Chapter 10.

Scarce resources

Background Reading: Fleck, Just Health Care Rationing, Sections 1-4 only (optional: read the rest) and Brock, Ethical issues in the use of cost effectiveness analysis for the prioritization of health resources (can skip Sections 7-9)

The God Squad

For most of human history, the kidneys were an organ you couldn't live without.

Among the kidneys' most important roles is to filter out waste from the blood, sending the good blood back into your circulatory system, and sending the nasty waste off to your bladder to be removed from the body.

So, when one's kidneys become damaged, either through disease or injury, it's a major problem. Kidney failure will eventually lead to death.

A solution to this problem was invented in the 1940s by a dutch physician named Willem Kolff, who developed a machine known as a dialysis machine to function as an artificial kidney.

A dialysis machine is a simple idea. The patient's blood is pumped out into the machine and made to flow along that membrane. The red blood cells and other good parts of the patient's blood remain on one side, while the bad stuff pass through the membrane to the other side where it is retained in a fluid that can be safely removed. The clean blood is then pumped back into the patients body.

Today, dialysis machines are relatively inexpensive. But in the beginning they were extremely rare compared to the number of patients that needed them to survive. So, difficult decisions had to be made to decide who gets the treatment.

At the Artificial Kidney Center in Seattle in the 1960' s, a committee was appointed to make the decisions. Because this committee was charged with determining life or death, they came to be known as the God squad.

The committee was not only doctors, but was required to consist of the following types of people.

As dialysis become cheaper and less necessary to ration, this committee was eventually disbanded, but not before making a number of controversial decisions, which tended to disfavor people who were poor, unemployed, of non-white racial descent, divorced, or homosexual.

Although the committee is gone now, the question remains: how do we allocate scarce resources?

The Bowels of Michael S.

A modern example of the problem arose in the example of the baby Michael S.

Michael was born prematurely to poor teenage parents in the United States, neither of whom had health insurance. Since they could not pay for their health care themselves, the cost of Michael's birth was covered by the hospital.

The case become complicated when Michael developed necrotizing enterocolitis or small bowel syndrome, a major infection of the small intestinal which leads to inflammation and eventually segments of intestinal tissue dying off.

After six month of treatment the physician pointed out that the treatment of Michael S. had cost the hospital $250,000 USD (£150,000). He could be expected to live another 6-18 months, which would cost the hospital as much as $1 million USD (£600,000).

Since the funding for Michael was part of the hospital's treatment of the poor fund, this fund would thus soon be depleted and, according to hospital policy, the hospital would have to close its doors to all other poor patients who could not afford care.

So, the hospital had to choose: either provide care for Michael S. for the short remainder of his life, or provide care for dozens of other underprivileged patients, but not both.

The Cost-Effective Analysis

What is the appropriate way to allocate resources in hard cases such as early dialysis, and the treatment of Michael S? One popular answer is known as cost-effective analysis.

There are two steps to this analysis: determining benefits, and maximizing efficiency, meaning that resources are allocated so as to provide the greatest amount of benefit given the available costs.

Determining benefits can be done through a variety of means. But in practice, it is often done using an adjusted life-years metric. The idea here is to assign a number of years of life to a patient given certain treatments, which is scaled up or down depending on whether or not certain quality of life standards are met.

One commonly used metric of this kind is the Health Utilities Index Mark 2; have a look to see the kinds of standards that are used to assign greater or lesser utility to treating a given patient.

But notice one particular consequence of this standard: if you could only save one of two patients, and the two patients would lead very similar kinds of lives after the life-saving treatment except that one patient ended up blind, then the metric chooses to save the not-blind patient.

Once the benefits have been set, cost-effective analysis just kicks in and calculate what allocation of resources will produce the maximum amount of benefit. Such methods feel safe in that they follow a simple rule, and do not require one to agonize over the particular ethical implications of treating or not treating a given patient.

It is often controversially referred to as objective in its approach to the allocation of scarce resources.

Problems with the Approach

Is this the correct way to allocate resources? Dan Brock argues that it is not, pointing to several difficulties with the approach. You will find his entire list of nine concerns in the Brock background reading. But here are a few highlights to consider.

One problem is that the benefit metric is very controversial. Different individuals and communities might disagree wildly on what they find to be more or less valuable about a year of life. For example, it the deaf community would surely be unimpressed by a criterion a year being deaf as a lower-quality year of life.

After all, one might reasonably think that ethicists working at Health Utilities, Inc., who created the Health Utilities Index mentioned above above, has no special claim on what's valuable about life as compared to any of the rest of us.

A second concern is that a year of life at different ages may be different. This metric treats a year of life with normal abilities to be of equal benefit at any age. But someone might think that there is much greater value to a year of life in your twenties than, say, a year of life between age 1 and 3.

A third concern is that it is not obvious which benefits should be counted when it comes to actually calculating the treatment that maximizes benefit. For example, if one were interested in economic benefit, then there might be more incentive to treat a working individual than a retired one, since the working individual will still have a positive economic impact on society.

How to move forward?

Advocates of cost-benefit analysis often argue that this approach allows one to think of the allocation of scarce resources as an economic, managerial, organization, of technological problem. That is, it aims to remove the moral aspect of these questions, in favor of a question whose answer can be calculated.

Tempting though this solution is, there is a sense in which it is an illusion. As we have seen above, there are a number of moral assumptions built into the analysis. This why Leonard Fleck argues that the problem of health care rationing is fundamentally a moral/political problem rather than an economic/managerial one.

Who bears the responsibility of making such moral decisions? According to Fleck, the responsibility is born by society as a whole, and should be decided democratically.

One of the primary difficulties with the God squad was the composition of the committee. Power over life or death was given to a chosen few on the God squad, instead of sharing the responsibility democratically.

An effect of Fleck's proposal is that democratic decisions about allocating resources will often be in disagreement with the preferences of many individuals. This, Fleck suggests, is just a part of democracy that we have already committed to in adopting a democratic government.

What you should know

Practice Questions