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cmf file 17 (2002) - resource allocation

From CMF files - cmf file 17 (2002) - resource allocation

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Improved living conditions enable people to live longer, but older people require more medical care and treatment. Medical research generates new technologies and creates new opportunities for providing care, but this is often expensive. Consequently many people see healthcare expenditure as a bottomless pit, but Christians need to emphasise the high priority of caring for people's individual needs, as well as remembering the historical witness that God can create vast benefit from apparently meagre resources.

Every working day, healthcare providers are confronted with the reality of limited resources. They are forced to make decisions and do the best they can within these constraints. Not only do they need to keep to a financial budget, they also have to allocate time and energy.

This process is complicated by the task of balancing the needs of individual patients while at the same time considering the demands of the community as a whole.

Decisions are made at macro and micro levels. In the UK the main macro decision is made by central government as it shares resources between needs such as healthcare, education, defence and transport. The next layer of decision-making divides resources between hospital trusts, health authorities and community-based medicine that is largely organised through groups of general practitioners.

The process of micro allocation then distributes resources between different departments within a hospital, for example cancer units or general surgery. Managers have to calculate how many beds a hospital can afford and how many staff to employ. GP units need to spread resources between demands as varied as flu vaccines and home visits. They also need to assess how much time and money should be spent on research and administration.

Making the best use of resources is a theme of some of Jesus' parables. In the so-called parable of the Talents, Jesus praises the people who have made best use of the resources they have been given, while admonishing the person who had not used his well.[1]

Therefore, examining these micro allocation decisions is an important task, and Christian thinking can enable the process. The Bible shows how God is concerned about the spiritual and physical health and wellbeing of populations, as well as being intimately concerned with the needs of individuals.

Considering Individuals

A healthcare provider is often faced by a patient who has particular demands, desires, needs and rights. Each carer has a duty to respond, and examining each of these issues in turn can clarify the thinking behind resource allocation and help create a just system of health practice.

Demands and desires

British culture has seen a move from paternalism, in which the doctor simply told the patient what to do, towards a situation where people are seen as clients and increasingly question a doctor's decision. This consumerist attitude can place more demands on doctors, and doctors have to assess whether it is appropriate to meet a particular demand or desire.

Patients are entitled to express their desires and preferences regarding different treatment options, and they are free to refuse any treatment. They are not, however, entitled to demand a particular treatment from their doctor. Just because a man demands viagra does not mean that his GP necessarily has to prescribe it.

Biblically there is a call for people to use resources wisely. In the book of Genesis, human beings are called to be stewards of the world's resources.[2] Applied to healthcare, this could imply that treatment only be given when it is genuinely needed. It is an incorrect use of resources to give inappropriate or unnecessary treatment just because a patient is asking for it.

In reality, the most persistent and demanding patients sometimes get what they want, while less demanding patients do not. But decision-makers need to remember that 'I want' should not necessarily mean 'I get'.

Needs

Along with demands and desires, doctors are bombarded with a plethora of patients' needs. The first stage, however, is to define what is meant by a need, and who makes the decision that this is indeed a need. Is it the doctor or other professional, the patient, relatives, or even a judge?

One view is that there are different levels of need.[3] Basic needs are those things required for humans to survive and function - food, water and shelter. These focus on universal physiological requirements of all people. Meeting basic needs prevents 'serious harm' to individuals.[4]

Non-basic needs are not required for basic physical survival, but contribute to our psychological, social and spiritual well-being. While bread and water are sufficient to meet basic needs, they would not meet other needs. It can be argued that basic needs should be met first, as they are the most pressing and urgent, before other types of needs. It is often difficult to distinguish what patients need from what they want. Is, for example, breast enhancement a need or a want? What about removing a large visible tattoo, where a previous decision is radically affecting an individual's ongoing life?

Furthermore, patients may need treatments they do not want, such as chemotherapy, and want treatments they do not necessarily need, such as cosmetic surgery.

Rights and duties

We still need to determine the moral basis for meeting a person's needs. Sometimes this is expressed in the notion of rights and duties and patients frequently demand their 'rights' in healthcare. Providers need to work out whether the person genuinely does have that right, and whether it is their duty to provide it.

Legal rights serve as a minimum standard of protection for all people in a country. If anyone fails to act professionally and harms a patient, he or she can be taken to court and may be barred from their area of work in the future, or even sent to prison. In healthcare, legal rights enshrine the minimum legal protection and standards of treatment that each patient can expect from doctors and other healthcare professionals.

As of October 2000, certain rights have been enshrined in British law through ratification of the Europe-wide Human Rights Act 1998. This includes notions of protecting people from harm. It is, however, unclear exactly what 'rights' can be demanded of healthcare professionals. Article 2 establishes that patients have a 'right to life' and Article 3 gives them a right not to be subjected to 'torture or to inhumane or degrading treatment or punishment'.

The implications of human rights and the corresponding duties for doctors are less clear than legal rights. For some patients, rights may even conflict. A 'Do Not Resuscitate' order could be seen as a person exercising their right to avoid degrading treatment, but is denying their own right to life.

In addition, rights have corresponding duties and responsibilities. If a patient has a 'right' to healthcare, then some member of the healthcare team must have a duty to provide it. In the UK this means that individuals are entitled to use NHS services, including good quality care and appropriate treatment, but they are not necessarily entitled to have any and every treatment that they may request or demand. Doctors should only agree to supply a treatment if it stands a good chance of success, is unlikely to cause harm and if there are enough resources.

Healthcare workers must be clear about the extent of their duties and responsibilities, recognising that these may vary depending on the type of rights involved. At the same time, patients must recognise their responsibility to act where possible in ways that do not needlessly endanger their own health. The Bible speaks of human beings being made in the image of God, and as such they should be treated with great care and reverence.[5]

In health care, doctors may experience pressure from patients based on rights claims, but should balance these with considerations of justice when examining how best to allocate resources.

Considerations of Justice

When balancing individual considerations and broader principles of allocation, finding a just use of resources is a fundamental notion for doctors. Three different forms of justice are important, namely fairness, equality and equity.[6]

Fairness

Justice seen in terms of fairness requires that a universal and uniform standard of treatment is given to all people. It means that treatment should be consistent between individuals and all people in the same circumstances should be treated in the same way.

Alternatively, some people suggest that notions of fairness should take into account an individual's contribution to society. This is the notion of giving people what they deserve.[7] This would suggest that someone who gives a lot should also receive a lot. Other people however indicate that fairness demands a universal standard of treatment for all people.[8]

Another consideration is whether fairness means that we should give priority to the people who need help because of disease or genuine accident, rather than those who deliberately put themselves at risk through activities such as smoking and bungee jumping.

One of the grounding principles of the Christian faith is that God does not treat us as we deserve, but because of his great love for us he cares for us even if we damage ourselves through deliberate actions or negligence. A health system that reflects God's love will work hard to provide for all, irrespective of how the need arose, not so much because this is fair, but because it reflects God's compassion. Christian compassion also extends equally to rulers and outcasts, irrespective of their contribution to society.

Equality

Equality, like fairness, highlights a minimum standard below which the treatment of each patient should not fall. Equality requires that similar cases are treated in similar ways and dissimilar cases are treated in dissimilar ways.[9] Inequality occurs where similar cases are treated in different ways. As such, equality aims to avoid discrimination based on inappropriate grounds, eg. age, race, sex, or religious beliefs.

There is a strong appreciation of equality in the New Testament of the Bible, where all human beings are seen as equal in God's sight. Biblical writers were convinced that Jesus Christ came to bring hope and new life to all people, irrespective of their race, background or gender.

When allocating resources, doctors should aim to be consistent and deal with patients in an evenhanded way, and should not allow discrimination on the basis of clinically irrelevant factors.

Equity

Both equality and fairness lead to consistency in dealing with patients and allocating resources. They are helpful, but in health considerations they appear to mask over an important issue. Just as people are individuals, their health needs will be highly specific. It is very difficult to identify a pool of people who are so similar that they can instantly receive the same treatment.

The concept of equity recognises that different people need different treatment. Equity allows differences to occur,[10] but only for morally justified reasons such as the specific clinical needs of each patient. Giving people equal consideration is not the same as giving them identical treatment.[11]

Equity allows for each person to receive the most appropriate treatment. It allows healthcare professionals to use their professional judgements about what the best treatment, or non-treatment, options are for an individual patient. This does not permit the minimum standards of equality and fairness to be compromised.

Inequity exists where differences in care and treatment are not morally justified. Two 37-year-old women are a positive match for a kidney transplant. One is wealthy, the other is poor. Offering the kidney to the first individual because she has more wealth would not be justifiable. It would be placing greater moral worth and value on her because of her wealth and would constitute inequitable treatment.

Another situation would be if one recipient was 37 and otherwise healthy, and another candidate was 77 and had recently been treated for cancer. Giving the kidney to the younger person would not breach notions of equity, because it is more appropriate to perform the operation on a healthier individual.

There will always be differences in the treatment received by individual people, but what is important is that these variations must be a response to the needs of the individual patient. This includes weighing up what is most appropriate for the individual with what is fair, equal and just treatment.

More than we deserve

So far most of the argument has been based on a moral and philosophical assessment of what individuals should expect. A Christian challenge to this should be to add a concept that we can receive more than we deserve.

Historically Christians have been at the forefront of establishing hospitals and providing health care, not because the patients deserve the care, but because the Christian shares Jesus' concern for weak and vulnerable members of society. This is driven from a fundamental belief that every person is made 'in the image of God'[12] and is therefore of enormous value.

In the Gospels, we have clear accounts of how Jesus treated people as individuals. He saw and responded to many needs, because he had compassion on those who were suffering in body, mind and spirit. He healed the people who were brought to him, irrespective of the underlying cause of the illness.[13] He acted from a principle of undeserved love, although it must be recognised that he did not heal everyone in the region.

In the judgement of the sheep and goats, Jesus indicated that helping a sick person is the equivalent to helping Christ.[14] This opportunity to 'treat Jesus' should cause us to seek the maximum resources for healthcare so that we can do this more often and more thoroughly.

In addition, the two occasions when Jesus fed thousands of people using meagre resources indicate that when a Christian sets out in obedience to God's call to serve, he or she can look to God to provide resources.[15] Many people, like the founder of the Barnardo homes, Dr Thomas Barnardo (1845-1905), and the founder of the hospice movement Dame Cicely Saunders (1918-), have discovered that even though their resources were tiny, God enabled them to achieve much.

It is easy to view resource allocation as a process of basic accounting, but Christians should expect that when they serve God great things happen. None of this, of course, detracts from the responsibility of being good stewards with the resources we have.

Conclusions

When confronting decisions about resource allocation, doctors are faced with the difficult task of balancing individual factors, such as patients' desires, demands, needs and rights, over and against principles of justice such as fairness, equality and equity which apply to all patients and the wider community.

We recognise that God created us as people with responsibility. Our desire to control our lives and ignore God has limited how effective we can be, though as Christians we recognise Jesus' ability to intervene in all situations.

While we may see glimpses of God's involvement in the way that people produce great results with tiny resources, we also look forward to a future when ill health and suffering will be a thing of the past - a time when no one will need to worry about allocating limited resources.[16]

In the meantime, Christians need to consider carefully how they make resource decisions as part of their God given responsibilities and that any decisions should reflect God's character of love, justice and generosity and his concern for the individual and the disadvantaged.

References

  1. Matthew 25:14-30
  2. Genesis 1:26-30
  3. Maslow A. Motivation and Personality, 3rd edition. Revised by Robert Frager, James Fadiman, Cynthia McReynolds and Ruth Cox. New York: Harper and Row. 1987 Chapter 2
  4. Doyal L and Gough I. A Theory of Human Needs. Basingstoke and London: Macmillan. 1991:50-1
  5. Genesis 1:27
  6. See also Wasson K. 'Ethical Arguments for Providing Palliative Care to Non-Cancer Patients.' International Journal of Palliative Nursing 2000;6:66-70
  7. Aristotle (1980). The Nichomachean Ethics. Translated by David Ross. Oxford: Oxford University Press
  8. Rawls J. A Theory of Justice. Cambridge: Belknap and Harvard University Press. 1991
  9. Wasson K, p69
  10. Downie RS and Telfer E. Caring and Curing: a philosophy of medicine and social work. New York and London: Methuen. 1980
  11. Outka G. 'Social Justice and Equal Access to Health Care,' in On Moral Medicine: theological perspectives in medical ethics, edited by Staphen E. Lammers and Allen Verhey. Grand Rapids: Eerdmans. 1987:632-43
  12. Genesis 1:26-27
  13. eg. Matthew 8:16; Matthew 12:15; Luke 4:40
  14. Matthew 25:38-40
  15. eg. Matthew 14:15-21; Matthew 15:32-38
  16. Revelation 21:1-5

Further Reading

  • Butler J. The Ethics of Health Care Rationing: principles and practice. London: Cassell. 1999
  • Cook ED. Who Lives and Who Dies? Farmington Papers E14 (May). Oxford: Farmington Institute. 2001
  • Kilner JF. Who Lives? Who Dies? Ethical criteria in patient selection. New Haven: Yale University Press. 1990


Article written by Katie Wasson

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