Modular Learning Outcomes

Upon successful completion of this module, the student will be able to satisfy the following outcomes:

· Case

· Discuss the ethical issues related to healthcare rationing and organ transplantation.

· Identify and discuss the origins of organ procurement organizations (OPOs).

· Discuss the early beginnings of transplantation and lessons learned.

· SLP

· Examine and resolve ethical dilemmas related to resource allocation.

· Discuss the theory of relational ethics as it relates to resource allocation.

· Discussion

· Discuss ethical dimensions of resource allocation and rationing in healthcare. What ethical guidelines should influence resource allocation in healthcare?

Module Overview

Rationing

According to Chris Hackler, in health care, we see rationing in one of three practices:

· Limit the amount money spent on health care is an example of the allocation of financial resources;

· Distribution of scarce organs for transplantation is an example of the distribution of scarce goods; and

· The practice of triage in the emergency room is an example of prioritizing services.

Managed Care and Rationing

While the managed care concept has been around since the early 1900s, it wasn’t until the Nixon administration that we saw the birth of the HMO and proliferation of “managed care.” As you are well aware, Managed Care is a financing philosophy that emphasizes the cost effective delivery of health care.

This approach to health care delivery has raised a number of ethical questions, one of which is whether managed care organizations (MCO) ration health care services due to the costs of such care, and the obligation and desire to be profitable.

This approach has placed providers in the unenviable position of gatekeepers. Providers are required to consider the costs of health care services being recommended; specially, in Health Maintenance Organizations where the providers receive annual bonuses based on the savings they created during the year by not referring patients to specialists and/or specialty care. The effect of these bonus arrangements has been obvious. There is a built in incentive to under-treat or limit care. Also, the providers have been prevented from acting as advocates for their patients; instead, they are agents for the MCOs.

Organ Transplantation

According to the United Network of Organ Sharing ( UNOS ), every 14 minutes a new name is added to the transplant waiting list. Although the number of issues are great, the number one issue related to organ transplantation is the shortage of organ donors. The implications become clear when one recognizes that there simply are insufficient number of donors and organs to effectively treat those in need.

In America, organ donations are made through a volunteer system. While pre-mortem donation is legally accepted in the United States, family members of a potential donor are always asked for permission before organs are removed.

In many countries, “presumed consent” is the accepted practice. With presumed consent, physicians and hospitals remove and transplant needed organs unless the decedent has expressly objected prior to his death.

As technology advances and medicine obtains better results from certain transplant procedures, ethical issues arise in the context of transplantation for patients with histories of drug or alcohol abuse. For example, should a recovering alcoholic receive a liver transplant? Should a smoker receive a lung transplant? Should an obese patient receive a heart transplant? Take a look at the assigned readings and let see if we can answer some of the questions raised.

Please click on this link for a news report regarding a Dutch reality program involving a kidney donation:  http://www.usatoday.com/life/television/2007-06-01-kidneys_N.htm

PSDA – The Patient Self Determination Act of 1991 requires health care organizations receiving federal money (Medicare or Medicaid) to inform their in-patients, in writing, about their rights to make health care decisions including the right to accept or refuse proposed treatment and the right to complete state permitted “advance directives.”

As medical technology advances and improves, and patients gain a better understanding of their rights, patients and families have and continue to insist on receiving life-sustaining treatment that may be considered as “futile” by health care professionals.

FUTILITY – According to Charles Weijer (Medical Futility, 1999) the term medical futility was coined in 1990 as a response to demands by patients and families for treatment thought to be inappropriate. Medical Futility is a professional judgment that takes precedence over the patient’s self-determination and autonomous rights.

Some define “medical futility” as a medical determination that a therapy or treatment is of no value to a patient and consequently should not be prescribed or provided.

It has been argued that treatments that merely preserve permanent unconsciousness or that cannot end dependence on intensive medical care should be considered as futile. (L. J. Schneiderman, “Medical Futility: Its meaning and Ethical Implications”, 1990)

Some health care providers view “futility” as legal practitioners and scholars view pornography: They may not be able to define it but they know it when they see it. Jacobellis v. State of Ohio (1964)

Cardio-Pulmonary Resuscitation and Do Not Resuscitate

We see futility raised in cases involving Cardio-Pulmonary Resuscitation and Do Not Resuscitate orders. CPR was originally intended for use in cases involving reversible cardiac arrests. The current practice appears to be the use of CPR in all cases unless there is a contrary order. DNR was intended to avoid aggressive attempts to revive patients where death was anticipated and inevitable. Patients and families; however, have demanded that CPR be performed at all times, even when health care providers believe it to be futile.

Research of the PSDA will lead to the conclusion that Cardiopulmonary resuscitation and emergency cardiac care are meant to reverse premature death. They should restore the process of living, not prolong the process of dying. When people reach the end of life, continued resuscitative efforts are inappropriate, futile, undignified and demeaning to both the patient and the rescuers.

Persistent Vegetative State (PVS)

The question of futility is also raised in cases involving patients in a persistent vegetative state (PVS). These patients receive treatment that is effective, but does nothing more than “maintain” a patient in PVS. As mentioned in module one, bioethics was placed on the map with the Karen Ann Quinlan case, where the parents of a young woman in a drug induced coma sought termination of life-support treatment. The Quinlan case initiated discussions about when to stop treatment.

What if the patient or family members have unrealistic expectations and demands with respect to treatment? Where patient and family cultural and religious beliefs demand continued or discontinued treatment, the physician’s ethical obligations are clearly invoked.

Module 4 – Background