Ethics, equity and economics. Ethics - theories of “justice” - medical versus economic polarisation Equity - definitions - “health”, “need” and “access vs. use” - micro versus macro Economics - equity and efficiency. Why ethics? .
- medical versus economic polarisation
- “health”, “need” and “access vs. use”
- micro versus macro
-maximise social well-being based on (consequentialist) utilitarianism
- malevolence (utility from suffering)
- ‘bottomless pit’ argument
- according to what criteria?
- Hippocratic oath, Nightingale Pledge
- ‘Agency and professional codes conduct
- ‘best interests’ of patient
- opportunity cost ignored (?)
- principally ‘utilitarian’
- based on opportunity cost
“I recall a patient who bled massively from his inoperable cancer of the stomach, I was the houseman and I had a strong sense that I must do my utmost for my patient, I ordered large quantities of blood to be cross matched and set up an infusion to replace the blood the patient had lost. It was not that I believed that the blood would cure him, but it would very probably save his life for a while longer, whereas without the blood transfusion he would have probably died there and then. A few days later the patient had another massive bleed and I again ordered more blood and set up a transfusion, again the patient survived what would almost certainly have been a fatal blood loss. The patient himself, knowing the situation, was keen to fight it as hard as possible.”
After the second massive bleed and equally massive blood transfusion, my chief gently pointed out that there was no point in pouring in the blood as I had been, the patient had widespread cancer secondaries, his stomach was riddled with cancer and likely to bleed whenever the cancer eroded a blood vessel; blood transfusions could do no more than prolong the patient’s life by a very short time. If I went on ordering blood at the predigious rate I had been, I would literally break the bank, the blood bank, causing enormous expense whilst seriously jeopardising the chances of other patients for whom a blood transfusion could really be lifesaving, rather than merely death prolonging.
I wanted to discuss all this with the patient, but he died the same day from a further massive bleed and that time I simply was not called. My superior had decided that there was nothing beneficial that could be done. More precisely, however, his analysis was surely based on a different assessment, notably that the benefit to the patient of repeated blood transfusions each time his stomach cancer bled, even if he himself wanted to fight to the last second, was insufficient to justify the enormous cost (to others) of providing the blood.”
- “healthcare is a human right…provide access…regardless of their ability to pay”
- “care of individuals is at centre of health care but must be viewed within context of [generating] greatest possible health gains for groups and populations”
income/wealth then why not change
- trade off with efficiency?
“ The social conscience is more offended by severe inequality in nutrition and basic shelter, or in access to medical care, than by the inequality in automobiles, books, furniture or boats”
- applies especially to finance i.e. inequality in contribution by use (direct payments) or income (taxation)
- applies especially to delivery of health care e.g equal resources, utilisation, access per head.
- most discussion refers to this.
(opportunity to use)
- unlikely to achieve equal ‘health’
- compromises consumer sovereignty
“To provide the people of Great Britain, no matter where they may be, with the same level of service”
“A fundamental purpose of a national service must be equality of provision so far as this can be achieved without an unacceptable sacrifice of standards”.
Report of the Royal Commission of the NHS
- Suits Index
- see Donaldson & Gerard
- Sen (1977) concept of ‘sympathy’
- own utility enhanced by anothers well-being
- fits within utilitarian philosophy
- Titmuss (1970) - ‘duty’ give for benefit of others
- constraint on utility maximisation (c.f. resource