For A-Plus Writer Only !!!!!!

161 Cultura Limited/SuperStock Ethical Resource Allocation 8 Learning Objectives 1. Understand the need to make ethically defensible rationing decisions in health care. 2. Analyze different methods of allocating health care resources. 3. Describe the steps decision makers must take to achieve moral authority through procedural justice. 4. Identify the ethical basis for setting utilization limits. 5. Understand the concept of medical futility. 162 CHAPTER 8 “How can a society or health plan meet population health care needs fairly under resource limita- tions?” (Daniels, 2008, p. vii). This compelling and controversial question gives rise both to health policy discussions and political debates. As enactment and implementation of the Affordable Care Act has proceeded, public and political discourse has become heated whenever allocating scarce resources—negatively labeled health care rationing—is discussed. One common allegation was that the ACA would severely impede Americans’ freedom of choice in health care by empowering expert panels (rather than treating clinicians) to make decisions about the care individuals could receive. A prominent political candidate went so far as to suggest that “death panels” would be set up by the government to “pull the plug on grandma” (cited in Viebek, 2012), and this concept remains prominent in the public’s mind. (Figure 8.1 shows how Americans view the ACA.) Figure 8.1: Negative views of ACA continue to outpace positive Given what you know about the Affordable Care Act, do you have a generally favorable or generally unfavorable opinion of it? This was the question asked during a June 2013 health tracking poll collected by the Kaiser Family Foundation. Although the law is still under development, why are more people opposed to it?

Source: Kaiser Family Foundation. (2013). Negative views of ACA continue t\ o outpace positive. Retrieved from ht tp://kff.org/health-reform/poll-finding/kaiser-health -tracking-poll-june-2013 The United States’ health system under the ACA does, in fact, ration health care. However, this phenomenon is not new or the result of a political agenda. Health care rationing is an inevitable feature of modern health care systems all over the world. Whenever the need or demand for any product or service outstrips its availability or supply, some form of rationing will occur. In recent decades, the most common rationing mechanism in U.S. health care has been economic: Those with the means or the third-party coverage to afford care went to the front of the queue, while poor and uninsured Americans were less likely to receive needed care.

In areas other than health care, this aspect of modern civilization is not usually morally trou - bling or tragic. Consider the difference between someone wanting a unique work of art and an 163 CHAPTER 8 organ transplant candidate. Both are seeking scarce and valuable “products” for which demand is greater than supply. Yet one is a luxury, while the other may save someone’s life.

The ethical allocation of health care resources is likely to become even more important in the near future because two phenomena will increase demand for health care services. First, the baby boomer generation, those born between 1946 and 1964, will turn 65 at the rate of 10,000 per day for the next 16 years (Pew, 2010). This enormous cohort, which now constitutes about one fourth of the entire population, will suffer from age-related health issues in growing numbers. Because baby boomers will be eligible for Medicare at age 65, they will place additional stress on a health care–funding mechanism that is often characterized by fiscal distress. (Figure 8.2 shows the pro- jected population growth of persons 65 and older.) Figure 8.2: Elderly population growth in the United States, 1900–2040 Baby boomers are aging, which means the population of senior citizens in the United States is growing exponentially. This means the health care needs for the elderly will also increase significantly. Is the United States prepared to handle a shift in resources?

Source: U.S. Administration on Aging. Retrieved from ht tp://aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx 164 CHAPTER 8 Section 8.1 The Moral Challenge of Resource Allocation The second increase in demand for health care services will stem from changes introduced by the ACA, which could increase third-party coverage through Medicaid and commercial health insurance by as many as 45 million individuals (APHA, 2013). The newly insured are not likely to have a high incidence of catastrophic health problems, but many of them will have unmet health care needs, which will increase demand and competition for services (Decker, Kostova, Kenney, & Long, 2013).

Health care resource allocation must meet ethical standards and be perceived as equitable in order to have both moral authority and public legitimacy. Health care administrators, who are increasingly called upon to justify their decisions, will benefit from pausing to consider the factors that meet both of these criteria as demand exceeds both supply and the nation’s willingness to dedicate additional resources to health care.

In this chapter we will take a close look at ethical questions in resource management and alloca- tion. We will analyze some of the difficult decisions health care administrators face, and we will consider what tools or strategies are ethically and legally required when setting priorities. We will also look at lessons from history that might help prevent some of the problems that befall this aspect of health care management.

8.1 The Moral Challenge of Resource Allocation R esource allocation in health care has been the subject of extensive research and expertise.

Resource allocation policy analysis frequently investigates organ transplants (Beauchamp & Chil - dress, 2009). Although organ allocation decisions and policies are logical and reasonable and are not intended to discriminate against any individuals in need of this precious resource, American organ transplantation guidelines have ethically problematic effects. For example, a patient who lives within the allowable travel time for two transplant centers may be wait-listed at both as long as the individual fulfills the other requirements. A patient who lives else- where, however, may only have access to one wait list (Beauchamp & Childress, 2009). Conversely, someone who has access to a private jet that is available at a moment’s notice may qualify for the organ lists of numerous transplant centers, as did billionaire Steve Jobs when he received a liver transplant in Memphis, Tennessee, despite living more than 2,000 miles away in Palo Alto, California (Grady & Meier, 2009).

Apart from the potential consequences of not receiv - ing scarce health care resources, what makes the pru- dent and equitable allocation of such resources a moral imperative? In Chapter 2, as well as in subsequent chapters, we studied the special duties that the goals of health care impose on health care administrators—duties that do not arise for commercial business managers. The objectives of medicine, along with the special moral and human importance of health and health care, make the health care leader’s attention to ethical stewardship of resources a fundamental priority. Aphp-St Antoine-Garo/Phanie/SuperStock Organ transplants are an area of medicine that can pose serious ethical dilemmas for health care workers. 165 CHAPTER 8 Section 8.2 Procedural Justice in Resource Allocation Decisions Fundamental Moral Questions in Resource Allocation How can leaders make ethically defensible resource allocation decisions while honoring moral obligations to patients, organizations, and communities? To determine the underlying obligations for just resource allocation, two ethical questions must be considered when deciding how to dis- tribute services and benefits in health care organizations: 1. Procedural justice: What do ethics require of the processes and policies that help deter - mine resource allocation? 2. Distributive justice: When are health and health care inequalities unjust and in need of correction?

Both questions address the issue of setting priorities: How do we align priorities with the ultimate ends of medicine as well as democratic deliberation about values? We will examine each of these questions in the sections that follow. Stop and Clarify: Rationing The term rationing is often used to describe rules that unfairly or unjustly limit access to a resource that potential recipients deserve and to which they would otherwise be entitled. Technically, how - ever, rationing will occur whenever there is a product, benefit, or service that is limited and for which demand outstrips supply. Even simple methods for allocating a scarce resource among those who want it—such as a first-come, first-served policy—are rationing processes, since they determine who will receive the resource and who will not. Ideally, system-wide rationing, also called macroallocation, should be transparent and explicit in order to avoid allegations of injustice or capriciousness. Histori- cally, however, Americans have been reluctant to have explicit discussions of “rationing,” particularly in health care (Beauchamp & Childress). Health care rationing typically occurs case by case, based on the judgment of the treating physician; this type of rationing is also called microallocation. 8.2 Procedural Justice in Resource Allocation Decisions W hile there is a clear moral obligation for the leaders of health care organizations to meet the health care needs of patients and communities, this moral duty cannot, in many instances, be met perfectly. It is often impossible to meet all of a population’s genu - ine health needs, because resources are too scarce or too expensive. The moral question then becomes “How can we meet the health care needs of our patients and communities fairly and justly when we cannot meet them all?” (Daniels, 2008, p. 13).

Chapter 1 explained that for the justice principle’s requirements to be met, any formal procedures or mechanisms by which a person attempts to resolve dilemmas must themselves be fair and equita - ble. Thus, health care administrators have a duty to craft resource allocation policies and procedures that maximize the chances of fair and equitable treatment. It is important to note, however, that nei - ther procedural nor distributive justice necessarily means that everyone must be treated the same.

Modern conceptions of justice (based on Aristotle’s definition) require people in similar situations to be treated similarly and people in different situations to be treated differently. This means 166 CHAPTER 8 Section 8.2 Procedural Justice in Resource Allocation Decisions inequality is sometimes the fair and just outcome of ethical resource allocation. For example, the egalitarian moral philosopher John Rawls (1971) argued that it would be fair to construct a system that unequally distributes goods, but only if by doing so the least well-off (the poor, for example) would benefit disproportionately.

Another reason just processes are fundamental to health care rationing is that those who make such rules and impose them on others are held accountable by their community and patient pop- ulation. Next, we will examine methods for establishing fair processes and determining who holds the moral authority. Stop and Clarify: Triage In clinical settings, the term triage refers to “a process of developing and using criteria for prioritiza- tion” (Beauchamp & Childress, 2009, p. 279). Medical triage weighs clinical considerations, in contrast with rationing, which addresses social issues. For example, hospital emergency departments do not treat patients on a first-come, first-served basis, but rather give priority to those in greatest need of immediate care. Another example of triage occurs in battlefield medicine, where resources are tradi - tionally focused on those who are likely to survive if they receive timely care, rather than those with the most serious wounds (Beauchamp & Childress, 2009). Crafting Fair Processes The really difficult health care resource allocation decisions arise when we can meet one person’s health care needs only if we do not meet the needs of another person (Daniels, 2008). Some will argue that health care resource rationing decisions are best left to the expertise of health care practitioners, policy experts, and economists. Questions of medical necessity, futility, and cost- benefit analysis are empirical and the province of experts. However, while enlisting health experts is necessary for a just and equitable resource allocation policy, it may not be sufficient. Relying solely on health care professionals can lead to the development of rules that are unresponsive to the needs and values of communities that will be most directly affected.

For these reasons, many commenta- tors have agreed that any health care– rationing scheme will need to earn its moral legitimacy from a democratic and deliberative process in which those affected by the limiting rules will have their voices heard along with the experts.

Four approaches to resource alloca- tion are presented in the following text:

allocation by expert panels, community consensus, lottery, and court order. This list does not exhaust all the possibilities, but it illustrates the wide variation in approaches to procedural justice found in contemporary U.S. health care. Blend Images/SuperStock Procedures must be in place to ensure the most ethical distribution of limited health care resources. 167 CHAPTER 8 Section 8.2 Procedural Justice in Resource Allocation Decisions Case Studies in Resource Allocation A. Allocation by expert panels versus community consensus Allocation by expert panels In the 1980s Oregon was among the many states where tax revenue lagged behind expenses. Increas- ing numbers of Oregonians sought the health coverage provided by the state through its Medicaid program, and there was a growing public debate about how to make the best use of limited state resources for health care (Crawshaw, Garland, Hines, & Lobitz, 1985). As in most states, Medicaid was the second most expensive line item in Oregon’s state budget (Zoloth, 1999). In early 1987, faced with a large budget shortfall, Oregon’s state legislature chose to reduce or eliminate coverage for services that, in the findings of an expert panel, were either too costly for the amount of benefit received or had very little benefit regardless of the cost.

One of the first benefits to be cut by the new plan was organ and tissue transplants. Coby Howard, the 7-year-old son of an unemployed Oregon woman, was receiving the standard treatment for his lymphocytic leukemia in 1987 when his illness worsened. The only treatment with any prospect of prolonging Coby’s life was a bone marrow transplant. Since Coby was enrolled in Medicaid, the new allocation policies meant that the transplant was no longer covered, and his family could not afford the $100,000 cost.

Media coverage brought the nation images of the adorable 7-year-old asking for money on a street corner to cover the operation, causing a public outcry against what was characterized as a callous bureaucratic policy. The media attention helped raise money for Coby’s bone marrow transplant, but contributions only amounted to $85,000 by the time Coby died (Zoloth, 1999).

Press reports of other Medicaid patients who were denied benefits raised more political rancor.

Although the state legislature attempted more expert and professionally led Medicaid reforms to address the furor that the Coby Howard case had stirred, there remained enormous public distrust for policy makers’ apparent “elitism, provider subjectivity, and political exclusion,” and their “closed door decision-making” (Zoloth, 1999, p. 34).

Allocation by community consensus Oregon’s legislature decided to pay more attention to grassroots public discourse in order to articulate Oregonians’ health care values and benefit priorities. The resulting democratic deliberation articu- lated principles for resource allocation (Oberlander, Marmot, & Jacobs, 2001).

Purpose Of Health Services:

1. The responsibility of government in providing health care resources is to improve the overall quality of life of people by acting within the limits of available financial and other resources. 2. Overall quality of life is a result of many factors, health being only one of these. Others include economic, political, cultural, environmental, aesthetic, and spiritual aspects of a person’s existence. 3. Health-related quality of life includes physical, mental, social, cognitive, and self-care func- tions, as well as a perception of pain and sense of well-being. 4. Allocations for health care have a claim on government resources only to the extent that no alternative use of these resources would produce a greater increase in the overall quality of life of people.(continued) 168 CHAPTER 8 Section 8.2 Procedural Justice in Resource Allocation Decisions Case Studies in Resource Allocation (continued) 5. Health care activities should be undertaken to increase the length of life, the health-related quality of life, or both, during a lifespan. 6. Quality of life should be one of the ethical standards when allocating health care resources involving insurance or government funds. Why Priorities Need to be Set 7. Every person is entitled to receive adequate health care. 8. It is necessary to set priorities in health care, so long as health care demands and needs exceed society’s capacity, or willingness, to pay for them. Thus, an “adequate” level of care may be something less than “optimal” care. How to Set Health Priorities 9. Setting priorities and allocating resources in health care should be done explicitly and openly, taking careful account of the values of a broad spectrum of the Oregon populace.

Value judgments should be obtained in such a way that the needs and concerns of minority populations are not undervalued. 10. Both efficiency and equity should be considered in allocating health care resources. Effi- ciency means that the greatest amount of appropriate and effective health benefits for the greatest amount of persons are provided with a given amount of money. Equity means that all persons have an equal opportunity to receive available health services. 11. Allocation of health resources should be based, in part, on a scale of public attitudes that quantifies the tradeoff between length of life and quality of life. 12. In general, a high priority for health care activity is one where the personal and social health benefits:costs ratio is high. 13. The values of the general public should guide planning decisions that affect the allocation of health care resources. As a rule, choices among available alternative treatments should be made by the patient, in consultation with health care providers. 14. Planning or policy decisions in health care should rest on value judgments made by the gen- eral public and those who represent the public and on factual judgments made by appropri- ate experts. 15. Private decision makers, including third-party payers and health care providers, have a responsibility to oversee the allocation of health care resources to assure their use is con - sistent with the values of the general public.

After broad discussions that included detailed cost-benefit analyses, a final list prioritizing Medicaid benefits was given to the Oregon legislature in 1991. The democratically derived list included 709 dif - ferent health care benefits ranked in order of perceived value. The process after that was relatively simple: Starting with number one on the list, the projected cost of each benefit was deducted from the state’s Medicaid budget until funding ran out. The first 567 priorities on the citizens’ list became the new Oregon Medicaid benefit package, and the cut-off point in the list of services was adjusted to fit the Medicaid budget in each budget cycle (Oberlander et al., 2001). This unusual combination of community consensus and technical expertise stabilized the political environment for Oregon’s health system but did not achieve cost savings and proved difficult to enforce.

(continued) 169 CHAPTER 8 Section 8.2 Procedural Justice in Resource Allocation Decisions Case Studies in Resource Allocation (continued) Discussion Questions 1. What lessons does the Oregon Medicaid benefit struggle of the 1980s and 1990s provide health care organization leaders today? 2. What ethical protections are provided by a public, transparent, deliberative process for health policy making? 3. On a spectrum between strictly utilitarian cost-benefit analyses on the one hand and popu- lation surveys of what people value and desire on the other, where do you think health administrators should make policy? B. Two other approaches: Allocation by lottery and by court order Allocation by lottery Oregon continues to be an exception among U.S. states in its willingness to make health care allocation decisions explicit. In 2008 funds became available to make Medicaid coverage available to an additional 10,000 Oregonians, but 90,000 were potentially eligible, so the state again faced a wrenching deci - sion (Baicker et al., 2013). The Oregon Health Authority decided to make Medicaid coverage available through a random drawing that determined who was eligible. The resulting natural experiment has garnered great interest in the health policy community (Baicker et al., 2013), but the extent to which Oregonians feel that it represents a fair approach to the allocation of scarce resources is far from clear.

Allocation by court order A recent example of an allocation mechanism comes from the 2013 case of Sarah Murnaghan, a 10-year-old cystic fibrosis patient awaiting a lung transplant. At the time of her initial eligibility for the list of prospective transplant patients, the national organization responsible for transplant policy did not make children younger than 12 eligible for the much larger pool of potential transplants available to adults (Goodnough, 2013). Her family, along with that of an 11-year-old cystic fibrosis patient, brought suit against the Department of Health and Human Services and were successful: On June 10, 2013, a federal judge ordered that the two children be placed on the adult waiting list (Ladin & Hanto, 2013).

The national policy-making organization then voted to allow expert review of children under 12 who were waiting for lung transplants to determine whether they might be eligible for the adult waiting list. While clinical specialists voiced concern that nonmedical intervention was dictating policy, the expert review found Sarah to be a candidate for the adult waiting list, and she received a double lung transplant (Ladin & Hanto, 2013).

Discussion Questions 1. What ethical principles support the use of a lottery to determine access to scarce health care resources? What principles would argue against using a lottery? 2. How would you evaluate the use of a court opinion to determine health care resource allo- cation? When do you think it would be appropriate?

Utilitarian, economic analysis Democratic, va lue pre fere nces 170 CHAPTER 8 Section 8.3 Distributive Justice in Resource Allocation Decisions 8.3 Distributive Justice in Resource Allocation Decisions T he processes for developing resource allocation policies must carry moral authority, but the policies themselves are also assessed to determine whether they follow the ethical princi- ples of distributive justice. The concept behind distributive justice is that individuals receive the appropriate type and quantity of goods and benefits (Beauchamp & Childress, 2009; Rawls, 1971). This topic is among the most controversial in U.S. policy and politics because of the conflict between principles of free market capitalism and social justice. In the 2012 presidential campaign, for example, candidates disagreed openly on whether more affluent Americans should provide financial support for fellow citizens in need (Leonhardt, 2010).

Beauchamp and Childress (2009) list six principles that could serve as guidance for meeting the criteria of distributive justice:

1. To each person an equal share; 2. To each person according to need; 3. To each person according to effort; 4. To each person according to contribution; 5. To each person according to merit; 6. To each person according to free-market exchanges. (p. 243) While these principles seem radically incompatible, we can find examples of each in relevant sec- tors. Social welfare benefits are distributed on the basis of need, employment options on the basis of merit, and public education on an equal basis, while many medical goods are exchanged in the free market, hourly wage employees are rewarded for effort, and many retirement benefits reflect employee contributions. Setting Limits To allocate health care resources in keeping with ethical principles of distributive justice, health care leaders must acknowledge the need to set limits. The combination of high cost and escalat - ing demand means that neither government-funded programs nor employer-sponsored health care benefits can extend to every possible treatment. Americans often resist acknowledging these facts for reasons that include concern that they will be denied essential, lifesaving care.

In countries with strong traditions of social solidarity and universal health care coverage, a reason- able level of consensus mitigates the concern that one person will be denied care that another person would receive; for example, because he or she can afford it. In the United States, there is no assurance that if one person agrees to do without a health care service, the savings will accrue to the benefit of someone in greater need. The savings is, in fact, likely to benefit the owners or executives of the health plan, particularly in the case of publicly traded companies. 171 CHAPTER 8 Section 8.3 Distributive Justice in Resource Allocation Decisions Determining Medical Futility The need to set limits in health care is not just a function of the practical need to choose who will receive access to resources when demand exceeds supply. Limit setting is also complicated by a fundamental tension between two competing ethical values in medicine: “1) the desire to achieve a valuable end, and 2) the desire not to waste time or resources trying to accomplish something that cannot be accomplished” (Trotter, 2007, p. 8). These two values clash in cases of what is sometimes termed “medical futility,” a term that, as Beauchamp and Childress (2009) note, has been used in such vary- ing circumstances as to become nearly meaningless. They suggest instead the term “clinically nonbeneficial treatment” (Beauchamp & Childress, 2009, p. 167), but even that term implies a determi - nation of clinical benefit that may not be clear if the treatment has not been administered.

Some of the most widely discussed ethi - cal and legal cases in health care have revolved around medical futility, partic- ularly how to interpret its basic concept:

“These debates generally hinge on one or both of the following: 1) parties in the debate disagree about the goal or goals that should serve as a standard for deter - minations of futility; or 2) parties in the debate disagree about what counts as ‘virtual certainty’ that an action will fail to achieve a goal” (Trotter, 1999, p. 528). Orienting the practice of health care leadership to the goals of medicine can help to clarify and resolve practical, ethical issues.

Determining the Legitimacy of Treatment Goals Difficult questions regarding the futility of a clinical intervention may be clarified with a consen - sus regarding the legitimate goals of medicine. For example, a treatment goal that is not aligned with the objectives of health care may be illegitimate. Medical futility cases can garner extensive media coverage and give rise to heated political debate, as in the case of Terri Schiavo. Whether to continue or cease Schiavo’s artificial nutrition and hydration following the determination that she was in a persistent vegetative state raised issues regarding principles such as reverence for life, the credibility of medical diagnosis, and patients’ wishes regarding life-prolonging treatment (Veatch, 2005). Creatas/Jupiterimages/Getty/Thinkstock Setting limits in health care is important to prevent care from extending past the point of effectiveness and to prevent unnecessary testing and procedures. 172 CHAPTER 8 Section 8.3 Distributive Justice in Resource Allocation Decisions Conflicts about medical futility may also arise in banal cases; for example, those in which a patient is seeking an excuse for a day away from work or a clinician performs an unnecessary diagnostic procedure to help defray the cost of the diagnostic equipment. Apart from the question of futility, some care that is inconsistent with the ethical goals of medical practice can have grave conse- quences. Several instances of repeated unnecessary heart surgeries, for example, have come to light in recent years, imposing not only illegitimate costs but serious risk of health consequences on the surgeons’ unfortunate patients (Abelson & Cresswell, 2012). Other famous cases of health care interventions at odds with the legitimate goals of medicine include the notorious Tuske- gee syphilis study, the U.S. experiments on Guatemalans (McNeil, 2010), and the universally con- demned actions of Nazi doctors during World War II (Beauchamp & Childress, 2009).

Measuring the Likelihood of Treatment Success In other instances, disagreement over a proposed treatment’s medical futility is not related to the legitimacy of the goal; rather, the disagreement centers on how to measure virtual certainty that the treatment will fail to achieve its (medically appropriate) goal. If a proposed treatment has a 50% chance of working, should it be implemented? In such a case many people would feel uncertain about taking the action and would want to know more about the proposed treatment.

What if the chances of a proposed treatment’s success were 1 in 100? Most would agree that a 99% probability of failure would more than adequately fulfill the certainty that an action will fail at achieving the intended goal criterion for medical futility. In such a case would ethics require that medical treatment be withheld? The sheer mathematical probability, while helpful in determining whether the medical intervention should be undertaken, will not conclusively determine medical futility. In fact, while a 99% risk of failure in attaining the goal may be determinative in some cases, in others it may be a risk a person is willing to take.

Other Factors Affecting Medical Futility In addition to statistical probability, two other factors help medical practitioners make ethically prudent decisions about medical futility. One is the value of the goal to be achieved. Some goals are demonstrably weightier than others. For example, while Coby Howard’s medical prospects were bleak whether or not he received the bone marrow transplant, this last chance for survival was widely viewed as medically necessary despite the low chances for its success. There may be instances, however, when a treatment such as Coby’s is set aside in favor of other important competing interests, including the health and lives of other patients who might benefit from treat - ments that Medicaid would be able to cover if it refused a low-chance transplant. Despite the priceless nature of potentially lifesaving treatment, other factors come into play when making difficult health care–rationing decisions.

A second factor relevant to decisions of medical futility is the cost, time, and resources necessary to undertake the action. While economics related to a proposed treatment should not determine whether the treatment is medically futile, neither should they be irrelevant. Resources dedicated to one intervention are not available for another, so the effect is the same whether the choice is financial or categorical (Beauchamp & Childress, 2009). 173 CHAPTER 8 Ethics in Focus: Medical Futility According to Griffin Trotter, a physician and ethicist, treatment is medically futile whenever there is certainty that it will fail to achieve its goal for the patient. The conditions necessary for there to be medical futility are listed below: 1. There is a goal; 2. There is an action or activity aimed at achieving this goal; and 3. There is virtual certainty that the action will fail.

Although the definition of medical futility is straightforward, many of the most vehement debates in medical ethics revolve around the interpretations of this concept. This is for at least two reasons according to Trotter. First, there is a disagreement about what the goal or goals should be for certain controversial treatments. For example, some will argue that prolonging the life of someone in a per - manent coma is not one of the legitimate goals of medicine, and perhaps even morally and profes- sionally wrong. For others however, this is seen as perfectly within the legitimate ends of medical practice, and perhaps even the correct moral and professional action to take.

The second disagreement is about what counts as “virtual certainty” for purposes of determining futility. For example, those who tend to have a “glass is half full” outlook will always choose the 1% chance for success, and therefore there is no “virtual certainty” that treatment will fail. Meanwhile, for people who have a “glass is half empty” outlook, a 99% probability of failure is considered “virtu - ally certain” and thus is determined to be a futile undertaking. 8.4 Chapter Highlights This chapter dealt with the often difficult and sometimes tragic decisions that must be made in health care administration due to limited resources for which demand exceeds supply. Policy makers have been heavily criticized for making rationing decisions behind closed doors without accountability. Policies and decisions made without the input of the population they are intended to serve run the risk of being unresponsive to the needs of the people and therefore illegitimate. • How can health care administrators and policy makers enhance the contribution of democratic, deliberative processes for ethically defensible health care rationing? • How can health care leaders make ethically defensible resource allocation decisions while observing their moral obligations to patients, their organizations, and their communities? • How do procedural justice, distributive justice, and priority setting help answer the fun- damental question of moral stewardship in resource allocation? • How can limits be set for the use of scarce resources in medicine, particularly with regard to the thorny issue of medical futility?

The concepts presented in this chapter provide the necessary context for the extended discus - sion of justice in Chapter 9, “Health Disparities and Social Justice.” Section 8.4 Chapter Highlights 174 CHAPTER 8 Section 8.4 Chapter Highlights Case Study: Resource Allocation in an Influenza Outbreak Reports of influenza outbreaks in Asia have been increasing for the past 6 weeks. It is now late Decem- ber. Influenza outbreaks have been reported throughout the United States, including states near yours. Anytown, where you are a health system manager, is seeing what may be the early effects of an outbreak. For the purposes of this case study, we will assume there are two types of drugs that are effective in treating or preventing influenza: vaccines, which provide immunity in most cases but must be administered before the individual is exposed to the disease, and antivirals, which reduce the severity and duration of flu symptoms when given to sick patients.

Your health system is reporting increases in emergency and physician office visits for symptoms con - sistent with influenza. School and business absences begin to rise. Health care, law enforcement, and other emergency personnel are calling in sick. Health system staff members with duties in critical areas such as information technology, direct patient care, and the clinical laboratory are asking for time off to care for ill family members.

The threat of an epidemic could not come at a worse time for your health system. State appropriations have been cut in response to a 2-year revenue shortfall, and a growing immigrant population is plac - ing new demands on your primary care clinic. Medicaid managed care organizations have approached you yet again with the threat of reducing your clinic reimbursement rates.

In response to media accounts of illness, there is a sharp increase in local demand for vaccine, but it will not be available for at least another month. Even then, the vaccine distribution protocol indicates that it will be given first to priority groups until enough is available for the entire population. Several of your colleagues have expressed concern about being sued by those who are denied immediate access to vaccines. Local pharmacies have run out of antiviral medications, and stories are circulating that physicians have been prescribing antiviral medications more broadly. Anytown has received a small allocation of antivirals from a Centers for Disease Control and Prevention stockpile distributed by the state Department for Public Health, and public concern over the way in which the antiviral medica- tions will be used is increasing. (Based in part on California Department of Health Services, Pandemic Influenza and Public Health Law Training , version 1.2 [June 26, 2006].) How would you use ethical principles to identify issues that you as a health system manager must address? For example: 1. How would you respond to someone who thought the only fair way to allocate antiviral medications was to give them out to the people who requested them on a first-come, first- served basis? 2. Of the four ways of allocating medical resources that are discussed in this chapter (expert, consensus, lottery, and judicial), which do you think is best suited to the type of emergency described in the case study, and why? 3. What ethical principles would support a decision to share all available information with the media as soon as possible? What principles would suggest withholding some information, at least in the short term? 4. Think of another kind of emergency where the supply of resources is greater than the demand, such as a natural disaster. What do you know about how those resources are allo - cated and who is making the relevant decisions? 175 CHAPTER 8 Section 8.4 Chapter Highlights Critical Thinking and Discussion Questions 1. The Affordable Care Act and the increase in Medicare enrollment caused by the aging baby boom generation are likely to increase demand for health care resources substan- tially in the near future. What procedures for policy making would you recommend to develop rules for access to health care? Does one of the four examples in this chapter (expert panels, community consensus, lottery, or court order) appear to be a good fit, or would you suggest something else? Defend your choice of policy-making procedure. 2. Having selected a procedure for policy making, what factors would you recommend taking into consideration to make decisions that are consistent with distributive justice?

Should these factors be articulated explicitly to the public so people know what level of access to expect? Should they be shared only with health care providers so they can apply and discuss them with individual patients? Is there another option that balances the interests of the public with those of individual patients? 3. How would you weigh the following factors when ethically deciding how to fund a type of treatment: (a) the cost benefit or cost effectiveness; (b) the actual cost of treatment (for example, a very effective treatment that is extremely expensive); (c) the likelihood that the treatment will succeed with most patients; (d) the likelihood it will succeed with a small group of patients; (e) the needs of patients who have experienced significant social or economic disadvantage; and (f) the political popularity of the treatment? 4. Your health system serves a community in which there is a high rate of diabetes among the low-income population. If you increase services for diabetes education, you will generate a net financial loss because such services are not reimbursed adequately.

What ethical factors would enter into your recommendation about increasing diabetes education? 5. Should Americans who have the resources to enroll in multiple organ transplant wait- ing lists (which means they can get to the site very quickly) be allowed to do so? Does it matter whether there is a shortage of suitable transplant candidates in a region? What ethical principles would you apply to this analysis? 6. The neurosurgery clinic that you manage has a long waiting list for nonurgent appoint - ments. The husband of your hospital’s CEO has been having back pain, and the CEO’s administrative assistant calls to ask whether you can schedule him to be seen the next morning. If you do so, the patients scheduled for the afternoon will all have to wait at least 30 minutes longer than they otherwise would. Recalling the basic ethical principles of health care, how would you handle this decision? 7. Back in the clinic that you manage, you discover there is a shortage of a critical medical item that is needed in nearly every neurosurgical procedure. Your patients represent a broad range of health conditions, races, ethnicities, educational and professional accom- plishments, lifestyles, immigration statuses, and criminal records. Describe and defend your preferred way of allocating the item that is in short supply, assuming that no law or institutional policy governs the matter. 176 CHAPTER 8 Key Terms macroallocation The processes performed and decisions made to determine how limited resources are distributed in large groups or populations. medical futility The near certainty that an action taken in pursuit of a goal will fail. Deter - minations of medical futility are often difficult because interpretations vary regarding the goals to be achieved, their relative value, what constitutes “virtual certainty,” and the trade- offs necessary. microallocation The processes performed and decisions made to determine how limited resources are distributed in individual cases or small groups. rationing Allocation of scarce resources; rationing is necessary and unavoidable when - ever the need or demand for any product or service outstrips the supply. triage A system that indicates which patients have priority for treatment. Priority setting varies depending on the type of health care setting and the circumstances (such as routine versus disaster). Section 8.4 Chapter Highlights