PHIL 226, Week 3

Allocation Problems

Macro-allocation: How should a society divide up its resources to fund health care?

Micro-allocation: Within a health care system, what services should be provided?

Note: these two questions can be interconnected, because increasing services in micro-allocation may require increasing resources in macro-allocation.

Purposive vs. functional approaches (from ch. 3).

• Purposive: Define what health is, then deduce what should be covered.
• Functional: Look at the function of health in the broader society.

Needs

From Thagard, The Brain and the Meaning of Life, 2010.

Need:  Condition without which a person would be harmed.  

Vital need:   Something without which a person cannot function as a human being .

Competence:   Psychological need to engage optimal challenges and experience physical and social mastery.

Autonomy:  Psychological need to self-organize and regulate one’s own behavior and avoid control by others.    

Relatedness:  Psychological need for social attachments and feelings of security, belongingness, and intimacy with others. 

Self-determination theory argues for these psychological needs.

Macro-allocation

Issues:

1. How much of a society's resources should be spend on health care? Ontario
   • 2012-2013 estimates: 47.6 billion for health, 23.1billion for education, 7.4 billion for training (colleges and universities)
   • Source: http://www.fin.gov.on.ca/en/budget/estimates/2012-13/volume1/Table_1.html
   • Defict: $15 billion
2. What kind of health system should a country have? (See week 2)
3. How can the effectiveness and efficiency of a system be evaluated?
4. Should ethical decisions take into account future generations?

Rationing

What should be the basis for rationing health care?

1. Cost?
2. Effectiveness?
3. Quality adjusted live years? QALY
4. Moral worth?
5. Contribution to society?
6. Ability to pay?
7. Age?

Age

Option 1: Treat old people the same as anyone else.

Option 2: Restrict expensive medical treatments for old people.

Arguments for Option 2:

1. Old people have had a fair share of life.
2. It is more tragic if a young person dies.
3. Spending too much on old people has bad overall consequences.

Arguments for Option 1:

1. Old people have the same rights as anyone else.
2. There is no such thing as a fair share of life.

Micro-allocation

Should alcoholics get liver transplants?

Consequences: non-alcoholics will have better outcomes.

Rights: but don't alcoholics have the same rights to health care?

Principles: does equality require equal treatment of alcoholics?

Related issues:

• Should smokers get less treatment for lung cancer?
• Should obese people get less treatment for diabetes?

Resource allocation guidelines

1. Choose interventions known to be beneficial on the basis of evidence of effectiveness.

Current issue: should patients with multiple sclerosis be provided with liberation therapy?

2. Minimize marginally beneficial tests or interventions.

3. Seek low cost treatments and interventions.

4. Advocate for one's patients but don't manipulate the system.

5. Resolve claims for scarce resources fairly on the basis of need and benefit.

6. Sensitively inform patients of cost constraints.

7. Seek resolution of shortages.

Futility

Examples where medical intervention may be futile:

1. Persistent vegetative state.
2. CPR (cardiopulmonary resuscitation) versus DNR (do not resuscitate).
3. Organ replacement for dying patients.

Arguments against decisions based on futility:

1. It ignores the values of the people involved.
2. It is always a matter of probability.
3. It neglects difficult issues of resource allocation.

Discussion question:

Do you know any people who have been denied access to health care they wanted? Was the denial justified?

Human rights

Declarations

United Nations declaration of human rights

Canadian Charter of Rights and Freedoms

Positions

1. Skeptical: There are no human rights.

Pure consequentialism: Ethics is only concerned with consequences.

2. Minimal (Libertarian): The only human right is to not be harmed by others.

3. Basic (Brian Orend, Human Rights, 2002):

There are five foundational human rights: personal security, material subsistence, personal freedom, elemental equality, and social recognition.

These are justified because they are required for the satisfaction of vital human needs, without which a person cannot function as a human being.

4. Maximal: There are many human rights listed in the declarations above.

Review Questions for Week 3

1. What is the difference between macro-allocation and micro-allocation?
2. What are the best criteria to use in rationing health care?
3. What are the arguments that health care for old people should be limited? Are these good arguments?
4. Short essay topic: Use the consequences, rights/duties, and principles reasoning patterns to evaluate whether alcoholics should get the same access to liver transplants as other people?
5. What are reasonable practical guidelines for approaching resource allocation in practice?
6. Should futility be used to limit the provision of health care?

Phil 226

Computational Epistemology Laboratory.

Paul Thagard

This page updated Sept. 24, 2012