Ethics of Resource Allocation and Human Rights Professionalism and Patient Safety 2017 Please look through the slides prior to the session and come prepared to ask questions or clarifications 2 Ethics Is the right course of action always obvious? Action or decision should withstand criticism; i.e., the reasoning process Aristotle – Character and Reasoning 10-Feb-17 © The University of Sheffield Decisions that 3 withstand criticism • Valid arguments – premises lead logically to the conclusion so if the premises are true, then the conclusion must be true. • Avoiding logical fallacy – a mistake in the logical relation between an argument’s conclusion and its premises; e.g., bifurcation – claiming that only two alternatives exist (Richard Cooper’s phase 1 Lecture on Philosophical bases….) 10-Feb-17 © The University of Sheffield 4 • Is Principlism alone adequate? • Consequentialism • Casuistry? – extracting theoretical rules from specific instances, interpretation of ethical principles or cases…. • Deontology • Virtue • Care Ethics 10-Feb-17 © The University of Sheffield 5 Breast cancer mum back in High Court for Herceptin battle Free IVF care 'denied to many' Secret NHS plan to ration patient care Cancer victim denied life-prolonging drugs on NHS is given hope with £10,000 anonymous donation 10-Feb-17 © The University of Sheffield Learning outcomes 6 • An understanding of • the key ethical theories of resource allocation • the challenges of ‘individual responsibility’ in distributive justice; and relevance of human rights to resource allocation • the factors that may form a part in the decision making models in distributive justice • And develop awareness of topical issues around resource allocation 10-Feb-17 © The University of Sheffield 7 Rationing needs have increased because.. • Shift from acute illness to chronic long- term • Normal physiological events medicalised • Increase in choice and increase in expensive drugs (This is not an exhaustive list) 10-Feb-17 © The University of Sheffield 8 • 2011/12 -2014/15, NHS spending will increase by only 0.4 per cent in real terms (House of Commons Health Committee, 2010). • On average, 1950 -2000 : 3.48 % per cent per year, rising to 6.56 % 1999/2000 -2010/11 (Appleby et al., 2009). http://www.kingsfund.org.uk/audio-video/john- appleby-nhs-productivity-challenge 10-Feb-17 © The University of Sheffield 9 What is Just(ice) healthcare? 10-Feb-17 © The University of Sheffield 10 Allocation theories based on • Egalitarian principles • Maximising principles • Libertarian principles 10-Feb-17 © The University of Sheffield 11 Egalitarian principles • NHS was founded on a requirement to provide all care that is necessary and appropriate to everyone (equal access)-Aristotelian equality/justice • Challenge: How to resolve the tensions between egalitarian aspirations and finite resources? (Rawlins and Dillon) 10-Feb-17 © The University of Sheffield 12 Maximizing principle • Criteria that maximize public utility • Who is best to decide this? Should doctors be involved in rationing decisions? 10-Feb-17 © The University of Sheffield 13 Libertarian approach • – each is responsible for their own health, well being and fulfilment of life plan. An Example èèèèè 10-Feb-17 © The University of Sheffield The German Health incentive 14 Schemes? (BMJ, v339,p725,2009) • Contributions are a percentage of income earned; so well off shoulder more burden • Incentives to change individual health behaviour. E.g., bonuses (cash, sports or kitchen eqpt, or reduction for insurance contributions) for participation in routine screening, health promotion and check-up programmes. • The pay out must come from the savings made by better10-Feb-17 © The health University of Sheffield behaviour. 15 • Incentives for early detection and treatment of chronic disease. • Compliance in prevention and treatment reduces co-payment by patient. • No claim benefits for reduction/responsible use of resources. • Carrot or stick? E.g., max co-payment for some cancers was increased from 1 to 2% non compliance. © The University of Sheffield 10-Feb-17 16 10-Feb-17 © The University of Sheffield 17 • The question of equity: Private programmes attract or retain higher income groups because they contribute more and cost less. • To what extent bonuses result in Change of behaviour? • Socio-Economic Status differences in incentive use? • Should doctors police health behaviour? 10-Feb-17 © The University of Sheffield 18 10-Feb-17 © The University of Sheffield 19 leading risk factors contributing to disease burden in high income countries (WHO, 2002) • Tobacco • 12.2 • Blood pressure • 10.9 • Alcohol • 9.2 • Cholesterol • 7.6 • Overweight • 7.4 • Low fruit and vegetable • 3.9 intake • 3.3 • Physical inactivity • 1.8 • Illicit Drugs • 0.8 • Unsafe sex • 0.7 10-Feb-17 © The University of Sheffield WHO 2002 20 In the UK in 2010 • 26% of both men and women aged 16 or over were classified as obese (BMI> 30kg/ m2). • 41% of respondents (aged 2+) said they made walks of >20 minutes at least 3 times a week • 20% of respondents reported that they took walks of at least 20 minutes “less than once a year or never” in GB. 10-Feb-17 © The University of Sheffield 21 In the UK in 2010 • Significant upward trend in household expenditure on eggs, butter, beverages, sugar and preserves. • Downward trend with fruit and vegetables 10-Feb-17 © The University of Sheffield What are the 22 arguments for and against? • Can individuals be held accountable (how and to what extent is debatable) for their current or future health? 10-Feb-17 © The University of Sheffield 23 • Obligation to help others in need regardless of why they are there in the first place provided that helping would not impose unacceptable sacrifices on others. A person who is unwell/poor health cannot exercise political and civil rights. 10-Feb-17 © The University of Sheffield 24 • Establishing causality between behaviour and the need for treatment is often uncertain/ impossible. • Justified inequalities (smokers) moralistic judgements (eating or exercise habits) • A person’s productivity is influenced by many factors over which the person has little control • Measuring the value of contribution 10-Feb-17 © The University of Sheffield Motivation for unhealthy 25 behaviour? • The costs of most unhealthy activities impact in the future, but the benefits from them occur in the present • The challenge of affluence to self control • Social networks – obesity (Christakis and Fowler, 2007). • Backward looking vs. forward looking 10-Feb-17 © The University of Sheffield 26 • The intrinsic value of every person’s life; and concern to this AND • Personal responsibility for the governance of our own life. 10-Feb-17 © The University of Sheffield 27 Sustainability in Resource Allocation The Hippocratic Canon offers the twin injunctions to do good and not to do harm. These ethics apply not only to individual patients, but to those systems that sustain human health, and not just to the current but to future generations. Sustainability also highlights prevailing tensions between freedom of action (autonomy) and the ethic of justice, as those most affected by harms to the global environment are those least responsible for causing them. The doctor will be able to recognise and articulate his or her own values and principles in relation to sustainability and, by upholding these values, to act with integrity.(13) …..From the Centre for Sustainable Healthcare 10-Feb-17 © The University of Sheffield 28 What is sustainable medical practice? Can you think of examples and challenges? The Brundtland Commission’s definition of a sustainable process is one that “meets the needs of the present without compromising the ability of future generations to meet their own needs.” Haines A, Dora C. How the low carbon economy can improve health. BMJ. 2012;344(mar19 1):e1018-e1018. doi:10.1136/bmj.e1018. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change. The Lancet. 2009;373(9676):1693-1733. doi:10.1016/ S0140-6736(09)60935-1. 10-Feb-17 © The University of Sheffield 29 The rule of rescue (Jonsen) • Can we fund expensive treatment to prolong life short term? • How does this marry with equal concern and self determination; does this maximise good with fairness? 10-Feb-17 © The University of Sheffield Eliminate choice 30 Restrict choice: regulate to restrict the options available to people Guide through disincentives: use disincentives to influence people to not pursue certain activities Guide choice through incentives: use financial and other incentives to guide people to pursue certain activities Guide choice through changing the default: make ‘healthier’ choices the default Enable choice: to change behaviours Inform and educate Do nothing /monitor 10-Feb-17 © The University of Sheffield 31 What are the current key resource allocation challenge in our healthcare system? Organ transplantation, expensive treatments to few leaving others without, lifestyle inflicted conditions….What else? 10-Feb-17 © The University of Sheffield 32 Cases you should know about and implications to practice • R (Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] • Montgomery v Lanarkshire Health Board (2015) 10-Feb-17 © The University of Sheffield 33 Human Rights in Medical Ethics 10-Feb-17 © The University of Sheffield 34 • Are Rights only about legality? • How about the value of moral rights? • Can a rights discourse help secure the best interests of dementia patients? 10-Feb-17 © The University of Sheffield Rights that are frequently 35 engaged in healthcare • Art 2 – the right to life (limited) • Art 3 – the right to be free from inhuman and degrading treatment (absolute) • Art 8 – the right to respect for privacy and family life. (qualified) • Article 12 – right to marry and found a family 10-Feb-17 © The University of Sheffield 36 R v Havering London Borough Council: R v Coventry City Council, 2008 • Medical evidence indicates that mortality rates amongst care home residents who were moved were higher than in those who were left in place.