JUSTICE AND THE ALLOCATION OF SCARCE RESOURCES

Health Care in The United States

Principle of Justice
- Equated to obligation to be fair in distribution of benefits and risks
- Maintenance of this principle simple in abstract and complex in application
- Reform of health care delivery, in regard to equity and access to health care
services, major issues

Formal Justice
- In distribution, equals must be treated equally, and unequals must be treated
unequally

Material Justice
- Principles that specify relevant characteristics or morally relevant criteria in
regard to treatment are material principles

Common methods for distribution of goods and resources:

To each person an equal share
To each person according to need
To each person according to merit
To each person according to contribution
To each person according to effort
To each person according to social worth

Fair Opportunity Rule

- No persons granted social benefits on basis of undeserved advantage
- No persons denied social benefits on basis of undeserved disadvantages

Macro-allocation
- Deals with larger societal issues of what kinds of health care will be provided to
the citizen as a whole.
- Province of Congress, state legislatures, insurance companies, private
foundations, and health organizations

Micro-allocation
- More personal determination of who will receive scarce resources such as
intensive care bed.

Two-Tier System
- Everyone guaranteed coverage for basic care and catastrophic health needs
- Cultural and social barriers bar the way for many citizens to receive health care
Lifeboat Ethics
- Who shall be saved from drowning, and what will be the criteria for our selection?
- The challenges faced by trying to feed the growing population of the earth.
- Garret Hardin an ecologist wrote Lifeboat ethics, where he puts the moral
questions of a growing population on earth versus the limited natural resources
on earth.

Triage
- Allocating scarce resources practiced and justified in crises of war or disaster

Medical Utility
- Which patient has best prognosis?
- Often difficult to assess

Social Utility
- Which patient has greatest social worth?
- Invites problems of racism, ageism, sexism, bias against retarded and mentally ill

First Come, First Served

- Random selection treats all patients as equal

Theories of Justice
1. Egalitarian Theories
- Emphasize equal access to goods and services
- Advocates of a right to health care
- Socialistic universal access health care systems

Norman Daniel’s Veiled Prudence

- Prudent planner does not know her age
- Prudent planner ignorant of her conception of the good
- Prudent planner guided by a time neutral concern for her well-being over the
lifespan
- Prudent planner has to plan for each stage of her life under assumption she will
live through it

Fair Innings Argument

- Finite span of years considered reasonable lifetime
- Everyone equal chance to have a full set of fair innings, to reach appropriate life
expectancy
- Injustice when one who has not had full opportunity to reach full allotment of
innings

2. Utilitarian Theories
- Criteria so public utility is maximized
- Public utility: greatest good for greatest number
- Political planning and intervention methods of redistributing goods and wealth
 QALY: quality adjusted life years
- Measures cost-benefit of applying a medical procedure

Callahan Natural Life Span Argument

- After a person has lived normal life span, medical care no longer oriented to
resisting death
- Medical care following natural life span limited to relief of suffering
- Technologies capable of extending life beyond normal life span create no
technological imperative for its use

3. Libertarian Theories
- Emphasize personal rights to social and economic liberty
- Choice of allocation system freely chosen
- Free-market system operates on material principle of ability to pay

Health Care Crisis

- Society spends 17.4 percent of gross domestic product on health care
- $2.9 trillion or $9,255 per person
- capita medical costs increased 1,000 percent
- Aging population places great burden on stressed system
- Use of high technology in medicine

World Health Care Models

Beverage Model
- Model originated in Great Britain by William Beveridge
- Health care financed by government and taxed based rather than insurance
based
- No medical bills; health care treatment public service
- Strong emphasis on primary care
- Costs controlled by rationing
- Long wait times for non-acute secondary and tertiary care
- Newest technologies not easily available
- Low costs per capita
- Government, as sole payer, controls what doctors can do and what they will
charge

Bismarck Model
- This model is named after Chancellor Otto von Bismarck
- Germany, France, Japan, Belgium, Switzerland
- Care providers and payer’s private entities
- Private not-for-profit health insurance (“sickness funds”) financed jointly by
employees and employers through payroll deductions
- Basically charities and cover everybody

National Health Insurance

- Canada, Australia, Taiwan, South Korea
 - Health care provider’s private
- Payer is government-run insurance program all citizens pay into
- Insured residents entitled to same level of care
- No profit motive, no need to advertise, no expensive underwriting
- National system great leverage and market power to negotiate lower prices

Out of Pocket
- Majority of world’s nations do not have resources to provide health care services
for their citizens
- Well connected and rich get medical care
- Poor do without
- Rural Africa, India, China, South America
-
Patient Protection and Affordable Care Act
- Law requires Americans to purchase health insurance
- Expands Medicaid rolls
- Establishes health-insurance exchanges to provide more competitive rates
- Provides subsidies to the poor and middle-class to assist them in purchasing a
private plan
- Imposes billions in new taxes, mainly on the rich and health care industry
- Still most complicated, expensive, and inequitable health care system in
developed nations
- National shortage of primary care physicians
- Disparity in reimbursement levels between Medicare and Medicaid
- Geography creates access maldistribution

The Quality Improvement Movement and Standard of Care

- Medical errors: top 10 causes of deaths
- Health care quality assessment top priority for health care providers
- Health care providers conform to specific standard of care to protect others
 ROLE FIDELITY

Code of conduct and ethics are common within many specialties of health care.
Regardless of specialty all must deal with similar ethical and moral problems.

Codes of conduct and ethics include:

- Appropriate scope of practice
- Conflicts of interests
- Serving best interest of patients
- Obligations to promote patient autonomy and privacy
- Obligations beyond patients to others in society
- Ethics of research
- Informing on unethical or illegal behavior

Common Problems with Professional Codes

- Vagueness as to duties and prohibitions and self-regulation and peer
enforcement
- Incompleteness as to duties
- Excessive concern with promotion and prestige of profession and financial and
business interests

Disparagement of Professional Colleagues

Gatekeeping
- One looks out for the interests of the profession or of others in a similar practice
- Result of professional obligations and training
- Strong sense of collegiality with others in practice
- As a member of the health profession, we are not only responsible for our actions
in regard to the patient but we are also charged with duty to ensure that the rest
of the health team is practicing appropriate care.

Disparaging: talking ill of

Gaming the System- term widely used with the advent of prospective payment
systems and managed care. The term as commonly used means that the diagnosis or
clinical condition is described in such a manner that the process stretches the truth or
fraudulent to get the plan to pay for a test that is strictly covered to pay at a higher rate.
- Practitioner attempting to get around the system
- Willing to lie in the process
- Often done on behalf of patient or at patient’s request
- Health care practitioners responsibility to be truthful, keep promises, be fair
- Lying undermines a person’s credibility
- If individual clinician found to be lying, can have harmful effect on entire health
care profession
- Gaming can harm other patients
Conflicts of Interest
Under no circumstances may physicians place their own financial interest above the
welfare of their patients. The primary objectives of the nature of the medical profession
is to render service to humanity: reward or financial gain is subordinate consideration.
Joint-venturing
- Group of individuals join together performing a business venture
- Any commercial relationship between practitioner and a company, in which
practitioner has material interest that could form basis for a conflict of interest,
spelled out in a disclosure statement
Self-referral
- To self-refer to an establishment in which you do not provide service but have an
economic interest is at least suspect and perhaps unethical

Sexual Misconduct in Health Care Practice

Sexual Relations
- Between practitioners and patients unethical
- Relationship between practitioner and patient always unequal
- Create emotional factors that interfere with therapeutic relationship and objective
judgment
- When practitioner feels potential for misunderstanding or mutual feelings of
romantic interest, it is time to end professional relationship

Scope of Practice
Role Fidelity
- Requires we remain within scope of clear legitimate practice
- One does not cross line without willful intention

Nurse-patient Relationship Models

Bureaucratic model: emphasis on maintenance of social order at expense of individual
patient’s welfare
Physician advocate model: goal is to enhance authority of physician

Impaired Colleagues
- Impaired colleagues place clients at risk
- Behavioral difficulties: absenteeism, illogical decision making, excessive errors
- Question is not whether practitioner has a duty to intervene, but the manner of
the intervention
- Health care provider must be confronted
- Made to seek effective assistance

*where possible, it is best that the individual be encourage to seek the help
independently; where not possible, help must still be obtained in order to protect
the patients and salvage the practitioner receives effective help and that those
with knowledge of the situation, treat the impaired colleague humanely, as we
would any patient needed our assistance.
Health Care Provision in a Multicultural Society
- We are a nation of immigrants, a multicultural society, a universal nation, a
pluralistic society
- We have competing ideas regarding basic issues such as the meaning of health
and illness
- Most health care practitioners in the United States adhere to Western system of
health care delivery
- Health care providers often not only ethnocentric but also xenophobic
Culture shock: communication barrier raised; problem patient or uncommunicative one

ANA Committee on Ethics

- Fundamental criteria for moral duty decisions:
- Patient at significant risk of harm, loss, or damage if practitioner does not assist
- Practitioner’s intervention or care directly relevant to preventing harm
- Practitioner’s care will probably prevent harm, loss, or damage to patient
- Benefit the patient will gain outweighs any harm practitioner might incur and does
not present more than a minimal risk to health care provider
- If practitioner answers yes to all four criteria, it is a moral duty to treat under
principle of beneficence
- If all criteria could not be answered with yes, the decision to treat would become
a moral option rather than a duty for the practitioner

Institutional Ethics Committee

- Interdisciplinary body of health care providers, community representatives, and
nonmedical professionals
- Address ethical questions within health care institution, especially on care of
patients
- Committees play advisory role
- Often multidisciplinary group
- Physicians, nurses, social workers, philosophers, laypersons, lawyers,
administrators, religious leaders
- Ethical training increasing in health care programs
 REPRODUCTIVE ISSUES

The Abortion Issue

Abortion statistics
- More than half of American women receiving abortions are in their 20s
- 17 percent of all U.S. abortions are teenagers
- 60 percent of women already have a child
- 37 percent have two or more children
- No racial or ethnic group makes up a majority of women having abortions
- 70 percent of women reported religious affiliation
- 40 percent of women with family incomes below federal poverty level
- 10 percent occur in second trimester
- 90 percent in first twelve weeks of pregnancy
- 60 percent occur in first eight weeks

Abortion is a very common experience for women

- 2012: 1.31 million abortions in United States
- Reasons diverse and complex
- Experience of abortion real, immediate, personal
- Americans evenly divided between pro-choice/pro-life positions

Pro-choice advocates favor intact dilation and evacuation

Pro-life advocates use term partial birth abortion
Fewer than a thousand third-trimester abortions performed each year

The Legal Debate

1973: In Roe v. Wade, Supreme Court, legalized a woman’s right to have an abortion
- Right not considered to be unrestricted
- Balanced the interests of the woman and the state
- Term person used only postnatally
- 28th week: allowed state to shift to protection of fetus

1976: Danforth v. Planned Parenthood of Central Missouri

- Statutory provision required a woman to receive her husband’s, or if a minor, her
parent’s or guardian’s, permission prior to having abortion
- Court held requirements were unconstitutional

1976: Hyde amendment restricted availability of Medicare funding for abortions

- Modified to allow funding in which mother’s life threatened by carrying fetus full
term or in cases of incest or rape
- It does primarily affect poor women

Webster v. Reproductive Health Services

- Court held that a state could ban public employees and public health facilities
from performing or assisting in performing nontherapeutic abortions
 - State legislatures in Northeast and West Coast have consistently supported
abortion rights
- Legislatures in a number of states have passed restrictive laws designed to stop
or slow process
Main framework of Roe v. Wade still in place and is the law of the land
The Moral Issues
- Personhood
- Sanctity of life
- Quality of life
- Autonomy
- Mercy
- Freedom
- Social stability
-
The Two Positions
Pro-life: anti-abortion, believes abortion is murder and should be stopped
Pro-choice: believes decision to abort is one of personal liberty and should be legal

Sanctity of Life Argument

- Fetus is a live human
- Killing him or her is wrong
- Allow for a few exceptions
- Human life sacred on basis of divine mandate, unalienable natural or human
rights, or common collective decision

Genetic code argument

The Facts of Fetal Development
- Conceptus: union of sperm and egg
- Zygote: full genetic code will determine sex, hair color, skin color, and other
attributes
- Embryo: zygote settles into uterine wall
- 8 weeks: entity is a fetus
- Second trimester: fetus will have begun to move (quickening)
- 5th month: neurologically, fetus can feel pain
- 6th month: fetus period of potential viability
- Third trimester: fetus develops minimal consciousness
- Birth occurs after nine months
- Infant completely dependent on mother

Killing and Self-Defense

- If someone is about to kill you, and the only way to save yourself is to kill the
other person first, then killing is permissible
- Doctrine of double effect: distinguish intended effect of an action from other,
unintended effects
-
“Human” or “Person”?
Traits Central to Personhood
- Member of the moral community
- Consciousness of objects and events
- Ability to feel pain
- Reasoning
- Self-motivated activity
- Capacity to communicate
- Concept of the self

The Viability Argument

- Viability: characteristic of biological independence
- Some argue a fetus has standing only when it becomes viable outside the
mother
- Some philosophers believe there is more to the abortion question than the issue
of personhood

Method of Analogical Thought Experiments

(Judith Thomson’s analogy on abortion issues)
- The Violinist Analogy- Thomson uses thought experiments to argue that fetus’s
right to life does not override the pregnant woman’s right to have jurisdiction over
her body, and that induced abortion is therefore nor morally impermissible.
- The Rapidly Growing Child Analogy- This analogy attempts to call attention to
the case of abortion when mother’s life is in danger.
- The Carpet-Seed Children Analogy- This analogy is meant to call attention to
the case of failed contraception.

Women’s Liberty and the Priority of Life Plan

- Pro-choice: crucial a woman have control over her life plan in the way a man
has control
- Pro-life: root of abortion problem is modern attitude toward sex
- Differing ideas concerning sexuality, one’s religious beliefs, or deeply held moral
beliefs
Pro-choice advocates worry about:
- The “backstreet abortion” if abortion is made illegal
- The quality of women’s lives if denied basic autonomy of reproductive self-control

Pro-life theorist:
- Will see the social problem as another manifestation of rampant immorality of
modern age
- Considers element of autonomy in reproduction a matter of “convenience” than a
life plan
- Traditionalism vs. Modernism
Pro-life Activists
- Tend to be more traditional and religious
- Sex should be reserved for marriage
- Tend to be less traditional and religious
- More career oriented with higher incomes
- Sex is a natural expression of oneself

Abortion and the Freedom of Religion

Pro-life Theorists
- Reject the idea their views on abortion are the result of their religious views
- They are result of basic moral reasoning
- Freedom of religion is not absolute
Pro-choice Theorists
- Reflect one’s most deeply held beliefs
- Even if views are not religious in the partisan sense, they are equally profound
Best solution: tolerance

The Environmental Perspective

- See humans as members of a biotic community
- Duty to maintain a balance of numbers with other members of that community
- Maintain and perhaps encourage use of abortion as a tool to control world
population
- Aggressive attitude toward family planning

The Family Planning Perspective

- Asks why we should favor accidental babies over planned babies
- People should have the right to choose at what point they will have their children
Pro-life perspective: family planning example of decadent culture of permissiveness

In Vitro Fertilization
- Eggs removed from a woman and fertilized in a laboratory dish (by husband or
another man)
- Embryos implanted in a woman (donor or other woman), where egg brought to
term
` Extra, or spare, embryos
- Implantation process may fail and be repeated
- Freezing of embryos
- Rating them for quality
- Discarding those that hold genetic defects
- Thawing them and disposing of them
- What happens to excess embryos can be a moral dilemma and controversial
- Women could postpone pregnancy without risking infertility or diseases of
pregnancy
- Identifying genetic abnormalities
Embryonic tissue in medical research
- Embryo: mitochondria, cytoplasm, DNA of mother and father
Surrogacy
- When a woman agrees to carry a baby to term and give it up to another set of
parents to raise
- Sometimes done for money, sometimes as a favor
- Pregnancy a deeply personal experience that should never be undergone for the
sake of others
- Very reason surrogacy supreme gift to another
Kantians: surrogacy problematic since birth mother is being used as incubator and not
regarded as a rational actor

Utilitarian: faced with very complicated utility calculations

-Well-accepted practice in spite of misgivings of some people
 ADVANCE DIRECTIVES

Living wills and other advance directives are written, legal instructions regarding your
preferences for medical care if you are unable to make decisions for yourself. Advance
directives guide choices for doctors and caregivers if you're terminally ill, seriously
injured, in a coma, in the late stages of dementia or near the end of life.

Advance directives aren't just for older adults. Unexpected end-of-life situations can
happen at any age, so it's important for all adults to prepare these documents.

By planning ahead, you can get the medical care you want, avoid unnecessary suffering
and relieve caregivers of decision-making burdens during moments of crisis or grief.
You also help reduce confusion or disagreement about the choices you would want
people to make on your behalf.

Power of attorney

A medical or health care power of attorney is a type of advance directive in which you
name a person to make decisions for you when you are unable to do so. In some states
this directive may also be called a durable power of attorney for health care or a health
care proxy.

Depending on where you live, the person you choose to make decisions on your behalf
may be called one of the following:

● Health care agent

● Health care proxy
● Health care surrogate
● Health care representative
● Health care attorney-in-fact
● Patient advocate

Choosing a person to act as your health care agent is important. Even if you have other
legal documents regarding your care, not all situations can be anticipated and some
situations will require someone to make a judgment about your likely care wishes. You
should choose a person who meets the following criteria:

● Meets your state's requirements for a health care agent

● Is not your doctor or a part of your medical care team
● Is willing and able to discuss medical care and end-of-life issues with you
● Can be trusted to make decisions that adhere to your wishes and values
● Can be trusted to be your advocate if there are disagreements about your
care
The person you name may be a spouse, other family member, friend or member of a
faith community. You may also choose one or more alternates in case the person you
chose is unable to fulfill the role.

Living will

A living will is a written, legal document that spells out medical treatments you would
and would not want to be used to keep you alive, as well as your preferences for other
medical decisions, such as pain management or organ donation.

In determining your wishes, think about your values. Consider how important it is to you
to be independent and self-sufficient, and identify what circumstances might make you
feel like your life is not worth living. Would you want treatment to extend your life in any
situation? All situations? Would you want treatment only if a cure is possible?

You should address a number of possible end-of-life care decisions in your living will.
Talk to your doctor if you have questions about any of the following medical decisions:

● Cardiopulmonary resuscitation (CPR) restarts the heart when it has

stopped beating. Determine if and when you would want to be resuscitated by
CPR or by a device that delivers an electric shock to stimulate the heart.
● Mechanical ventilation takes over your breathing if you're unable to breathe
on your own. Consider if, when and for how long you would want to be placed
on a mechanical ventilator.
● Tube feeding supplies the body with nutrients and fluids intravenously or via
a tube in the stomach. Decide if, when and for how long you would want to be
fed in this manner.
● Dialysis removes waste from your blood and manages fluid levels if your
kidneys no longer function. Determine if, when and for how long you would
want to receive this treatment.
● Antibiotics or antiviral medications can be used to treat many infections. If
you were near the end of life, would you want infections to be treated
aggressively or would you rather let infections run their course?
● Comfort care (palliative care) includes any number of interventions that may
be used to keep you comfortable and manage pain while abiding by your
other treatment wishes. This may include being allowed to die at home,
getting pain medications, being fed ice chips to soothe mouth dryness, and
avoiding invasive tests or treatments.
● Organ and tissue donations for transplantation can be specified in your
living will. If your organs are removed for donation, you will be kept on life-
sustaining treatment temporarily until the procedure is complete. To help your
health care agent avoid any confusion, you may want to state in your living
will that you understand the need for this temporary intervention.
 ● Donating your body for scientific study also can be specified. Contact a local
medical school, university or donation program for information on how to
register for a planned donation for research.

Do not resuscitate and do not intubate orders

You don't need to have an advance directive or living will to have do not resuscitate
(DNR) and do not intubate (DNI) orders. To establish DNR or DNI orders, tell your
doctor about your preferences. He or she will write the orders and put them in your
medical record.

Even if you already have a living will that includes your preferences regarding
resuscitation and intubation, it is still a good idea to establish DNR or DNI orders each
time you are admitted to a new hospital or health care facility.

Creating advance directives

Advance directives need to be in writing. Each state has different forms and
requirements for creating legal documents. Depending on where you live, a form may
need to be signed by a witness or notarized. You can ask a lawyer to help you with the
process, but it is generally not necessary.

Links to state-specific forms can be found on the websites of various organizations such
as the American Bar Association, AARP and the National Hospice and Palliative Care
Organization.

Review your advance directives with your doctor and your health care agent to be sure
you have filled out forms correctly. When you have completed your documents, you
need to do the following:

● Keep the originals in a safe but easily accessible place.

● Give a copy to your doctor.
● Give a copy to your health care agent and any alternate agents.
● Keep a record of who has your advance directives.
● Talk to family members and other important people in your life about your
advance directives and your health care wishes. By having these
conversations now, you help ensure that your family members clearly
understand your wishes. Having a clear understanding of your preferences
can help your family members avoid conflict and feelings of guilt.
● Carry a wallet-sized card that indicates you have advance directives,
identifies your health care agent and states where a copy of your directives
can be found.
● Keep a copy with you when you are traveling.
Reviewing and changing advance directives

You can change your directives at any time. If you want to make changes, you must
create a new form, distribute new copies and destroy all old copies. Specific
requirements for changing directives may vary by state.

You should discuss changes with your primary care doctor and make sure a new
directive replaces an old directive in your medical file. New directives must also be
added to medical charts in a hospital or nursing home. Also, talk to your health care
agent, family and friends about changes you have made.

Consider reviewing your directives and creating new ones in the following situations:

● New diagnosis. A diagnosis of a disease that is terminal or that significantly

alters your life may lead you to make changes in your living will. Discuss with
your doctor the kind of treatment and care decisions that might be made
during the expected course of the disease.
● Change of marital status. When you marry, divorce, become separated or
are widowed, you may need to select a new health care agent.
● About every 10 years. Over time your thoughts about end-of-life care may
change. Review your directives from time to time to be sure they reflect your
current values and wishes.