Resource Allocation

Curricular Objectives

1. To be able to discuss resource allocation, and justice.
2. To recognize morally relevant criteria for resource allocation.
3. To recognize legally proscribed criteria for resource allocation.

Summary of Cases

1. Chris C, a 21 year old computer programmer with cystic fibrosis, has been listed as a candidate for retransplantation. Chronic rejection and poorly controlled fungal infections are destroying the double lung transplant he received 15 months ago. He has intermittently required positive pressure ventilation to maintain adequate oxygenation during flareups of infection or rejection. The presence of infection and the risks associated with repeat transplants predict a survival rate of 65% at one month, and 38% at twenty-four months. Mrs. J, a 42 year old schoolteacher and mother of three children, has been listed as a candidate for double lung transplantation because of rapidly progressing pulmonary hypertension associated with hemoptysis and hypoxemia. She is unable to manage at home because of decompensated right heart failure unresponsive to maximal therapy. As a first time lung transplant candidate who is free of infection, her predicted survival probability at one month is 82%, and 62% at two years.
   Dr. K has ONE donor for THESE TWO patients. He knows that the best result can be achieved by transplanting both lungs of the donor into one of his patients.
   (Case I adapted from "Bioethics for clinicians: 13. Resource allocation".)
2. Dr. M is told that there are no open beds in the intensive care unit when 63 year old Mr. W is brought to the emergency room with severe but potentially reversible brain injury following a motor vehicle accident. Dr. M considers going through the charts of each patient in the ICU, to find the one whose need for intensive care might be less than that of Mr. W. She also considers sending Mr. W to the floor, but knows that this will overtax the capabilities of the floor staff, who are not prepared to manage his elevated intracranial pressure and seizures. Because of recent hospital closures in the region, no other facility is available to share responsibility for the care of patients with neurosurgical problems of this magnitude.

Lesson Plan

The first 10 minutes should be spent reviewing one of the cases, or another case that is pertinent for the residents, such as rationing of prostheses on an orthopedic service, or waiting lists for surgery. The remaining time is spent in a facilitated discussion.

Answer:
Resource allocation is the distribution of goods and services to programs and people competing for them. Macroallocations of resources are made at the level of countries, provinces, or cities, when they make allocations to education, civil defence, and health care, or to different programs within the health care envelope. Mesoallocations are made at the level of institutions; hospitals, for example, allocate their resources to programs such as cancer treatment, cardiology, or dialysis. Health care resources are microallocated at the level of individual patients.

Answer:
When patients' needs, and not simply their wants, cannot be met because of scarcity of resources, we are confronted with a problem of rationing. Rationing has long been a part of the daily responsibility of most caregivers. Nurses budget their allocation of time at the bedside for individual patients. When leaving, they mention the needs of other patients, and their willingness to return when significant need for additional allocations of their time and skill are required. Doctors leave morning hospital rounds to attend other waiting office patients. Sometimes inequality of need or benefit causes displacement in the natural queue of waiting patients, for example, when surgeons move emergency cases ahead of scheduled elective cases.

Answer:
Age, gender, or religion are not morally relevant criteria for allocation when there is a shortfall, for example when comparing two candidates for the only available organ transplant or intensive care bed. Discrimination on these grounds is also illegal. Greater benefit or greater need would be morally relevant arguments for ranking a patient ahead of one whose need is less urgent, or whose benefit would be less substantial or durable.

Answer:
Doctors are expected to give primary consideration to their duty to provide care for their patient. Financial considerations should be taken into account, but do not justify omission of appropriate care.

Answer:
The overall goal of clinicians is to provide optimal care within the limits imposed by the allocation of society's resources to the institution, program, and specific situation in which they treat patients. Strategies to achieve this goal include:

1. Choosing interventions known to be beneficial on the basis of evidence of effectiveness.
2. Minimizing the use of marginally beneficial tests, such as the diagnostic zebra-hunt.
3. Minimizing the use of marginally beneficial interventions, such as the latest generations of antimicrobials for common infections.
4. Seeking the least costly tests or treatments that will accomplish the diagnostic or therapeutic goal.
5. Using the natural queue, treating patients in order of appearance unless morally relevant considerations of need and benefit require modification of this approach.
6. Ranking patients with whom you have an established patient-doctor relationship ahead of unknown or future patients.
7. Supporting rather than opposing reasonable efforts to conserve health care resources.
8. Avoiding manipulation of the rules of the health care system to give unfair advantage to your own particular patients.
9. Resolving conflicting claims for scarce resources justly, on the basis of morally relevant criteria of need and benefit.
10. Employing fair and publicly defensible procedures for resolution of conflicting or competing claims.
11. Seeking resolution of unacceptable shortages at the level of hospital management (meso allocation) or through political action at the level of government (macro allocation).
12. Informing your patients of the impact of cost constraints on care in a humanistic way, as a matter of respect for persons. Embittered blaming of administrative or governmental systems during discussions with the patient at the point of treatment should be avoided.
13. Developing guidelines for individualization in the face of uncertainty in order to promote a reasonable balance between individual choice and systemic cost control.

Bioethics Bottom Line

RESOURCE ALLOCATION
Not all medical goods and services can be supplied to all patients who might want or need them at a time of their convenience. Ethically defensible, socially responsible policies are helpful in resolving resource allocation problems.

Resources are macro allocated by governments to support programs such as health care, education, civil defence and transportation. Morally relevant criteria of benefit and need and procedures mediated through elections, legislation and judicial processes and public disclosure of allocation decisions assure that ethically defensible and socially responsible allocations are made. Institutions meso allocate resources for intrainstitutional programs such as cardiology, oncology, surgery or obstetrics. Need and benefit are clarified by representatives of the medical departments and allocation decisions are overseen with public scrutiny through the board of trustees. Micro allocation is conducted at the level of individual patients treated at the bedside, clinic, or operating room.

Need and benefit are clarified and used by caregivers to determine access. Categories of need are most clearly spelled out in policies on priority of emergencies for surgical care. The process of allocation is less publicly reviewed at this level, but patients should be told when and why they are unable to get the care that they need in a timely way.

Morally unacceptable criteria for allocation of resources include age, gender, ethnic origin, religion, sexual preference or race. When resources are in short supply so that they are not available to all who might benefit from them or need them, there allocation is referred to as rationing. This is generally done on the basis of rational principles and should be guided by the morally relevant criteria of benefit and need. Coping strategies to eliminate or reduce rationing include:

1. Choosing interventions known to be beneficial on the basis of evidence of effectiveness.
2. Minimizing the use of marginally beneficial tests, such as the diagnostic zebra-hunt.
3. Minimizing the use of marginally beneficial interventions, such as the latest generations of antimicrobials for common infections.
4. Seeking the least costly tests or treatments that will accomplish the diagnostic or therapeutic goal.
5. Using the natural queue, treating patients in order of appearance unless morally relevant considerations of need and benefit require modification of this approach.
6. Ranking patients with whom you have an established patient-doctor relationship ahead of unknown or future patients.
7. Supporting rather than opposing reasonable efforts to conserve health care resources.
8. Avoiding manipulation of the rules of the health care system to give unfair advantage to your own particular patients.
9. Resolving conflicting claims for scarce resources justly, on the basis of morally relevant criteria of need and benefit.
10. Employing fair and publicly defensible procedures for resolution of conflicting or competing claims.
11. Seeking resolution of unacceptable shortages at the level of hospital management (meso allocation) or through political action at the level of government (macro allocation).
12. Informing your patients of the impact of cost constraints on care in a humanistic way, as a matter of respect for persons. Embittered blaming of administrative or governmental systems during discussions with the patient at the point of treatment should be avoided.
13. Developing guidelines for individualization in the face of uncertainty in order to promote a reasonable balance between individual choice and systemic cost control.

CLINICAL RATIONING

Rationing can be defined as the distribution of goods or services in a situation of resource scarcity where not all health care expected to be beneficial is provided to all patients who might need or want it. Prototypical situations of rationing in contemporary medicine might include: coronary artery bypass grafting, dialysis, intensive care, and access to solid organ transplant.

The appropriate ethical framework from which to approach rationing decisions is justice. Aristotle's formal Principle of Justice states that equals should be treated equally and unequals treated unequally. The principle requires clarification of the criteria of inequality or differences that can be used to guide allocation decisions. There are several sets of criteria for different contexts. (To each according to merit in a foot race, to each according to contribution in a joint business venture.) There is general agreement that the appropriate criteria for distributing health care services are NEED and BENEFIT. The criteria should be applied using transparently FAIR PROCEDURES.

For example, in the case of intensive care, justifiable criteria for rationing might include severity of illness (need) and prognosis for survival (benefit). The precise formulation of these criteria and their relative weighting might be determined by a committee including public representation (fair procedures). The intensive care unit admission criteria might then be communicated to the broader hospital community including potential patients (transparency).

The logical opposite of justice is discrimination. In rationing decisions, discrimination occurs when decision makers appeal to material principles that have been specifically prohibited by an appropriate authority such as national constitution or human rights law. Prototypical examples of criteria that are explicitly prohibited from use in rationing decisions include gender, race, national or ethnic origin, colour, religion, age, physical or mental disability, and sexual orientation.

Several observations regarding the application of the theories of justice to clinical rationing decisions are warranted. First, no one disputes that resources are scarce and rationing decisions are required. Second, it is unfair to ration based on implicit criteria that may vary from physician to physician. Third, rationing criteria must be explicit, evenly applied, publicly known, and open to review. Fourth, it is unfair to begin rationing by denying resources to the most vulnerable patients. Finally, an alternative to rationing is to augment the availability of the scarce resource.

References

Beauchamp TL, Childress JF. Justice. Principles of biomedical ethics. New York: Oxford University Press; 1994. p. 326 and ff.

McKneally MF, Dickens BM, Meslin E, Singer P. Bioethics for clinicians: 13. Resource allocation. CMAJ 1997; 157:163-7.

Further Reading

Daniels N. Just health care. New York: Cambridge University Press; 1985.

Morreim EH. Fiscal scarcity and the inevitability of bed side budget balancing. Arch Intern Med 1989; 149:1012-15.

Pellegrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press; 1993. p. 92 and ff.

Teaching Aid: Resource Allocation

The Cases Revisited
Mrs. J should receive the double lung. Although her need is approximately equal to that of Chris C, her ability to benefit is substantially greater. The surgeon knows from sound empirical evidence that repeat lung transplantation has a poor prognosis, particularly when chronic infection exists. He can minimize recriminations related to the team members' feelings of loyalty toward Chris C if the transplantation program policy clearly spells out specific and fair procedures to follow when difficult allocation decisions must be made involving similarly deserving patients.

The attending physician should provide reassurance and appropriate care for Mr. W in the emergency department, as this is the only facility available. If she chooses to discuss the role of cost constraints with the patient or his family, she should do so in a sensitive way that does not undermine their confidence that he will receive the care he needs. She should involve the administrator on call to bring in additional skilled personnel to provide interim care in the emergency department and to help her arrange for the patient's transfer to a facility prepared to care for him. In this way, she clarifies the responsibility of the hospital as a community institution to resolve the mesoallocation problem at an administrative level. The hospital may in turn address the macroallocation of resources at the provincial or regional level through its representatives to the government. The physician should not attempt to resolve problems of this magnitude on her own and should not compromise the care of Mr. W. She may choose to contribute to the resolution of similar problems in the longer term by making suggestions about system reform to the health ministry or helping with appeals for public support of additional facilities.

(McKneally MF, Dickens BM, Meslin E, Singer P. Bioethics for clinicians: 13. Resource allocation. CMAJ 1997;157:163-167.)

Research Ethics

Bioethics

Substitute Decision Making