1. Explain the financial, social worth, and medical factors that influence how organ transplants are awarded.
2. Contrast the American and British ways of rationing health care.
a. What are the benefits and weaknesses of each?
b. In which system is it ethically easier for a physician to say “no” to a request for expensive treatment? Why?
c. Which system do you think is the most ethical and why?
There was a time not long ago when doctors could offer only limited help, but they dispensed that help generously to their patients. Today, doctors have amazing medical resources, but they are limited in supplying them by scarcity and economics. How, for instance, do they decide whether a patient gets a liver transplant? First, they have to determine if the patient is a good candidate for organ transfer. Then they have to locate a liver donor or apply to an organ
registry. They also have to consider how the surgery will be paid for since they will need approximately $100,000 to cover the expense.
What should doctors do? Should they follow the market approach and allot treatment to those who will pay the most for it? Should they decide on the basis of medical need? Should they depend on a committee to make the decision? Should they depend on a lottery system or an HMO to make decisions regarding allocating treatment? Or should they follow the customary approach, which is a bunch of practices that mask the fact that treatment is being rationed? Each
of these approaches has its advantages and disadvantages.
The market approach is consonant with the free market economy. It simplifies the choice because the transplant goes to those who can pay for it, either with their own money or with insurance. Many libertarians feel comfortable with this idea because people would get the care that they have earned and deserve. Many of us would be troubled if society followed this option exclusively. It is, however, a component of the customary approach discussed below.
The medical-need approach would allot organs by giving priority to patients who most need them to stay alive. It would be supported by a prognosis on the patient’s likelihood of recuperating to live a healthy life. According to medical need, a 93-year old man who would almost certainly die with a transplant would have priority over a 30-year old woman who could live for six months without a transplant. According to medical prognosis, the woman would receive the transplant.
The lottery approach is another simple approach to rationing transplants that guarantees a kind of fairness because it treats all seekers of expensive and scarce treatment equally. This approach may be too simple because it does not take into account the seriousness of need, the likelihood of success, the length of time on a waiting list, or the person’s age or importance to their families and society. On the other hand, everyone would have an equal chance of receiving treatment.
The committee approach merely moves the decision making from a doctor to a
committee without dealing with underlying ethical concerns. The committee is likely to reflect the arbitrary biases of its members. It does, however, distribute feelings of guilt and gives its members a feeling of justification because one’s judgment is supported by one’s peers. The customary approach, on the other hand, offers some comfort to the medical establishment. It conceals the reality that people are denied treatment because of rationing and conceals reasons of
economics and bias that shape the rationing. In short, it does not rock the medical status quo.
For these reasons, the customary approach will remain in place with only minor
modifications until situations, interest groups, and individuals mount campaigns for more transparency. This is the ordinary course of democracy: Elites make decisions for their own benefit until people make them decide for the benefit of ordinary people.
One practical decision-making strategy for allotting organ transplants or other scarce and/or expensive procedures is an explicit or implicit checklist. Using such checklists, doctors, committees, and HMOs automatically disqualify certain groups of people from receiving them.
Such people might be excluded on the basis of: age, criminality, drug or alcohol abuse, mental illness, likelihood of medical failure, quality of life, low social standing, or lack of insurance.
Carl Cohen (as cited in Card, 2004) argues that there are no special reasons that should automatically deprive alcoholics of liver transplants, a position with which many Americans disagree as evidenced by the furor that erupted when Mickey Mantle, an alcoholic, got a liver while those who had not been alcoholics went without. Daniel Callahan (as cited in Card, 2004) argues that scarce treatments should not be allocated to people who have completed their
productive life spans because society owes people a good life, not a long life, and because giving old people those treatments will deprive younger people of opportunities for a full life. He believes that old age is meant to be a time of reflection and making peace with inevitable death.
George Annas (as cited in Card, 2004) considers ideas for deciding between prostitutes,
playboys, poets, and other reprobates. He says the process should be “fair, efficient, and
reflective of important social values” (p. 458). He believes that the initial screening should be based exclusively on strict medical criteria. The secondary criteria should minimize social worth
criteria and move toward a randomized method of selection, for which he prefers a modified “first come, first served” procedure. For example, every prospective kidney recipient would first be typed with prospective donated kidneys on the basis of compatibility and likelihood of successful outcomes. After the first selection had been completed, the prospective recipient who
had been on the list the longest would be awarded the transplant.
On controversial measures of distributive justice, such as the allocation of medical resources, conflicting moral and economic stances prohibit our assuming any common moral consensus. Rational ethical consensus needs to be constructed with careful attention to all points of view and the details of particular situations. General ethical considerations must be balanced against each other in making such decisions. For these reasons, an ethics committee composed of broadly represented stakeholders should probably be consulted in the allotment of scarce medical resources. In such a committee, political considerations would either be sublimated to ethical ones or, at least, would be balanced among competing interests.
A doctor’s ethical decision making is more difficult in the United States than it is in the United Kingdom. The British National Health Service provides universal health care to all citizens, but it makes explicit what medical procedures will not be supported. More elaborate xray, MRI, and Cat Scans are not supported, for example, under the justification that their cost would subtract from the care provided to the remainder of the population. In other words,
medical resources are rationed. Of course, the middle class and wealthy can fly to countries such
as Belgium and receive any treatment they can afford to pay for, so health care is really only
rationed for the working class and the poor.
American doctors are pressured on both sides: by their patients to provide treatments of
questionable worth and by HMOs and hospital administrators to limit the use of expensive tests
and treatments. In the U. S. the cost-containment role is taken over by a number of organizations
such as HMOs that pressure hospitals and doctors to limit expensive procedures. A doctor risks
his livelihood and practice if he or she continually orders tests and procedures that are
discouraged by HMO accountants. Doctors and hospitals are also financially rewarded if they
spend less than the amount set by the HMO. Thus by means of operant conditioning, they are
taught to provide their patients less service than might be appropriate. Some authors believe that
this conditioning turns doctors into double agents who slight their patients in favor of HMOs and
In this connection, an Oklahoma study (Khalig, Broyles, & Robertson, 2003) found that
insurance status, prospective payment, and the unit of payments make a difference in the length
of hospital stays. Medicare-insured, Medicaid-insured, and the uninsured experience
significantly shorter episodes of hospitalization than their commercially insured counterparts.
These shorter stays were found to contribute to physician-induced (iatrogenic) injury. This study
and many others argue that medicine in the United States needs to find a different method of
financing. Whatever happens, however, the chances are that, because of the progress in treating
chronic diseases and American’s high expectations, the cost of health care will continue to rise
no matter who pays for it.
Another reason that medical costs are high in this country is the American tort system.
Premiums got so high in West Virginia because of the thousands of law suits against doctors that
physicians staged a 1-day strike to protest. Worse, so many physicians have moved out of that
state that people in some areas have to drive two or more hours to see a doctor. Two issues are
important here. The first is the many unnecessary lawsuits that people bring against doctors,
lawsuits that frequently cost insurance companies millions of dollars.
On the other hand, doctors, like the rest of us, make mistakes. For example, if a doctor
sews up after an operation and leaves a clamp inside the patient, what should he or she do?
Ignore it and hope for the best? Wait until the patient reacts badly and then reopen? Cover up
the incident? Confer with lawyers to design a defense strategy? Consult with accountants to see
if his or her insurance premiums will skyrocket? Tell the patient and relatives what happened,
apologize, reopen, and correct the mistake?
Thurman (as cited in Card, 2004) says that the barriers to admitting mistakes are:
1. The provider’s difficulty in confessing mistakes.
2. The fear of implicating other providers.
3. The possibility of liability exposure. (p. 484)
The first barrier has psychological force but no ethical force. We all make mistakes, but ethical people admit and correct them as quickly as possible. Honest admission of mistakes is cheaper than cover-up because cover-up adds fraud to mere malpractice and angers the patient or family, who might then sue the doctor or hospital. Doctors are discouraged from speculating about the behaviors and intentions of other providers. Instead, they should relate only their present observations of a patient and not assign guilt to anyone. Both the national and state legislatures are currently struggling to find a solution to medical liability that is fair to both doctors and to patients who have truly been harmed. Some states, like New York and Pennsylvania, exempt “mere” medical malpractice from punitive damages.