What is a just and fair way to make scarce resources available in order to alleviate suffering, when the available resources cannot be distributed equally?
When people are dying and you can only save some, how do you choose? Maybe you save the youngest. Or the sickest. Maybe you even just put all the names in a hat and pick at random. Would your answer change if a sick person was standing right in front of you?
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Micro-allocation (balancing patients’ needs)
“Morally unacceptable criteria for allocation of resources include age, gender, ethnic origin, religion, sexual preference or race.”
This involve balancing the conflicting claims of patients, funders, etc., to distribute resources, such as time spent, dealing with crises (e.g. staff off sick), patients arriving late for appointments, scarce resources, type or length of intervention, etc., to patients and in faculties. How to decide? The formal principle of distributive justice, i.e. treat similar cases similarly, could be starting point. Beauchamp and Childress have also identified six material principles of justice, which further assist in such decisions, viz:
- to each person an equal share
- to each person according to need
- to each person according to effort
- to each person according to contribution
- to each person according to merit
- to each person according to free-market exchanges
Nearly all these principles can be applied to the scenarios mentioned above, but with differing results for different individuals and/or instances! Who takes priority? How should individuals be rewarded for work? Many different variables need to be considered in each case, often resulting in different priorities and conclusions! Which are the most compelling? Are the assumptions made always right?
Meso-allocation (institutional policies)
Meso-allocation concerns policy that is implemented at an institutional level, such as those that will affect individual departments e.g. physiotherapy, occupational therapy, cardiology, oncology, etc. These departmental needs and benefits are clarified and overseen by representatives of the health and medical departments and allocation decisions are made with public scrutiny through a board of trustees.
Macro-allocation (priorities in public policies)
This concerns the policy regarding distribution of resources at national, provincial and local levels, which seems of little consequence to physiotherapists, yet is covered in Ethical Principle 7 of the SASP and Duties to society in Guidelines for Ethical Practice laid down by HPCSA. Thus it is up to the profession, either nationally, via its various substances or individually, to conclusive arguments that adequate physiotherapy services should be supplied and equally distributed, be it in geographic, institutional or financial terms. Garbard and Martin deal with macro-allocation in the following three categories:
1. Priorities among medical treatments
How should priorities be ranked and funding of medical/health care be decided? By opinion polls, interviews with members of the public, health professionals and/or funders? Should these change with changes in demands, epidemiology or prevalence of disease? Is it proper for individuals with strong belief (and often vested interests) in specific conditions/treatments, to lobby for these? In the financial analysis it is the politicians or lawmakers who will have to make the final decision. It is recommended that although one needs to recognise the importance of passionate commitments of advocates for specific causes, an impartial perspective of the full good of the community and society should carry the greatest weight.
2. Healthcare versus other good
Should there, for example, be national funding for essential medication required by at risk groups of people, such as elderly people, AIDS sufferers, etc., when the public is not prepared to pay increased taxes to cover such goods and other programmes that then have to be downsized in order to fund these?
3. Systems of healthcare
Which systems of delivering healthcare within the society best satisfies the requirements of justice as well as the requirements of benevolence (compassion, decency)? This will partly reflect the tradition of each society, e.g. the Canadians wanted healthcare to be provided equally to all; the British agreed to a two-tiered system, where the (basic) healthcare supplied to all citizens can be supplemented by either supplemental insurance or direct private payment; in the USA a variety of methods exist, namely “welfare” to the indigent to total private funding in a strongly entrepreneurial, free-market society where provision of basic healthcare is not recognised as a right and nobody is satisfied nor are there viable options; in the socialised Nordic countries a social system of national health and welfare exists; in the RSA it is at present very similar to the USA, although the Department of Health is moving towards a national health system, where all individuals will have some form of health cover. There are a variety of ways of viewing distribution of healthcare, either as specific systems or the outcome required/wanted. Gabard and Martin suggest three alternative systems, which seem to apply mainly to developed countries:
- a free market system
- a single-federal/national system or
- state-based managed competition
The dilemma for the clinician is about providing a reasonable level of care when there are limitations imposed by the inequitable distribution of resources at either a micro-, meso-, or macro-level. The following general guidelines may be of some use in working through the dilemma:
- Choose interventions known to be beneficial on the basis of evidence of effectiveness
- Minimize the use of marginally beneficial tests or marginally beneficial interventions
- Seek the tests or treatments that will accomplish the diagnostic or therapeutic goal for the least cost
- Advocate for one’s own patients but avoid manipulating the system to gain unfair advantage to them
- Resolve conflicting claims for scarce resources justly, on the basis of morally relevant criteria such as need (e.g., the patient’s risk of death or serious harm could be reduced by the treatment) and benefit (e.g., published evidence of effectiveness), using fair and publicly defensible procedures (ideally, incorporating public input)
- Inform patients of the impact of cost constraints on care, but do so in a sensitive way. Blaming administrative or governmental systems during discussions with the patient at the point of treatment should be avoided; it undermines care by reducing confidence and increasing anxiety at a time when the patient is most vulnerable
- Seek resolution of unacceptable shortages at the level of hospital management (mesoallocation) or government (macroallocation)
- Fink, S. (2009). Worst Case: Choosing Who Survives in a Flu Epidemic. New York Times.
- Fink, S. (2016). Whose Lives Should Be Saved? Researchers Ask the Public. New York Times
- Martin F. McKneally, Bernard M. Dickens, Eric M. Meslin, Peter A. Singer (1997). Bioethics for clinicians: Resource allocation. Canadian Medical Association Journal, 157 (2): 163