Maximising Welfare / Benefit
In many ethical dilemmas in health care, for example informed consent, confidentiality or end of life decisions, the focus is on the individual patient. However, in considering how to make the best use of limited health care resources, the focus of the decision shifts from the individual patient to a group of patients or potential patients, which may be the national population, a local community, or users of a specific service in an a hospital. One ethical theory that lends itself to community or population level decisions is utilitarianism. For a utilitarian, the ethically correct action will be that which results in the maximum overall benefit.
Thus, in making decisions about health care this theory requires consideration of the benefit to be gained from the various competing options in terms of the improvement in health for an individual and also the number of individuals who could benefit. In the context of the allocation of limited healthcare resources a key issue is the cost of the benefit achieved by the healthcare intervention. This approach would tend to favour resources being allocated to less expensive treatments or services that provide the greatest benefit. This may be a treatment that produces a large benefit for a small number of people or a small benefit for a large group of patients.
A criticism of this theory is that it fails to take into account the ‘need’ for healthcare intervention and relies rather on cost effectiveness. For example, it may favour preventative treatment such as cholesterol lowering agents to prevent future deaths from heart disease compared to renal dialysis for end stage renal disease.
The practical application of utilitarian theory in allocation of health care resources can be seen in the use of Quality Adjusted Life Years (QALYs) as a means of quantifying the net benefit from health care interventions to allow comparison of different interventions.
QALY stands for Quality Adjusted Life Year.
Alan Williams has described the thinking behind the development of QALYs thus:
“The essence of a QALY is that it takes a year of healthy life expectancy to be worth 1, but regards a year of unhealthy life expectancy as worth less than 1. Its precise value is lower the worse the quality of life of the unhealthy person (which is what the ‘quality adjusted’ bit is all about).”
A. Williams, ‘The Value of QALYs’, Health and Social Service Journal July (1985), 3.
Health care interventions are measured both by the number of extra years of life, and by the increased quality of life, that they can achieve. Thus an intervention that provides 10 years of extra life at full health would have a QALY value of 10, and an intervention that improves quality of life from 0.5 to 0.8 for a person with a predicted further life expectancy of 30 years, would have a QALY value of 9. [0.3 (0.8-0.5) multiplied by 30]. Once the QALY value of a health care intervention is calculated and its cost is known it is then possible to calculate the cost per QALY of each intervention and provide a direct comparison between interventions. The general idea is that a high priority health care activity is one where the cost per QALY is as low as it can be.
Some examples of Cost per QALY calculations:
|Hospital dialysis for end-stage renal disease for patients aged 55 – 64 years (compared with no treatment)||£45, 000|
|Coronary artery bypass graft for patients with mild angina (compared with medical management)||£26,000|
|Breast cancer screening programme||£6,800|
|Cervical cancer screening (women aged 20-59 years)||£200|
Reproduced from Medical Ethics and Law, the core curriculum. T. Hope, J. Savulescu and J. Hendrick, (Churchill Livingstone) 2003 Chapter 13 (table 13.2).
Several objections have been made against QALYs. These include:
1. Many healthcare interventions are not the subject of a QALY assessment and direct comparisons between the cost -effectiveness of different treatments is not possible.
2. QALYs are based on population-level information. They do not take into account the personal response of individuals to their illness and their views of their need for treatment.
3. QALYs are ageist. Ageism is unfair discrimination against a person on the grounds of their age. Some would consider QALYs ageist under this definition because providing treatment for younger people is likely to give a better QALY calculation. Individuals who have a greater span of life ahead of them, typically a younger person, would gain more from treatment on the basis of their predicted life expectancy in comparison with an older person who would have fewer years to benefit from a particular healthcare treatment. So a one -off life-saving intervention performed on a one-year old with a life expectancy of 80 years has a better QALY rating than the same intervention performed on a 70 year old. This would not apply to all treatments. If the treatment needs to be continued indefinitely then the cost per QALY calculation may not favour the younger person because the cost would be greater the longer the patient continued to live.
There are conflicting views about whether QALY calculations are ageist. Most supporters of QALYs argue that QALYs are not ageist because the age of the patients is not taken directly into account. An urgent life-saving treatment for an 80 year old, who was then expected to live 5 years would have the same priority, under the QALY method, as a 40 year old whose life-expectancy was 5 years (because of some underlying, untreatable illness). Michael Lockwood argues that QALYs “are not ageist enough”. He thinks the 40 year old should have greater priority than the 80 year old (in the above example) on the basis of a ‘fair innings’ argument, that is, the older person has already had the advantage of a long life and that treatment should be preferentially given to a younger person.
(Lockwood M, “Quality of life and resource allocation”, in Philosophy and Medical Welfare, edited by J. M. Bell and S. Mendus, Cambridge: Cambridge University Press 1988).
4. Patients who suffer a disability unconnected with the medical condition requiring treatment would be disadvantaged; John Harris calls this ‘double jeopardy’. Those who have a disability would be considered to have a lower quality of life and therefore would benefit less from treatment for an independent separate condition than those who, with treatment could be returned to full health. (Harris J. “Qualifying the Value of Life” Journal of Medical Ethics, Vol 13, Issue 3 117-123, Harris, J. Double Jeopardy and the Veil of Ignorance - A Reply. Journal of Medical Ethics 21:151-157).
A PCT has to decide on whether to allocate resources to neonatal intensive care services or to increase provision of coronary artery bypass grafts.
A QALY assessment will look at the relative cost of the different treatments and the change in quality of life and life expectancy that will result if the treatment is provided. Neonatal intensive care and coronary artery bypass grafts will both save lives. Some patients who require neonatal intensive care will go on to have healthy lives (QALY value of 1 for each year of life) while others may have diminished quality of life. Patients having coronary artery bypass grafts may not be completely healthy following treatment and will therefore not achieve a QALY value of 1 for each year of life. As heart disease is more common in the elderly, the average life expectancy for patients having coronary artery bypass grafts is likely to be less than that for patients requiring neonatal intensive care. Assuming for the sake of this example that the cost of neonatal intensive care and the cost of coronary artery bypass grafts are the same, then even though some babies will not survive intensive care, the potential life expectancy of the survivors will tend to weigh in favour of this intervention, and against the intervention that is aimed at an older age group.
Equity and Distributive Justice
A possible criticism of the utilitarian or QALY based approach to resource allocation is that it does not provide an equitable or fair way of distributing resources.
Aristotle, explaining his view of distributive justice, says, in effect, that equals should be treated equally, and unequals treated unequally in proportion to the relevant inequalities. This is known as Aristotle’s “formal principle of equality”. Its value lies in its implicit demand that we spell out the criteria we are using when we call people equal or unequal. Aristotle’s own criteria were based on merit; modern criteria may (or may not) be based more on need.(Nichomachean Ethics 1131a-1131b. See for example the edition of Crisp R, Cambridge, CUP, 2000 pp 85-87). The utilitarian or QALY based approach could be said to treat unequals equally, in that it does not take account of differences in need for health care but focuses entirely on the benefit gained from an intervention. Some individuals or groups of patients will have poorer health than others, or more serious diseases, and will have a greater need of health care. If degree of need is a main criterion, a just distribution of health care resources may require that these individuals or groups have more resources, even if the benefit gained by treatment is small compared to that achieved by a different treatment in patients who are less sick.
One ethical theory that considers equity, or fairness, rather than overall benefit is John Rawls’ ‘Theory of Justice’ (Rawls J. A Theory of Justice, The Belknap Press, 1971, revised edition 1999). Norman Daniels has applied this theory to the context of health care. For Rawls, a just system of distribution of ‘goods’ within a society is one in which those members of society who are worst off will be better off under this system than any other. Thus, in the context of health care we should allocate resources to ensure that those in poorest health, or greatest need, are as well off, in terms of health, as they can be.
Assessing and addressing inequity
Reducing health inequalities is seen as an important aim of the National Health Service. But there are different ways of looking at inequality, and some inequalities may be easier to address than others. Which inequalities are inequitable, that is, unfair? The concern about ‘post code prescribing’ relates to inequality of access to treatment across different parts of the country for all those with the same condition, for example access to fertility treatment for all women who meet specific criteria. Other types of inequality arise when comparing access to treatments for different conditions. How does one compare the need for hip replacement with the need for smoking cessation clinics, or the need for a new cancer therapy with the need for a treatment for multiple sclerosis? Even within the context of a specific medical condition, some patients may have a greater need for treatment because of more severe disease. Thus providing equal treatment without some assessment of health status or healthcare need is not always a just or equitable approach in health care.
Considering the social determinants of health
Non-medical factors may produce inequalities between individuals or groups with the same medical conditions such that more resources are required to achieve the same benefit in health. For example, greater resources per person may be needed to improve mortality and morbidity from diabetes or ischaemic heart disease in groups with a high degree of social deprivation than in affluent middle class patients. Is it equitable (fair) to provide greater resources for the more disadvantaged group.
‘The veil of ignorance’
In trying to make decisions about allocation of resources in the context of different needs, it may be helpful to use the concept of the ’ veil of ignorance’ put forward by John Rawls in his Theory of Justice. Faced with a range of possible societies (or possible methods of healthcare resource allocation) you must decide which society you would wish to live in given that you would not know your position in that society, whether you would be old or young, rich or poor sick or healthy. Rawls would argue that a rational person would choose the society (or to allocate resources) so that the most disadvantaged were as well off as they could be.
Determining morally relevant reasons for treating people differently
In considering equitable distribution of health care resources, care must be taken to ensure that any differences between individuals or groups that are used to justify different treatment are morally relevant differences. Thus, differences in race, sex or income are not seen as morally relevant. More controversial issues include whether factors such as personal responsibility for health and the presence of dependents are morally relevant in decisions about priority - setting in health care.
The influence of targets on resource allocation decisions
The recent introduction of targets into the NHS, with penalties for trusts that do not meet those targets, and rewards for those that do, may have an effect on decisions around resource allocation and priority setting. If failure to meet a target would result in fewer resources for future patient care, then it could be argued that maximum overall benefit will be achieved by always meeting targets. However, depending on how targets are set, the focus on achieving targets may result in patients with conditions not the subject of targets being treated unfairly.
To what extent should a patient’s wishes regarding the choice of the course of treatment be respected?
Respect for patient autonomy is a fundamental ethical principle that has assumed greater prominence in the healthcare setting over recent years. The emphasis on informed consent to treatment and shared decision-making within health care highlights the importance of this ethical principle. However, in considering how to allocate scarce health care resources for the whole community, or for all patients with a particular condition, respect for the autonomy of a specific individual may conflict with other values such as equity or the need to benefit the whole community or group, or with the autonomous choices of other individuals. Does respecting a person’s autonomy to make decisions about their treatment mean that they should be able to choose an expensive treatment over a cheaper treatment? If the consequence of complying with such a choice is that treatment will be unavailable to other patients because of the limited available resources this may not be fair.
A balance needs to be struck between respect for individual autonomy, benefiting the whole population and fair distribution of limited resources.
Process of Decision Making
The lack of agreement on basic theory underpinning resource allocation has led to a focus on the process of decision-making. One example of an ethical approach to the process of resource allocation decision-making is that of Daniels and Sabin. (Daniels N. Sabin JE., Limits to health care: fair procedures, democratic deliberation and the legitimacy problem for insurers, Philosophy and Public Affairs, 1997; 26: 303- 350.) This approach is known as accountability for reasonableness. It focuses particularly on macro-level decision-making; that is decisions about treatments and services for populations, such as those made by a PCT. However, the rationale for a process of accountability would be just as relevant for decisions affecting individual patients. Acknowledging the competing ethical principles involved, Daniels and Sabin suggest that for such decisions to be ethical they must satisfy four criteria:
1. Publicity - Decisions and their rationales must be publicly accessible.
2. Reasonableness -The rationales for decisions should appeal to reasons and principles that are accepted as relevant by people who are disposed to finding terms of cooperation that are mutually justifiable.
3. Appeals - There is a mechanism for challenge and dispute resolution.
4. Enforcement - There is either voluntary or public regulation of the process.
A summary by Daniels appeared in Daniels, N. (2000) “Accountability for reasonableness”, British Medical Journal 321, 1300-1301.