Extract
A fifty-five-year-old man with severe type-A hemophilia (factor-VIII
deficiency) and high-titer antibodies to factor VIII sustained an
intertrochanteric hip fracture. Open reduction and internal fixation
was performed uneventfully with intraoperative infusion of recombinant
activated factor VII (rFVIIa), a new and expensive product used
to treat factor-VIII deficient patients with antibodies to exogenous
factor VIII. On the second postoperative day, the rFVIIa was discontinued
and an activated prothrombin complex concentrate (aPCC), a less
expensive product, was given. Substantial bleeding ensued over the
next twenty-four hours, necessitating transfusion of six units of
packed red blood cells to maintain hemodynamic stability. The rFVIIa
was restarted, resulting in prompt control of the bleeding. This
medication was continued for the remainder of the postoperative
period, with adequate hemostasis. The cost for treatment with aPCC
is $10,400 per day. The cost for treatment with rFVIIa is $92,400
per day. This patient consumed $1.2 million worth of rFVIIa during
his hospital stay.
A fifty-five-year-old man with severe type-A hemophilia (factor-VIII
deficiency) and high-titer antibodies to factor VIII sustained an
intertrochanteric hip fracture. Open reduction and internal fixation
was performed uneventfully with intraoperative infusion of recombinant
activated factor VII (rFVIIa), a new and expensive product used
to treat factor-VIII deficient patients with antibodies to exogenous
factor VIII. On the second postoperative day, the rFVIIa was discontinued
and an activated prothrombin complex concentrate (aPCC), a less
expensive product, was given. Substantial bleeding ensued over the
next twenty-four hours, necessitating transfusion of six units of
packed red blood cells to maintain hemodynamic stability. The rFVIIa
was restarted, resulting in prompt control of the bleeding. This
medication was continued for the remainder of the postoperative
period, with adequate hemostasis. The cost for treatment with aPCC
is $10,400 per day. The cost for treatment with rFVIIa is $92,400
per day. This patient consumed $1.2 million worth of rFVIIa during
his hospital stay.
The case described above raises complex ethical issues about
justice and professional responsibility in a health-care system without
a policy for health-care rationing. The physicians involved in this
patient's care wanted to continue to use the much more expensive
recombinant factor because it was controlling the bleeding so effectively.
They also were very much aware of its costs. They knew that the
patient's insurance would not absorb the expense and that their
hospital was likely to bear the financial burden. On the one hand,
they had an obligation to provide the best possible care for their
patient. On the other hand, they felt obliged not to overburden
their institution and thereby undermine its financial viability.
Our nation has debated the establishment of a system for the
just allocation of health care for decades. As medical knowledge and
technology have led to the development of more effective interventions
that increase function, improve quality, and prolong life, the demand
for medical care, the cost of treatment, and the annual expenditure
on medicine have increased markedly. Still, we have no national
system. Most people in the United States with access to health care have
some private insurance either through their employer or through
Medicare or Medicaid. The primary objective of these third-party
payers is the limitation of their costs. The justification for their
inscrutable policies is hard to make out, and the fairness of their
policy application is even more difficult to discern. At the same
time, our society accepts the rhetoric that "life has infinite value"
and expects doctors to provide patients with the highest quality
medical care available. Still, hospitals have to meet their payrolls.
Physicians are caught between these competing demands, and it is
hard to identify the physician's professional responsibility.
Because resources are limited, a society must decide how its resources
will be distributed, which activities to fund, and which activities
to limit. When a society engages in public discussion and achieves
consensus on principles of allocation and policies for denying treatment,
physicians have a good reason to conform to the rules. Policies that
reflect important human concerns, that apply to all, and that are
based on principles endorsed by a broad consensus of the population
should be supported. Physicians should cooperate with rationing
plans that everyone knows to be equitable in design and implementation because
they offer a just distribution of treatment to patients when some
needs cannot be met. Unfortunately, because we have no such national
policy for the rationing of health care in the United States today,
physicians are faced with decisions about rationing care at the
bedside.
Some bedside rationing is inevitable. Where the shortage is glaringly
obvious to all and where an allocation to one patient deprives other
patients of the resource, doctors should and do prioritize. Physicians
ration their limited time and energy when they make allocation decisions
about whom to see next in the emergency room, who gets one of the
limited number of beds in a special unit, or who gets a transplant organ.
Urgency and efficacy are the well-accepted medical principles of
rationing, and physicians are troubled by such triage only when
they suspect that other unacceptable principles (e.g., priority
for the rich, famous, or powerful) are being smuggled into the decision-making
process.
But rationing in situations in which the shortage is not obvious
and the principles are not so clear, not so well-accepted, and not
so consistently applied is substantially different. In the case
described above, a single patient consumed $1.2 million worth of
health-care resources. Fiscal responsibility would seem to argue
against the massive expenditure on one patient. No single health-care
institution, insurance carrier, or society could support such an
expense on a regular basis. An attempt to provide such treatment
as standard care would ultimately jeopardize any health-care system. So,
should the physicians in this case have made rationing decisions
at the bedside?
There are several persuasive reasons for opposing bedside rationing
of medicine. In the accepted triage situations, decisions to withhold
or to modify treatments because of limited resources are justified
by the more effective use of those resources in the treatment of
other patients. But when physicians are tempted to practice bedside
rationing in a case like the one described above, they are not able
to redirect the money that is saved on one patient to the treatment
of other patients with more pressing medical needs or a greater
likelihood of benefit. Under our current health-care arrangements, funds
and other resources are not directly transferable from one allocation
to another.
Also, any individual utilitarian calculation of the amount of money
that is saved on an individual patient is speculative at best. Without
evidence of cost-saving and efficiency, the ultimate apparent advantage
of bedside rationing could turn out to cost more in resources than
it actually saves. In the case described above, using the less expensive
replacement factor could have cost the hospital even more than $1.2
million. A poor outcome following treatment with the cheaper factor
might have led to significant medical complications, a prolonged
stay in the intensive care unit, the need for additional blood products,
and additional medical and surgical procedures.
More principled considerations also dispose us against bedside rationing.
The opening line of the section on allocation of limited medical
resources in the American Medical Association's Code of Medical
Ethics states, "A physician has the duty to do all that he or she
can for the benefit of the individual patient." The Code goes on
to explain that the only criteria to be considered in the delivery
of patient care should be the likelihood of benefit, the urgency
of need, the change in the quality of life, the duration of benefit,
and, in some cases, the amount of resources required. In light of
physicians' historical commitment to act for the good of their patients
and the universal social understanding that physicians will act
in the best interest of their patients, only a similarly powerful
and broadly shared reason could justify a retreat from the primacy
of patient welfare. The choices that physicians make and the treatments
that physicians prescribe should, first and foremost, benefit their
patients and not insurance carriers, hospitals, pharmaceutical companies,
sales representatives, or themselves. In the case described above,
use of the less expensive replacement factor jeopardized the patient's hemodynamic
stability and could have resulted in substantial harm. The patient's
doctors therefore had a moral obligation to use the more expensive
and effective medication.
Another argument against bedside rationing is that individual, piecemeal
allocation decisions are likely to be inconsistent and, therefore,
unfair and discriminatory. Without universal application of policy
guidelines, bedside rationing decisions can only reflect the beliefs,
values, and opinions of an individual physician with respect to
a particular situation at a particular point in time. Treatment
decisions about relevantly similar cases are likely to differ among
various medical specialties, across geographic regions, among physicians
at the same hospital, and even among different cases involving the same
physician. Yet, justice requires that similar cases be treated similarly
and that irrelevant differences be disregarded. Moreover, physicians
are required to face their patients with nonjudgmental regard. Ad hoc
bedside rationing decisions invite unprofessional judgments and
tempt injustice.
Bedside rationing is unacceptable. But beneficence also has limits:
the scarcity of resources, the needs of others, and justice all
must be taken into account. Although physicians are obliged to act
for the benefit of their patients, they are also ethically required
to consider the good of all patients in a fair allocation of society's
medical resources. Thus, when scarcity is apparent, physicians must
not ignore the consequences that they foresee. Hospitals provide
patients with important opportunities for treatment and care and
therefore must be kept viable. At the same time, physicians must
avoid the moral hazards of bedside rationing. The importance of
both agendas creates the need for an allocation policy, a need that
is especially acute in the absence of a national policy for the
just distribution of health care. Physicians therefore have a professional
responsibility to come together to meet that need. At the institutional
level, or, when that is not possible, at the departmental level,
doctors of good will must come together to forge and implement rationing policies
for their practice. Physicians are well aware of the rising costs
of medical care. They are also able to appreciate policy implications.
Ultimately, they are the ones who will have to decide to ration
treatment or to accept responsibility for not rationing.
The justification for any policy must be clear so that the principles
that the policy expresses can be endorsed by all. When health-care
allocation policies are well justified, equitable, and just, physicians
should comply for the sake of the greater good. A well-conceived
policy should have been in place to guide the physicians in deciding
which treatment to use in the case described above. As long as there
is no policy, the default principle of acting for the patient's
good must remain the physician's ruling standard for medical decisions.
1.
Brown LD.
Health reform in America: the mystery of the missing moral momentum.
Camb Q Healthc Ethics.
1998;7:239-46.
2.
Rhodes R, Battin MP, Silvers A, editors. Medicine and social justice: essays on the distribution
of health care.
New York: Oxford University Press; 2002.