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Ethical Issues

Resource Allocation

Professional guidance

Any professional guidance will set the benchmark for ethical thinking on a particular topic. In general there is little professional guidance for health professionals in making decisions about allocation of resources. Guidance issued by the GMC identifies that a doctor should consider the needs of his patients individually, whilst also taking into account that treatment for a particular patient may impact on the availability of treatment for his other patients.

General Medical Council (GMC)

The GMC states that while the duty of a doctor is to his or her individual patient, there is also a duty to other patients and the wider community.

The duties of a doctor registered with the General Medical Council

“Patients must be able to trust doctors with their lives and well-being. To justify that trust we as a profession have a duty to maintain a good standard of practice and care and to show respect for human life. In particular as a doctor you must:

- make the care of your patient your first concern”

Duties of a doctor GMC

However, there may be a conflict between the doctor’s duty to a particular patient and his or her duty to other patients and the wider community.

The GMC document ‘Priorities and Choices’ directly addresses the issue of determining priorities in the context of limited resources.

Priorities and Choices, July 2000 paragraph 8

“In determining priorities between individuals for a limited resource, clinicians should have regard for the three duties of care [to protect life and health, to respect autonomy and to treat justly]. In many cases this assessment will give priority to the need to protect life and health, so that those whose healthcare needs are greatest or most urgent on clinical assessment will receive priority.”

The GMC recognises the particular difficulties that face clinicians who also have a managerial role within health care (for example medical and nursing directors or clinical members of PCT executives).

Management in Health Care - The Role of Doctors, May 1999, paragraph 7.

“Conflicts may arise when doctors are called upon to make decisions about the use of resources and about patients’ care, when the needs of an individual patient and the needs of a population of patients cannot both be fully met. Dilemmas of this kind have no simple solution. When taking such decisions, doctors should take into account the priorities set by Government and the NHS and/or their employing or funding body. But they must also be clear about their own role. As clinicians, doctors must make the care of their patients their first concern, bearing in mind the effects of their decisions on the resources and choices available for other patients. As managers, doctors must allocate resources in the way that best serves the interests of a community or population of patients. In both roles, doctors should use evidence from research and audit to make the optimum use of the resources available”

National Institute for Clinical Excellence (NICE)

The National Institute for Clinical Excellence (NICE) was set up as a Special Health Authority for England and Wales on 1 April 1999. It is part of the National Health Service (NHS) and its stated role is to

“provide patients, health professionals and the public with authoritative, robust and reliable guidance on current ‘best practice’.”

NICE guidance and funding implications

NICE sets out the obligations of health professionals to provide treatment which it has recommended to be provided. This is set out in ‘A Guide to NICE’ (page 6):

“Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.”

However there seems to be some contradiction about who is responsible for any increased funding implications of NICE recommendations. On one reading of A Guide to NICE the NHS is responsible through its technology appraisals:

“Since January 2002, the NHS has been obliged to provide funding and resources for medicines and treatments recommended by NICE through its technology appraisals work programme.”

On another reading the responsibility would fall to local NHS organisations e.g. PCTs:

“Local NHS organisations are expected to meet the costs of medicines and treatments recommended by NICE out of their general allocations”.

The issue of funding NICE recommendations has received attention recently with the publication of NICE guidance on provision of infertility treatments.

NICE guidance recommends that the NHS funds up to three cycles of IVF treatment for those couples meeting specific criteria. However, NICE guidance will not yet be fully implemented and the Health Secretary has said that couples will only be offered 1 cycle of IVF treatment and there is no deadline for full implementation of the guidance. There is a question for PCTs about how they will implement this recommendation within their limited healthcare budget.
CG11: Fertility: assessment and treatment for people with fertility problems.

This issue was considered in:
NICE, the draft fertility guideline and dodging the big question, J R McMillan, J. Med. Ethics, Dec 2003; 29: 313 - 314.