#1763 - Yernier Mind The Gap - Medical Law

Yernier – Mind the Gap!

Intro

• There is a complexity in health care – it is three values coming into play as an inconsistent triad:

  • Butler: Three services available – cheap, quick and reliable. Can have any two, but not the third

    • If it’s cheap and quick it won’t be reliable

    • If it’s reliable and cheap, it won’t be quick

    • And if it’s quick and reliable, it won’t be cheap

  • In healthcare, the three seem to be:

    • Economic efficiency

    • Justice

    • Decent quality care

  • Here, it also seems to be that we can have any two but not all three.

    • If we want to provide comprehensive and qualitative care that is economically efficient, i.e. that promotes the public interest in a cost-effective way,

      • it is likely that we enter into a health care system that offers such care only to those who can afford it. This raises objections based on considerations of justice.

    • If, on the contrary, we want to provide decent-quality care on the basis of people’s need rather than their ability to pay, it might turn out that the system is not efficient.

    • And if we want to provide care equally to all those who need it, while preserving efficiency, the package might be very limited and of low quality.

• Essentially, the central question is the following: how best to square the proverbial welfare circle?

  • What is scarcity?

    • Quite a lot of problems that all contemporary health care systems face originate from scarcity of health care resources

      • Scarcity means that we do not have sufficient resources, and that there are limits to our technology and our management skills in producing enough to meet the existing demand.

      • Consequently, it implies that not all ofour own or society’s goals can be realised at the same time;

        • that it is necessary to make choices as to how to use and allocate scarce goods and services; and thus, that we must trade off various goods against others.

    • There are two aspects to scarcity

      • The external aspect, or opportunity cost – that is, the loss of something you might otherwise have had

        • E.g. losing an evening with a nice dinner in favour of writing an academic paper

        • The loss is the enjoyment you would have derived from the dinner

        • The external aspect refers to scarcity as a natural condition of limited resources (such as time, money, attention, et cetera).

      • The internal aspect, which is a modern anthropological, socially or technologically induced construction

        • It holds that even if we would hypothetically face abundance of resources, we would still experience scarcity

          • due to anthropological, social or technologically induced intensification of our needs and desires.

        • So even if my resources were endless, my wants or needs for other resources would also be endless;

          • and I would still have to choose. The internal aspect of scarcity as such refers to the tendency toward infinity that is internally connected to obtaining and using resources.

            • I will always lack time or money to realise all my projects, and I can always imagine wanting or needing more of it.

  • Scarcity in healthcare

    • The internal aspect is found in that fact that no matter how much you throw at healthcare, you will always need more

      • Even a society solely dedicated to funding healthcare would never meet all demands

        • Because the nature of healthcare is that by supplying, we generate demand

        • It discloses the infinite capacity to do ever more – and ever more expensive – things for the patients

    • The external aspect of scarcity reveals itself in the fact that all countries must set limits on the amount of resources they can spend on health care

      • in relation to other social goals like housing, education, safety, poverty policy, et cetera

Approaches to scarcity: the economic approach

• Assuming we don’t have a star trek universe where we assume complete abundance, then we have two catalysts for scarcity:

  • Increasing modern medical technology

    • The increasing gap between supply and demand in health care is, as it turns out a self-inducing and self-increasing process.

      • For it happens that advance in medicine creates new needs that did not exist until the means of meeting them came into existence,

        • or at least into the realm of the possible (like the various possibilities in assisted reproduction).

  • Modern medicalisation of life

    • Secondly, the cost-increase in health care is also catalysed by the increasing medicalisation of life

      • Health and life is seen as the chief of all goods that need to be protected and promoted by all means

• So how do we manage scarcity?

  • Enhance efficiency and effectiveness

    • A possible strategy for managing the gap between supply and demand in publicly financed health care lies in the varied efforts that have been made, and continue to be made, to enhance efficiency and effectiveness of the health care system, also known as rationing.

      • To walk this road, it is argued, is to generate more beneficial care from a given budget with no diminution in its quality.

        • The more beneficial care that can be generated from the budget, the narrower will become the gap between supply and demand

    • We can ration in the following ways:

      • Reduce Supply

        • There is the possibility of reducing the number of beneficiaries e.g. only the elderly over 65

        • Or we can rate the intervention in term of QALYs – the more quality adjusted life years that technology brings

          • Then the more we should try and maximise it.

        • The general idea of the supply-side strategy lies in a sharper definition of the range of services that the public system provides,

          • thereby taking services off the public menu that have hitherto been available, l

            • eaving more resources for providing those that remain.

          • Put bluntly, it is a process of rationing by exclusion, in which those who require the excluded services must either buy them privately, or go without

      • Reduce demand

        • Another assortment of strategies is designed to bear down upon the level of demand for health care,

          • thus trying to stimulate proper use of public health care.

          • If less use can be made of services, especially in circumstances that are thought to be inappropriate,

            • resources will be conserved for deployment elsewhere.

        • From the patient-side, this could be done by increasing the share of private pocket contribution (e.g. prescription costs)

          • or by installing waiting lists.

        • From the side of health care provider, this can be done by stimulating economical management of care

          • (by means of denying questionable treatment or by dilution, i.e. by reducing the comprehensiveness of care,

            • or by using cheaper materials or hiring cheaper staff)

    • While preserving equity

      • It is important to bear in mind that the general case for improving efficiency and effectiveness of health care cannot seriously be faulted

        • Otherwise, it’s just a reckless abuse of the stewardship of public funds

        • But enthusiasm for efficiency may not ignore ethical issues in healthcare

          • i.e. avoiding quality skimping and avoiding cherry picking and discrimination

          • efficiency is not an end in itself – it is there to try and sustain equitable healthcare, and not disadvantage the vulnerable

The justice Approach

• Therefore, we need to decide what is so important that it is featured within a just healthcare system

  • And what is to be considered not part of the core of healthcare

    • Indeed what is it in health care that is so important that it should be equally guaranteed to everyone?

    • What should we and what can we reasonably expect from just health care to guarantee to all?

• Rawls and the social contract

  • He considered that all parties and institutions were to be seen as normal and fully cooperating members of society, roughly equal in ability,

    • and possessing the two moral powers – capacity for a sense of justice and for a conception of the good.

  • Furthermore, social cooperation is imagined as one that is advantageous to all: by cooperating they each get more than they could get by not cooperating.

  • And finally, Rawls resumes the Humean conception of scarcity as one of the circumstances of justice:

    • questions of justice arise within a context of moderate scarcity, ontologically understood as a given fact:

      • natural and other resources are not so abundant that schemes of cooperation become superfluous,

      • nor are conditions so harsh that fruitful ventures must inevitably break down

• Daniels adaptation

  • Rawls didn’t consider healthcare much as he saw health as a natural good. However, Daniels sees it as a social good

    • Daniels sees the aim of healthcare resourcing as promoting and protecting equality of opportunity

      • He stresses that there are limits to what we can reasonably expect from a healthcare system

    • Firstly, he stresses in a general sense that fairness also includes efficiency in management and allocations,

      • since when resources are constrained their inefficient use means that some needs will not be met that could have been met

        • Meeting health care needs should not and need not be a bottomless pit.

          • Efficiency is a matter of justice.

    • Secondly, by connecting the fair equality of opportunity principle with a narrow and objective biomedical concept of health and disease and with a needs concept that is oriented toward the normal opportunity range, Daniels takes an objective course

      • The moral importance of meeting health care needs is thus located in the objective impact on opportunity rather than in the subjective impact on happiness.

      • His theory on just health care is an objective goods theory within which not all health care needs are moral bedrock,

        • but only those that are...