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Saturday, August 08, 2009

Rationed Care Favoring the 15-40 Age Group: Ezekiel Emanuel's Article from The Lancet: "Principles for Allocation of Scarce Medical Interventions"

From The Lancet, v. 373, issue 9661, p. 423-431, 31 Jan. 2009. Free, no-hassle registration required to access the full text of this article. We urge our readers to read the complete text of this article and form their own conclusions.

Below are excerpts from Obama's senior health care advisor Ezekiel Emanuel's article:


Summary:

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness.

No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years.

We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

In health care, as elsewhere, scarcity is the mother of allocation. Although the extent is debated, the scarcity of many specific interventions—including beds in intensive care units, organs, and vaccines during pandemic influenza—is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary.

Allocation of scarce medical interventions is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria. During the 1960s, committees in Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependants as criteria.

How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested. Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multiprinciple allocation systems.

We evaluate three existing systems and then recommend a new one: the complete lives system.

[There follows a discussion of medical resource allocation principles: Treating People Equally (Lottery, First-Come, First-Serve) vs. Favoring the Worst-Off: Prioritarianism (Sickest First, Youngest First) vs. Maximizing Total Benefits: Utilitarianism (Save the Most Lives, Prognosis or Life-Years) vs. Promoting and Rewarding Social Usefulness (Instrumental Value, Reciprocity).]

The Complete Lives System Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system.

This system incorporates five principles: youngest-first, prognosis, save the most lives, lottery, and instrumental value.

As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid.

Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.” Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants.

Adolescents have received substantial education and parental care, investments that will be wasted without a complete life.

Infants, by contrast, have not yet received these investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfilment requires a complete life.

As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; this argument is supported by empirical surveys.

Importantly, the prioritarianism of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo.

Consequently, poor adolescents should be treated the same as wealthy ones, even though they may have received less investment owing to social injustice.

Age-based priority for receiving scarce medical interventions under the complete lives system

The complete lives system also considers prognosis, since its aim is to achieve complete lives. A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life.

Considering prognosis forestalls the concern that disproportionately large amounts of resources will be directed to young people with poor prognoses. When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable. Some small benefits, such as a few weeks of life, might also be intrinsically insignificant when compared with large benefits.

Saving the most lives is also included in this system because enabling more people to live complete lives is better than enabling fewer. In a public health emergency, instrumental value could also be included to enable more people to live complete lives.

Lotteries could be used when making choices between roughly equal recipients, and also potentially to ensure that no individual—irrespective of age or prognosis—is seen as beyond saving.Thus, the complete lives system is complete in another way: it incorporates each morally relevant simple principle.

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated (see figure).

It therefore superficially resembles the proposal made by DALY advocates; however, the complete lives system justifies preference to younger people because of priority to the worst-off rather than instrumental value.

Additionally, the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them. Conversely, DALY allocation treats life-years given to elderly or disabled people as objectively less valuable.

Finally, the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents. Prognosis allocation encourages physicians to improve patients' health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates.

Objections

We consider several important objections to the Complete Lives System.

The Complete Lives System discriminates against older people.

Age-based allocation is ageism. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age.

Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years.

Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Age, like income, is a “non-medical criterion” inappropriate for allocation of medical resources. In contrast to income, a complete life is a health outcome. Long-term survival and life expectancy at birth are key health-care outcome variables. Delaying the age at onset of a disease is desirable.

The complete lives system is insensitive to international differences in typical lifespan. Although broad consensus favours adolescents over very young infants, and young adults over the very elderly people, implementation can reasonably differ between, even within, nation-states.

Some people believe that a complete life is a universal limit founded in natural human capacities, which everyone should accept even without scarcity. By contrast, the complete lives system requires only that citizens see a complete life, however defined, as an important good, and accept that fairness gives those short of a complete life stronger claims to scarce life-saving resources.

Principles must be ordered lexically: less important principles should come into play only when more important ones are fulfilled. Rawls himself agreed that lexical priority was inappropriate when distributing specific resources in society, though appropriate for ordering the principles of basic social justice that shape the distribution of basic rights, opportunities, and income.

As an alternative, balancing priority to the worst-off against maximising benefits has won wide support in discussions of allocative local justice. As Amartya Sen argues, justice “does not specify how much more is to be given to the deprived person, but merely that he should receive more”.

Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending.

The complete lives system explicitly rejects waste and corruption, such as multiple listing for transplantation. Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions. Hearts for transplant and influenza vaccines, unlike money, cannot be replaced or diverted to non-health goals; denying a heart to one person makes it available to another.

Ultimately, the complete lives system does not create “classes of Untermenschen whose lives and well being are deemed not worth spending money on”, but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.





Read the entire article here.

Video: 'The Complete Lives System' of Ezekiel Emanuel


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