Issues that may present to a clinical ethics committee
The issue of resource allocation is beginning to come to Clinical Ethics Committees for consideration.
Below we use hypothetical cases to illustrate the ethical principles a committee needs to consider in approaching requests for advice on issues of resource allocation.
Case One: Who should have the intensive care bed?
Most choices regarding resource allocation are made at a managerial level. However, clinicians are faced with difficult decisions about determining priorities within the limited resources available in their area. For example, what should you do if the intensive care unit is full and a patient that requires intensive care is admitted to the hospital?
Barry is a 32 year old man with meningitis and is brought into the A&E department of hospital A. He is unconscious with an extremely low blood pressure and evidence of renal failure. His condition is grave and without intensive care support he is almost certain to die. With intensive care support he may make a full recovery. Until this illness he has been fit and well. The Intensive Care Unit (ICU) in hospital A is full, with some patients critically ill and some in a relatively stable condition but for who optimum care would still require the facilities of an ICU. There is evidence that moving a patient from an ICU early increases their chances of complications and may increase mortality. There is an available bed in an ICU in hospital B, which is fifty miles away. The intensive care consultant on call must decide if Barry should be moved to hospital B or if a patient already in ICU should be transferred to allow Barry to be admitted. The clinical ethics committee is asked to review the case retrospectively and advise on how such cases should be approached in the future.
Questions for the committee to consider
- Does the clinical team, or the institution, which the CEC is advising owe an equal duty of care to both patients?
- If each patient is owed the same duty of care, should the aim be to maximise the chance that both patients live, or minimise the chance that both patients die.
- In contrast to 2, should the sickest patient be given any greater priority in receiving best possible care?
- If the patient in ICU is owed a greater duty of care, is this sufficient to justify the decision not to admit the other patient, given the foreseeable probable outcome?
- Is patient autonomy relevant in this situation?
- Keep in mind that it is not possible to provide the best care to both patients
Discussion of the issues
The first step in considering such a dilemma is to establish the clinical facts and clarify the concepts used. This process may involve seeking expert opinion from sources outside the clinical team treating the patient and / or outside the Trust. This is an important part of the process of any ethical discussion, but is particularly important in issues of resource allocation when underlying ethical principles include terms such as benefit and need that may be open to interpretation. Thus information such as what will be the benefit of a certain course of action, and to whom it will accrue, and the relative need of the individuals involved, is essential to inform the ethical debate.
One way of looking at the dilemma would be to consider the relative benefit of different courses of action. The benefit to Barry of being admitted to ICU is clear; he will die if he is not given intensive care. However, the actual benefit will depend on the likelihood of his surviving even with intensive care. If his chances of making a full recovery are 80% the potential benefit will be greater than if his chance of surviving, even with intensive care, is 10%. The effect of transferring Barry to another hospital on his likely survival would also be important. For a patient already in ICU in hospital A, there can be no benefit from moving them out of ICU and transferring them to another hospital. The assessment here would be of the possible risk of such a move and the likely effect on their long-term recovery. If the risk is small, and the risk of moving Barry is great, then a utilitarian calculation of the overall benefit may support the transfer of a stable patient in hospital A to provide a bed for Barry. However, a greater risk of transfer for patients already in ICU combined with only a small chance of benefit to Barry from admission (a high likelihood that he will not survive even with treatment) may give a different answer if the criterion for the decision is overall benefit.
Responding to need
Another way of looking at this dilemma is from the point of view of the relative need for intensive care treatment. Barry is in urgent need because without intensive care treatment he will die. One can argue that we have a moral responsibility to respond to such urgent need even if the chances of success are small and it involves a small risk of potential harm to others.
Respecting a patient’s autonomous wishes is an important ethical principle in health care. What weight should be given to the refusal of a patient, or their relatives, to agree to a transfer to another hospital to allow a very sick patient to have their bed? What about the autonomous wish of the patient in the casualty department to have appropriate care in the hospital to which they have been brought? In terms of acceding to patients’ or relatives’ wishes, the principle of autonomy is not particularly helpful in this situation.
Duty of care
Health professionals in an ICU have a duty of care to their patients and must act in their patients’ best interests. Therefore it may be very difficult for them to make a decision that is not entirely in their patient’s best interest. The question arises as to whether the intensive care team also has a duty of care to a patient who is currently physically elsewhere in the hospital but who is in need of intensive care treatment. A further question is whether the hospital management has an equal duty of care to both patients, and if so how does this fit with the clinician’s duty of care?
Case two: Should a clinician prescribe a new treatment that is more expensive than the standard treatment?
Dr Z is consultant at a specialist cancer unit. A new cancer treatment has recently become available for use in patients who have reached the end of conventional treatment for a particular type of cancer. Without further treatment less than 5% of patients will survive for 6 months. With the new treatment 40% of patients survive for six months and 5% are still alive at one year after treatment.
40% of patients survive for 6 months
If we treat 100 people we will gain 20 life years (40 multiplied by 0.5)
Cost of treating 100 patients is £500,000
Cost per life year gained is £25,000 (500,000 divided by 20)
5% of patients survive one year
If we treat 100 patients we will gain 5 life years
Cost of treating 100 patients is £500,000
Cost per life year gained is £100,000 (500,000 divided by 5)
Thus, the cost of one life year gained with this treatment is £25,000 if we use 6 month survival figures and £100,000 if we use one year survival figures.
Dr Z has a patient for whom he wishes to prescribe the new treatment. Alice is a 27 year old mother of two young children. Dr Z argues that an extra 6 to 12 months of life will make a huge difference to Alice and her children, and it is possible that within those 12 months further advances in treatment may be made. Furthermore, if she is one of the 5% of patients who survive for one year, she may go on to survive for much longer as there is little experience of this drug in the longer term. The Trust managers are concerned that they will not be able to meet the total cost of treating all patients who may benefit from this drug without cutting other services or treatments. They ask the clinical ethics committee to consider the ethical implications of this request for treatment.
This issue could come to a CEC of an acute trust where a clinician is asking the acute trust to fund such treatment.
If the acute trust says that it cannot afford the treatment, then the issue could go to the local PCT as a request for further funding to the acute trust.
Questions for the Committee to consider
If this treatment were funded, how many other patients would have a claim on this drug?
Is the cost per life year gained greater than that normally funded by the Trust? If so, from which budget should the funding come? From the envelope of resources for cancer care, or from other services? In which case, is this fair?
Does the fact that this patient has dependent children affect the decision? If it does, and if it provides a reason for giving greater priority, does this have implications for allocation decisions elsewhere in the Trust?
Does the increase in probability of extended life, and the predicted extent of extended life, justify paying more for a treatment than the Trust can normally afford? Are there other examples within the Trust of expensive interventions being used because of a chance of saving someone’s life?
Discussion of the issues
A utilitarian approach to this dilemma would be to consider the cost effectiveness of the new treatment compared to other treatments currently provided by the cancer unit and by the trust as a whole. Money used to fund the new treatment would need to come from other treatments or services, assuming that the trust was fully committed financially. Therefore, to maximise benefit to all patients across the Trust it is necessary to have a threshold for cost effectiveness of treatments or services that the Trust will fund. This allows different treatments or services to be compared directly on cost effectiveness terms and ensure that resources are used efficiently. Inefficient use of resources will reduce the overall benefit that can be achieved. If the Trust had a threshold of £20,000 per QALY or per life year extended, then the new treatment proposed by Dr Z would not fulfil the cost effectiveness criterion. One problem with only considering the cost effectiveness of the new drug is that other treatments already available may be less cost effective.
Responding to need
Are there reasons other than cost effectiveness to fund this new treatment? A persuasive argument would be the pressing need of Alice for treatment, without which she will die very soon. Even if the treatment only extends her life by six months that is a significant length of time for someone who is otherwise likely to die in a few weeks. In comparison, other treatments that are funded within the trust may not extend life but simply improve the quality of life for those having treatment. Is extending life always more important than improving the quality of life?
Fairness and morally relevant differences
If it were not possible to provide funding for every patient who might benefit from this treatment, could Dr Z argue that the fact that Alice has two small children who would benefit from having their mother around for even a short amount of time, gives her a stronger case than others without children for receiving treatment? This raises the question of whether having children is a morally relevant difference and justifies ‘unequal’ treatment. What if, rather than having dependent children, Alice is the main carer for her elderly mother?
How much account should be taken of Alice’s views of what treatment she wants? Respecting patient autonomy is important but the wishes of individual patients must also be balanced against the interests of others. In the context of limited resources, as we saw in case one, the principle of individual autonomy is not particularly helpful.
Case three: Prevention or treatment?
Decisions about setting priorities for treatments and services on a larger scale raise difficult ethical issues for PCTs. A PCT may seek advice on the ethical issues arising from these ‘macro-level’ decisions from a priorities forum, or a PCT may develop their own ethics committee to inform these decisions.
Metroville PCT has a sum of recurring money that has been ring-fenced for use in the area of ischaemic heart disease. The PCT has two proposals for developing services in this area and must decide which proposal to fund.
Proposal 1 is from the local acute trust and is for an increase in angiography and angioplasty services. The proposal cites evidence from research studies to show that reducing waiting times for angioplasty will save lives and is a cost effective use of resources.
Proposal 2 is from the local diabetes group and is for a project that will focus on the small Asian community within the population. This community has a high prevalence of diabetes and ischaemic heart disease and traditionally has tended to use health care services only when they are acutely ill rather than attending for regular care of their chronic diseases. The proposal is to provide a specialist diabetes nurse and health advocate for this population and an educational programme for the whole community focusing on prevention of diabetic complications and promotion of life-style changes to reduce the incidence of new cases of diabetes. There is no research evidence for this intervention but there is some anecdotal evidence from other areas that this approach has some success.
The PCT must choose one of these proposals.
Questions for a priorities forum to consider
- Should the aim of the PCT be to provide the best value health care for the whole population by always funding the most cost effective treatments, or are there other considerations that would outweigh the cost effectiveness argument?
- If overall value to the whole population is the most important consideration, how does the PCT compare the value of different interventions when different levels of evidence are available for each?
- Is providing a service that is equally accessible to everyone in the population who could benefit from it (angioplasty and angiography) fairer than providing a service that will only benefit a specific section of the population who could benefit (diabetes intervention for minority ethnic group)?
- Should the PCT put more resources into services for specific groups that are currently disadvantaged in health terms, compared to the general population, to redress the balance, even if these services are less cost effective than those usually funded by the PCT?
- Should services that have an immediate impact in terms of saving lives always be preferred over those that may reduce the risk of future death (and thus save lives in the future)?
Discussion of the issues
As with individual clinical cases, the first step in considering such an issue is to obtain as much relevant information as possible about the two interventions, including the views of users of the services as well as providers.
An important consideration for a PCT is how to use its limited budget in an efficient manner in order to provide as much overall benefit as possible for the community it serves. A utilitarian perspective of maximising benefit will require an assessment of the evidence of how effective each intervention is and the cost of obtaining that benefit. QALY calculations, if available, would be useful in this context. However, not all health care interventions have robust research evidence, including economic data. Some interventions are difficult to assess in a randomised controlled trial, and some medical conditions are less attractive to researchers or funders of medical research. A lack of evidence about the effectiveness of an intervention is not the same as good evidence that the intervention is not effective. Making a decision that was informed only by evidence of cost effectiveness of the competing interventions would tend to favour interventions for which evidence was available and could lead to unfair treatment of patients with equal need. The priorities forum of Metroville PCT may wish to consider evidence of effectiveness for the diabetes intervention other than that from formal research studies to obtain a more balanced view of the likely overall benefit to its population.
A different approach to this difficult decision would be to consider what would be a just distribution of resources in the context of existing health inequalities within the population served by the PCT. If the Asian community was particularly disadvantaged in terms of its health compared to the population as a whole, then one could argue that targeting resources at this group will reduce inequality in health between it and the general population.
Responding to need
One argument for funding the increased angioplasty service could be that those patients who will benefit from this service are in more acute need than those who will benefit from the diabetes intervention. Even if more lives could be saved in the long term from a preventive service, there are identifiable individuals on the angioplasty waiting list who may die very soon if not treated. Is it more important morally to save the lives of identifiable patients in the short term or to save the lives of as yet unidentified patients in the long term?
Equal access to treatment
What if waiting times for angioplasty were longer in this PCT than in other areas of the country? If this were the case one could argue that this is unjust and that the resources should be used to redress this inequality. A similar argument could be made for the diabetes intervention. How do we balance the demand of equal access to a specific treatment for all who would benefit, and equal access to appropriate treatment for people with different conditions but equal need?
How much weight is given to the different principles and perspectives will affect the outcome of the decision. There is no ranking formula for this process. What is important is that members of the committee or forum consider carefully all relevant facts and values in deliberating the issue. As PCTs will be expected to justify their decisions to their population, a fair and transparent process that is followed for each decision will also be of great importance.