boy-X and Baby Girl-Y. Thus, the major issue is cost and the question is one of distributive justice. The payer's decisions should be fair, not only to Baby Boy-X and Baby Girl-Y, but also to current and future patients who are dependent on the same sources to cover the cost of their care.

How can policy-makers fairly allocate relatively scarce medical resources in cases such as these? Six criteria are frequently "weighed in the balance" by ethicists when analyzing whether justice is served in the distribution of a limited resource: need, equality, contribution, ability to pay, effort, and merit.

1. Need

With the possible exception of patients who undergo purely elective procedures like breast augmentations and face-lifts, most patients who receive medical treatment need it. Need, however, can be a relative thing. A patient may assess the level of his or her need differently than would his or her physician. Likewise, the physician may have a different view than a third party payer. Need, then, may not be the best single criterion on which to base allocation decisions. Without surgery, Baby Boy-X will die. Baby Girl-Y also needs medical care to control her seizures and to treat her anemia. In addition, Baby Girl-Y will require full-time nursing care for the rest of her life. While it is impossible to determine whether Baby Boy-X or Baby Girl-Y needs medical care more than the hospital's other patients, one thing is certain. If allocation decisions were based on need alone, the limited resources available to any health care organization would quickly be exhausted.

2. Equality

Equality does not serve well as an effective criterion for allocating health care resources either. Living within any institution's catchment area are individuals who require few if any health care services, as well as individuals who, like Baby Girl-Y, will require continuous care for the rest of their lives. No one would advocate admitting healthy individuals to the hospital so they can get an equal share of publicly financed health care. Likewise, no one should advocate denying health care to an individual merely because the cost of his or her care has exceeded some predetermined quota. Simply because Medicare, Medicaid, and private health insurance policies decline to pay for various services or, once a certain threshold is crossed, any services, does not weaken the ethical argument. Egalitarian lottery application of health care resources is arbitrary and unfair. After all, the historic justification for the pooling of funds termed "insurance" is based on a contract to allow distribution to those in grea ter need.

3. Contribution

From another angle, to deny care to Baby Boy-X and Baby Girl-Y because they have not made significant contributions to society would be unfair. Like all other infants and children, these two patients have never had the opportunity to make a contribution to society. Furthermore, the university medical center in which they are patients is a large, urban health care facility of 280 beds. It seems reasonable to assume, therefore, that the hospital, as part of its mission, is probably a major provider of indigent care. Given that many indigent patients are poorly educated, unskilled, and unlikely to have made significant contributions to society, allocation decisions based on one's ongoing contributions to society would not be in keeping with the hospital's mission.

4. Ability to pay

Likewise, decisions regarding the allocation of health care should not be based on one's ability to pay. Despite the pluralism that characterizes American society. the United States is a country that recognizes and affirms the values of compassion and giving. Americans--individually and collectively--give billions of dollars annually to private charities and in foreign aid. To deny care to patients solely because they are unable to pay is counter to the fundamental belief in generosity and charitableness held by most Americans.

5. Effort

While not applicable in these two cases, effort could be one of several criteria that influence allocation decisions. Patients who repeatedly sign themselves out of the hospital against medical advice or who are habitually non-compliant call into question the level of effort that they are willing to expend to help themselves. It is not unreasonable. therefore, to question the wisdom of spending limited resources on their care. These two cases clearly demonstrate, however, that in and of itself, a patient's level of effort can not be used as the sole criterion on which to base allocation decisions.

6. Merit

From an ethical standpoint, perhaps the best criterion upon which one could base allocation decisions is that of merit, defined as the potential to benefit from the additional investment of limited health care resources. As a premature infant, Baby Boy X is an unlikely candidate for transplantation. Given current technology, it is also unlikely that, even with surgery, he will live a normal life. Thus, further expenditure of resources on the care of Baby Boy-X could hardly be justified based on the criterion of merit. On the other hand, while Baby Girl-Y will not lead a normal life, she can benefit from pediatric home health care. She would not, however, merit further expenditure on cosmetic procedures, spectacles, or a hearing aid. She suffers from severe cerebral atrophy and, unlike a less severely handicapped patient, her quality of life is unlikely to be improved by interventions such as these.

Conclusion

The very idea of making a treatment decision based on the availability of resources is repugnant to many. In an ideal world, there would be no limit to the resources available. The truth of the matter, however, is that medical care resources have always been, are right now, and will always be limited--and, therefore, in some way, rationed. For one reason or another, some individuals are treated while others are not. The key to this dilemma is that service providers, administrators, patients, legislators, and policy-makers all have to become involved in prioritizing the conflicting claims to the available resources. This will become increasingly crucial as the baby boom generation ages and the demands on our health care system soar.

Acknowledgement

The authors thank Patricia A. Wilhelm, CNS, MSN, RNC, and Katherine E. Taylor, RN, BSN, CCRN, for their assistance in developing the two cases. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government.

Christopher R. Armstrong, MD, MPH, is a specialist in Aerospace Medicine and Director of the Naval Branch Medical Clinic, Marine Corps Air Station New River. in Jacksonville, North Carolina. He can be reached by calling 910/450-6400 or via email at [e-mail].

Robin Whitlock, MDiv, is an associate professor in the Department of Medicine and Director of The Episcopal Ministry to Medical Education at Tulane University School of Medicine in New Orleans, Louisiana. He can be reached by calling 504/588-5428 or via email at [e-mail]. tulane.edu.