Medical resource allocation: rationing and ethical considerations - part I.
Despite past measures to contain costs, U.S. health care expenditures have increased from $74 billion in 1970 (7.3 percent of GNP), to $809 billion in 1992 (13.4 percent of GNP), to a projected $1,616 billion by the year 2000 (16.6 percent of GNP). In addition, the distribution of medical resources is heavily skewed toward a very small proportion of the population. In 1985, for example, 55 percent of all hospital expenses were incurred by 4 percent of the patient population, less than 1 percent of the entire population. Experience has already shown us that those who can afford health care coverage are the ones who more frequently use services. Thus, we are already witnessing a form of rationing of resources based on the ability to purchase health care as a commodity good.
If health care is deemed a social good, the method of allocation must be addressed. In our pluralistic society, many legitimate but contradictory goals exist. Competing goal orientations frame the parameters of public policy that deal with biomedical resource allocation. Such goal orientation is directed, in varying degrees, to maximize individual freedom and choice, social or public good, quality of life, human dignity, and social stability. Which individual rights and responsibilities of citizenship are to be considered? Do societal pressures, no matter how intense, justify restrictions on individual goods? Unless society decides that other priorities of the infrastructure are to be subjugated to health service delivery, difficult decisions will be forced upon us, consciously or by default.
To varying degrees, all political decisions involve tradeoffs. Regardless of which protocol for resource allocation is followed, it is clear that some groups and individuals in our society will benefit and others will be deprived. We must accept the concept at the onset that, regardless of which policy is adopted and no matter how scarce biomedical resources are distributed, some deaths are going to be unavoidable.
Dependence on technology to cure our health problems is tied to the American tendency to look for technological fixes for all of our problems. America's preference for curative over preventive medicine has been well documented. However, many advances in prevention have come from outside of medicine, including improved sanitation, nutrition, housing, and education. Some Americans use the benefits of biomedical technology to avoid more difficult changes in life-style, i.e., smoking, drug dependency, guns, driving habits, obesity, lack of exercise, and environmental destruction. For those amenable to change, a more systematic approach to preventive health counseling and follow-up care is required. Is this to be done in the name of individual rights and self-determination? If we do not demand prevention-oriented changes, are we quickening the pace toward forced decisions regarding allocation?
Although the U.S. Constitution makes no mention of a right to health care, the prevailing value system in the United States places heavy emphasis on the notion of rights. The courts have often interpreted the right to life to include an inherent claim of all citizens to health care and to autonomy in making decisions concerning health. Many people in our society seem to want medical care and to value health services. Because ours is a society based on principles of freedom, justice, and equality of opportunity, we have attended seriously to those who claim technological health care is a right that should be available to all. At the same time, the United States has been hesitant to institute utilitarian policies that limit the amount of medical resources that can be committed to any one individual. The view that the individual's claim to medical resources is predominant has kept us from making hard health care allocation choices. Schramm sees the status quo as leading to a "tyranny of our own making [through which we will] impoverish ourselves and successive generations by indulging in too much medicine."
This paper supports our society's noncontroversial position that everyone has a right to life, but with the understanding that the meaning and the value of rights are contingent on the availability of resources needed for respecting and preserving those rights. When resources are limited, corresponding rights to those resources must also become limited. To what extent and in what way does this principle, known as the doctrine of necessity, excuse the deaths that result from a particular choice concerning the allocation of limited life-saving biomedical resources and funds? There are "several significant differences between the direct killing of another person and permitting a person to die when it is not possible to save all."
The Oregon Plan may represent a prototypical future model for approaching resource allocation in health care. The Oregon Basic Health Services Act mandates universal access to basic care, but includes the rationing of services to Medicaid recipients.
Oregon drew national attention in 1987 when it stopped Medicaid funding of soft-tissue transplants for children. Officials justified the action by claiming that there are more effective ways to spend scarce public dollars than to provide high-cost benefits to relatively few people. Estimating the per case cost of transplants at $1.1 million, Oregon officials decided that resources could be better utilized and more positively affect society if those dollars were expended in the area of prenatal care. In this utilitarian approach, the state made a choice between individual children in need of transplants and pregnant women who can't afford prenatal and maternal care.
The Oregon Basic Health Services Act seeks to improve access through reallocation of health care dollars. Under the plan, Medicaid services become available for 100 percent of the population at or below the federal poverty level. In doing this, Oregon explicitly rejects the rationing strategy that predominates in the United States today--that is, excluding whole categories of poor and near-poor by denying coverage to people rather than rationing low-priority services.
The Oregon Plan embodies three principles:
* There is a social obligation to guarantee
universal access to a basic
level of care.
* Reasonable and necessary limits
on resources mean that not every
beneficial service can be included
in the basic level of health care.
* A public process, involving consideration
of social values, is required
to determine what services will be
included in the basic level of health
care. Oregon's health care planners
felt that rationing lower priority
services to the poor rather than
excluding whole groups of the poor
and near-poor from insurance
would reduce inequality in society,
even if some current Medicaid
recipients may be, to some extent,
worse off than they are now.
The Oregon Plan involves explicit public rationing, disavowing covert rationing of the market and provider decisions. In 1990, 47 public community meetings were held throughout the state. Citizens were asked to rank the importance of various categories of treatment and were asked, "Why is this health care service important to us?" One frequent criticism of the community meeting procedure is that it did not involve a representative cross section of Oregonians--507 were physicians and too many were college educated, white, and financially well off. Only 9 percent of those at community meetings were uninsured, compared to 16 percent for the state. Medicaid recipients were also underrepresented at the meetings, which were intended "to build consensus on the values to be used to guide health resource allocation decisions."
Worries about fairness and ethical justice in the Oregon rationing process come from the plan's targeting the poor rather than the whole population. These concerns converge with concerns about the kinds of inequality the system tolerates.
Societal contribution has been discussed by Outka as one way of evaluating and allocating medical resources. This concept gives moral primacy to notions such as public interest, the common good, the welfare of the community, or the greatest good for the greatest number. It may refer to interests of the social group considered collectively, where the group's welfare is the decisive criterion for determining what constitutes any member's proper share. The common good may also refer to an aggregation of distinct individuals and be considered distributively.
How do we determine the relevant criteria, given the tremendous range of factors that effect social value and worth? How does one quantify and compare the needs of the spirit--i.e, art, education, religion--with political life, economic activity, and technological development? Occasionally, criteria of social worth focus on past contribution, but most often they are primarily future-oriented. If the patient's potential and probable contribution to the society is stressed, how can this be abstracted from the individual's present web of relationships, social dependents, and occupational and spiritual activities? The possible magnitude of an individual's contributions to society (as an abstraction) is measured in terms of social roles, relationships, and functions. This utilitarian approach would, in effect, dull and perhaps even eliminate the sense of a person's transcendence and his dignity as a person, which cannot be reduced to his past or future contributions to society. Shatin insists that our medical decisions regarding allocation of resources are already based on an unconscious scale of values, usually dominated by material worth. He recommends that we discover the values that most people in our society hold and then use them as criteria for distributing medical resources.
Quality-adjusted life-years are a measure of health outcomes that reflects both lives saved and the patient's valuations of quality of life in alternative states of health. The concept of cost per quality-adjusted life-year as a guideline for resource allocation is founded on six ethical assumptions:
* Quality of life can be accurately
measured and used.
* Utilitarianism is acceptable.
* Equity and efficiency are compatible.
* Projections of community preferences
can be substituted for individual
* The old have less capacity to benefit
than the young.
* Physicians will not use quality-adjusted
life-years as clinical
Quality-adjusted life-years signal two shifts in the locus of control and the nature of the clinical encounter. Formal expressions of community preferences and societal usefulness would counterbalance patient autonomy, and formal tools of resource allocation and applied decision analysis would counterbalance the use of clinical judgment.
Quality-adjusted life-years are derived from operations research in engineering and mathematics and were introduced in the United States as a way of elucidating the trade-offs between quality of life and additional survival years. The result represents "the net health effectiveness of the program or practice in question."
A quality-adjusted life-year is a numerical description of the value that a medical procedure or service can provide to groups of patients with similar medical conditions. The concept attempts to combine expected survival with expected quality of life in a single measurement. An additional year of healthy life is worth a value of one (year) and a year of less healthy life is worth less than one.
Calculations of quality-adjusted life-years are based on measurements of the value that individuals place on expected years of life. In theory, questions would be employed to elicit a measure of quality-adjusted life-years for an individual patient who faces a choice between alternative therapies that yield different probabilities for pain reduction, abilities to engage in activities of daily living, and life expectancies. In effect, quality-adjusted life-years discount years of life saved by a health care intervention by how much the patient's subjective well-being is diminished by discomfort or distress. It measures true medical therapeutic successes, not merely transient improvement in the physiological state of the individual.
Most proponents expect quality-adjusted life-years to inform resource allocation decision, especially large-scale decisions that deploy resources across disease states and population groups. In theory, a quality-adjusted life-years analysis compares the merits of devoting resources to an intervention likely to extend lives within a population for a specific period, but with high levels of disability and distress. This is compared to another intervention that may not yield as many years of life saved but generates higher levels of subjective well-being. Within the policy arena, this concept is further affected by the recently implemented Americans with Disabilities Act.
The debate about quality-adjusted life-years occurs on at least four levels. First, there are methodological problems of theory, measurement, and interpretation. Second, assuming the technical properties of a quality-adjusted life-years-based policy guidance are clarified and agreed on, the practical questions of implementation arise. Third, quality-adjusted life-years present moral and professional challenges to the fundamental values and assumed prerogatives of physicians. Fourth, quality-adjusted life-years hold a conspicuous, critical place in the recent evolution of health policy, an evolution preoccupied with the agenda of cost containment.
Quality-adjusted life-years assume that quality of life can be measured well enough to make policy judgments about it. It also assumes that at some point--the same point for all persons--quality of life deteriorates to an extent that it has lost its value and is merely replaced with a physiological existence. Quality-adjusted life-years risk projecting community preferences over those of individual patients. The ethical principle of autonomy or self-determination would be trumped by that of justice and fairness, which is generally more important for a community. The preferences of a selected population sample in hypothetical medical situations would be used as if they were individual patient preferences. However, individual patient preferences cannot always be accurately assessed by others. Even family preferences may not represent those of the patient.
Quality-adjusted life-years assume that the duration and quality of an individual's life are not different from most other commodities that can be purchased. While utilitarianism may be an acceptable ethical theory for making health policy at the macro level, clinical practice is not primarily conducted at present to benefit society as a whole, the public interest, or the common good.
As our society more openly evaluates utilitarianism, legitimate concerns arise over how quality-adjusted life-years may influence the conduct and direction of health policy. Whatever course is chosen, it must recognize medicine for what it can measurably produce, rather than for merely humanistic care. Our society, where the limitation of resources is starting to agree with the prima facie concern of the community, is in a dilemma of deciding whether to continue to recognize the best interests of the individual over the best interest of society. Quality-adjusted life-years appear to symbolize the persistence of health care as a commodity and to shift the balance of power and philosophy of clinical practice from highly discretionary physician-patient encounters to more standardized, quantified and regulated protocols. On the other hand, quality-adjusted life-years are a new health measurement tool that many health care economists and decision analysts believe has promise to provide health care to those who have the greatest capacity to benefit from it.
Rationing To The Elderly
Callahan suggests limiting health resources to the elderly through public policy decisions and clinical practice. He states that "our common social obligation to the elderly is only to help them live out a natural life span; that is, the government is obliged to provide deliberately life-extending health care only to the age that is necessary to achieve that goal." He and others believe that an age-based standard for the termination of life-extending treatment would be legitimate and would not detract from affirmation of the dignity and value of individual human life and of old age.
The ethical and economic issues of providing health care for the elderly are similar to the issues of providing care to the rest of our society: cost effectiveness in the delivery of care and the allocation of resources. However, the difficulties of providing care to the elderly include three unique features. First, the increasingly endemic nature of their illnesses make them more controllable than curable. Second, the increasingly large number and proportion of the elderly that are ill or impaired is the price of an extended life span and its concurrent increase in chronic illness. "The third is the growing necessity to make painful moral choices in the care of the dying elderly as a class, particularly among those who end their days incompetent and grossly incapacitated, more dead than alive."
Trends in the number and proportion of the elderly and their health care costs is striking. Between 1900 and today, there has been an eightfold increase in the number of those over the age of 65, an almost tripled proportion of our population. Those over age 85, the fastest growing age group in our society, are 21 times as numerous as in 1900. In the early 1960s, less than 15 percent of the federal budget went to those over the age of 65. By 1985, that number had grown to almost 28 percent. Slightly more than $80 billion of private and government money was spent on health care for the elderly in 1991, and this number is expected to grow to $200 billion in constant 1980 dollars by the year 2000.
Concerns about providing health care to the elderly take many forms. Increasingly large shares of health care dollars are going to the elderly in comparison with benefits for children. Is that fair and sensible? A disproportionately large portion of health care expenditures goes to the care of the dying elderly. Is that really beneficial, and is it wise to spend so much on burdensome and futile terminal care?
The suggestion has been made by Fuchs that controlling the excessive medical costs of the dying elderly would be a major step toward eliminating the excessively large health care costs of that age group. "The United States spends about one percent of the gross national product on health care for elderly persons in their last year of life." He goes on to say that "one of the biggest challenges facing policy makers for the rest of this century will be how to strike an appropriate balance between care of the [elderly] dying and health care services for the rest of the population." Here, too, there is a need to control the use of "unnecessary" resources in the nonelderly, but terminal, patient.
Daniels has promoted the concept of "normal opportunity range" for the allocation of resources to different age groups. The foundation of his idea is that "meeting health care needs is of special importance because it promotes fair equality of opportunity. It helps guarantee individuals a fair chance to enjoy the normal opportunity range for their society." A "fair chance," however, is one that recognizes different needs and different opportunities for each stage of life"; it is an age-relative opportunity range.
Callahan states that we have a collective "social obligation to help people live out a natural life span, but not to actively help extend life medically beyond that point." Medical intervention, technology, and treatments whose effects only forestall the moment of death without returning the patient to bodily and functional integrity are not demanded by this obligation. Beyond the point of a natural life span, Callahan and others believe, relief of suffering is all that is ethically necessary. The fear of most elderly is frailty, not death. They fear the loss of independence and self-direction, declining mental capacities, and impoverishment by health care costs. A societal decision to deliberately limit life-extending, high-technology care to the chronically ill or terminal elderly is not a symbol of abandonment. Rather, it is symbolic of respect for the dignity of human life and a blow to the injustices of the escalation of the costs of medical care that keeps people alive at extraordinary costs. Financial costs, as well as personal and societal costs, can keep the elderly population alive in physiological balance, but frequently without a meaningful quality to life. (Part II of this article will appear in the March 1994 issue of Physician Executive.)
[1.] Blank, R. Life, Death, and Public Policy. DeKalb, Ill.: Northern Illinois University Press, 1988. [2.] Faltermeyer, E. "Let's Really Cure the Health System." Fortune, March 23, 1992. [3.] Bluestien, J. "Allocation of Scarce Life Saving Resources." In Bandman, E., Ed., Bioethics and Human Rights. Boston. Mass.: Little Brown and Company, 1978. [4.] Childress, J. "Who Shall Live When All Cannot." In Wertz, R., Ed., Readings on Ethical and Social Issues in Biomedicine. Englewood Cliffs, N.J.: Prentice Hall, 1973. [6.] Daniels, N. "Is the Oregon Rationing Plan Fair?", JAMA 265(17):2232-5, May 1, 1991. [7.] Outka, G. "Social Justice and Equal Access to Health Care." In Veatch, R., and Branson, R., Eds., Ethics and Health Care Policy. Cambridge, Mass.: Ballinger, 1976. [8.] Garfield, A. "The Delivery of Medical Care." In Wertz, R., Ed., Readings on Ethical and Social Issues in Biomedicine. Englewood Cliffs, N.J.: Prentice Hall, 1973. [9.] Shatin, L. "Medical Care and the Social World of Man." American Journal of Orthopsychiatry 36(l):97, Jan. 1966. [10.] La Puma, J., and Lawlor, E. "Quality-Adjusted Life-Years. Ethical Implications for Physicians and Policymakers." JAMA 263(21):2917-21, June 6, 1990. [11.] Patrick, D., and others. "Toward an Operational Definition of Health." Journal of Health and Social Behavior 14(l):6-23, March 1973. [12.] Callahan, D. Setting Limits: Medical Goals in an Aging Society. New York, N.Y.: Simon and Schuster, 1988. [13.] Daniels, N. Just Health Care. New York, N.Y.: Cambridge University Press, 1985.
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|Date:||Feb 1, 1994|
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