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PubMedDate not supplied

Ethics and public health emergencies: rationing vaccines.

There are three broad ethical issues related to handling public health emergencies. They are the three R's-rationing, restrictions and responsibilities. Recently, a severe shortage of annual influenza vaccine in the US, combined with the threat of pandemic flu, has provided an opportunity for policy makers to think about rationing in very concrete terms. Some lessons from annual flu vaccination likely will apply to pandemic vaccine distribution, but many preparatory decisions must be based on very rough estimates. What ethical principles should guide rationing decisions, what data should inform these decisions, how to revise decisions as new data emerge, and how to implement rationing decisions on the ground are all important considerations. In addition, ethicists might be able to help policy makers think through the importance of international cooperation in surmounting global rationing dilemmas and to accept the inevitable responsibilities of government in making and implementing rationing decisions.

Decision Making↗
PubMed1995

Rationing health care: the political perspective.

The politics of rationing are messy and treacherous. As long as rationing remained implicit, politicians were shielded from the impact of decisions about who to treat and who not to treat. Explicit rationing changes all this by making the process of reaching choices more visible. However, implicit rationing may actually be a better way of dealing with difficult and complex issues. There is, nevertheless, scope for improving the process and making it more open and accountable. While efforts to terminate ineffective treatments are welcome and overdue, they are not a substitute for rationing. Finally, while politicians are being called upon to set national priorities and guidelines for rationing care, there is resistance to doing so when the decisions are so context specific and can only be made effectively at a micro level.

Decision Making↗
PubMed1993

Rationing fairly: programmatic considerations.

CONCLUSION: I conclude with a plea against provincialism. The four problems I illustrated have their analogues in the rationing of goods other than health care. To flesh out a principle that says "people are equal before the law" will involve decisions about how to allocate legal services among all people who can make plausible claims to need them by citing that principle. Similarly, to give content to a principle that assures equal educational opportunity will involve decisions about resource allocation very much like those involved in rationing health care. Being provincial about health care rationing will prevent us from seeing the relationships among these rationing problems. Conversely, a rationing theory will have greater force if it derives from consideration of common types of problems that are independent of the kinds of goods whose distribution is in question. I am suggesting that exploring a theory of rationing in this way is a prolegomenon to serious work in "applied ethics."

Civil Rights↗
PubMed1989

Ethical constraints on rationing medical care by age.

In a statement published in this issue, the Public Policy Committee of the American Geriatrics Society endorses the view that chronological age should not be a criterion for exclusion of individuals from medical care. This article aims to amplify the Committee's position by placing it within a broader context and identifying its justification in ethical argument. The paper is divided into three parts. The first part clarifies the difference between allocation (the distribution of funds between categories) and rationing (the distribution of funds within a single category). It is argued that given the current allocation of funds to medical care, some form of rationing is unavoidable. As others have noted, rationing is already occurring in an informal and piecemeal fashion. However, ethically sound rationing requires publicly debated and defensible policies. The second section of the paper reviews a number of arguments advanced in favor of rationing medical care on the basis of age. Objections to these arguments are carefully set out. The final part of the paper details and defends a series of positive arguments establishing special duties to the elderly. The paper concludes that to the extent that scarcity forces rationing, older persons should not be excluded because they are old.

Age Factors↗
PubMed2000

Age-based rationing in the allocation of health care.

OBJECTIVES: This article seeks to review debates about age-based rationing in health care. METHODS: The article identifies four different levels (or types) of decision-making in health resources allocation--societal, strategic, programmatic, and clinical--and assesses how the issues of rationing vary in relation to each level. RESULTS: The article concludes that rationing is least defensible at the clinical level, where it is also most covert. The role of rationing at other levels is more defensible when based on grounds of cost-effectiveness rather than equity. The article emphasizes the importance of fairness in health allocation and suggests that efficiency criteria need to be considered in that context. DISCUSSION: The article suggests that rationing is most problematic where it is least overt. This raises further questions about how rationing can be made more explicit at different levels of decision making.

Age Factors↗
PubMed1995

Clinical and ethical perspectives on rationing of high-cost drugs.

OBJECTIVE: To analyze the use of high-cost drugs from a clinical decision-making approach and ethical perspectives on rationing. CASE: The case of a 26-year-old intravenous drug user with AIDS raises issues of how to ration high-cost drugs such as foscarnet, monoclonal antibodies (MAbs) for septic shock, and granulocyte colony-stimulating factor. ASSESSMENT: Should a patient with a terminal illness receive high-cost drugs given limited healthcare resources? Necessary clinical information including treatment algorithms, risk to benefit ratios, and cost-effectiveness data are evaluated. Rationing, especially bedside rationing, by the clinician is rejected because it is contrary to the clinician's ethical obligation of beneficence and nonmaleficence. Patient autonomy and desires may also conflict with society's interest in equitably distributing resources. Treatment could be denied if costs exceed benefits for the outcomes and thus deny resources to others who have more basic healthcare needs. There is no obligation to offer medically futile care or for the patient to accept extraordinary medical care. CONCLUSIONS: An ethical argument for rationing cannot be made because of the lack of a clear clinical and societal consensus on specific criteria for rationing of healthcare dollars. The decision to use high-cost drugs in the case presented is made using a clinical decision-making approach based on available treatment guidelines. This assumes that the patient continues to consent to therapy and that there is continued benefit.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Testing two mechanisms by which rational and irrational beliefs may affect the functionality of inferences.

This article describes a role playing experiment that examined the sufficiency hypothesis of Rational Emotive Behaviour Therapy (REBT). This proposition states that it is sufficient for rational and irrational beliefs to refer to preferences and musts, respectively, if those beliefs are to affect the functionality of inferences (FI). Consistent with the REBT literature (e.g. Dryden, 1994; Dryden & Ellis, 1988; Palmer, Dryden, Ellis & Yapp, 1995) results from this experiment showed that rational and irrational beliefs, as defined by REBT, do affect FI. Specifically, results showed that people who hold a rational belief form inferences that are significantly more functional than those that are formed by people who hold an irrational belief. Contrary to REBT theory, the sufficiency hypothesis was not supported. Thus, results indicated that it is not sufficient for rational and irrational beliefs to refer to preferences and musts, respectively, if those beliefs are to affect the FI. It appears, then, that preferences and musts are not sufficient mechanisms by which rational and irrational beliefs, respectively, affect the FI. Psychotherapeutic implications of these findings are considered.

Adult↗
PubMed1997

Drug rationing in the UK National Health Service. Current status and future prospects.

There are major problems in attempting to ration drug use in the UK. These include the large indigenous pharmaceutical industry, the nature of funding of drugs within the National Health Service (NHS) and the political sensitivities of rationing. Rationing of services within the NHS has therefore usually been implicit rather than explicit, and there is little public debate about rationing of health services. In relation to drug therapy, prescribing in primary care technically can only be rationed by encouraging the general practitioner (GP) to contain his or her own costs-effectively moving the difficult decision to the GP. Direct incentives to the GP, in the form of incentive payments or by fundholding seem to have some success in containing costs, largely by simple generic substitution. There are established systems in hospitals to control the costs of drugs, including formularies and drug management committees. Hospitals commonly try to transfer drug costs to the GP budget. While in part this is clinically appropriate, it can lead to tensions. Health authorities and GP fundholders now include prescribing, particularly at this interface, in their contracts with hospitals. Economic evaluations currently play little part in aiding decisions about choice of drug. These decisions tend to be dominated by the need for short term cost containment in the UK. Recent reforms of the NHS have moved responsibility for the rationing of services to the local authorities or purchasers; this might in time create an additional, local hurdle for pharmaceutical companies trying to market new drugs. A proposal to introduce a national limited formulary in which drugs will be selected partly on the basis of an economic evaluation seems impractical, although similar ideas might be further developed.

Health Care Rationing↗
PubMed2005

Downward delegation of implantable cardioverter defibrillator decision-making in a restricted-resource environment: the pitfalls of bedside rationing.

Implantable cardioverter defibrillators have been shown to reduce all-cause mortality in some patient populations at risk of sudden death. New Canadian guidelines recommend implantable cardioverter defibrillator therapy for these patients. However, the need for these devices exceeds the funded volumes in many Canadian jurisdictions. As a result, rationing of this resource has been necessary. While rationing at the macro (Ministry of Health) and meso (hospital) levels has achieved some level of acceptance by society, the responsibility for the decisions taken at the micro (individual) patient level actually rests with the physician at the bedside. This 'bedside rationing' creates a moral dilemma for physicians, who are torn between their traditional fiduciary role as 'patient advocate' and the competing role of 'gatekeeper'. This 'downward delegation' of rationing decision-making obscures the reality that rationing occurs, and encourages covert, opaque and inconsistent approaches. The remedy is the development of fair, legitimate procedures for making rationing decisions that include guidelines that structure and constrain those decisions. Macro- and meso-level stakeholders must also recognize and take responsibility for their part in restricting resources in a broadly inclusive and transparent process.

Canada↗
PubMed1991

Age-based rationing and women.

The expense of caring for growing numbers of older individuals can create strong incentives to ration health care based on age. While not directed explicitly at women, this form of rationing would affect women disproportionately because more women than men occupy the ranks of older Americans. A proper understanding of age-based rationing requires attention to gender issues. Once gender issues are taken into account, age-based rationing appears to perpetuate broader gender inequities in the society. This position is supported by three arguments. First, although age-based rationing leads to inequalities between age groups, the inequalities it produces between the sexes are more ethically troubling. Second, these departures from equality cannot be justified even when they benefit society at large by enabling investments in other health care priorities. Finally, since older women represent a disadvantaged and vulnerable group, age-based rationing is difficult to justify even if our obligation to protect the vulnerable is minimal.

Aged↗
PubMed1984

Rational-emotive therapy and the reduction of interpersonal anxiety in junior high school students.

This study evaluated the effectiveness of rational-emotive therapy and rational-emotive imagery. Fifty-nine junior high school students who volunteered to participate in treatment for interpersonal anxiety were randomly assigned to rational-emotive therapy without imagery (RET), rational-emotive therapy with imagery (REI), relationship-oriented counseling (ROC), and waiting-list control (WLC) groups. Groups met for seven 50-minute treatment sessions during a three-week period. Assessments were conducted at pretreatment, posttreatment, and three-week follow-up. Both self-report and sociometric measures were used to evaluate treatment outcome. At postassessment, both the RET and REI groups were rated on sociometric measures as significantly less interpersonally anxious than the WLC group. Mean scores favored the RET and REI groups, but no significant differences between these groups and the ROC group were obtained. The self-report measure did not significantly differentiate between groups, but the REI group demonstrated significant pre- to follow-up changes. Both the RET and REI groups yielded greater reductions in irrational thinking than did the ROC and WLC groups. In addition, the pattern of the results supported the use of rational-emotive imagery as a component of rational-emotive therapy. The practical implications of these findings are discussed.

Adolescent↗
PubMed1999

Analysis of Fe content in daily food rations in principal socio-economic groups of population on the basis of questionnaire and analytical studies.

The study aimed at estimation of representative rations for the purpose of laboratory reconstruction of the rations on the basis of questionnaire studies in principal socio-economic groups in the Wielko-polska region. The reconstructed representative rations provided material for analytical studies. Sex of individuals and the four seasons of the year were taken into account. In all studied groups, daily food ratios covered lower proportions of recommended dietary allowances for Fe in females than in males. The food rations covered recommended dietary allowances for Fe only in physical or mental male workers. The improper relations between Fe and energy content in food rations of women at the reproductive age were found to deserve a serious concern. Statistical analysis of the results demonstrated that the suggested way of determining representative rations may serve to evaluate Fe nutrition of pre-school children, children of primary schools, university students, mental and physical workers and of retired workers.

Anemia↗
PubMed2002

Effects of food ration on survival and sublethal responses of lake chubsuckers (Erimyzon sucetta) exposed to coal combustion wastes.

Study organisms in chronic toxicological bioassays are often provided with excessive resources to remove food limitations as a confounding experimental variable. Under more ecologically realistic situations, resources are often less abundant and such restrictions may alter the responses of organisms to environmental contaminants. Here, we investigated the interaction between resource level and sediment toxicity in the lake chubsucker, Erimyzon sucetta. For 78 days we fed fish one of three ration levels (1X, 2X, 4X; uncontaminated food) that was grazed directly from either clean sand or coal ash-contaminated sediments. Despite provision of uncontaminated food, fish exposed to the contaminated sediments accumulated significant whole body concentrations of As, Se, Sr, and V. Food ration affected the pattern of Se accumulation, with lowest concentrations accumulated by fish supplied with the lowest rations (1X). Paradoxically, fish in the 1X-ash treatment were most adversely effected by ash-exposure, despite having Se burdens much lower than fish in the 2X- and 4X-ash treatments. Fish in the 1X-ash treatment exhibited higher mortality, lower proportional growth, and increased incidence of fin erosion compared to fish provided with higher rations. Such results may, in part, be explained by the apparent inability of fish with reduced rations to maintain positive energy balance, as evidenced by their higher standard metabolic rates compared to control fish fed similar rations. Our results underscore the importance of considering resource quantity and nutritional factors in chronic bioassays in order to draw more ecologically realistic conclusions about contaminant effects.

Animal Feed↗
PubMed1979

The informal rationing of primary medical care.

All social services are rationed, yet the effects of such rationing on the client are rarely fully explored. This article reviews the evidence on the existence of informal rationing devices in general practice. It examines the effects on patients of a wide range of informal rationing devices now used by individual general practitioners. Various suggestions for reforming the present rationing of primary medical care are evaluated and the likelihood of any reform being carried out is assessed. Although this article concentrates solely on rationing in the primary care sector of the National Health Service, the issues discussed are relevant to most welfare agencies as they are presently organized.

Appointments and Schedules↗
PubMed2002

Cotrimoxazole prescribing by dispensing and non-dispensing doctors: do they differ in rationality?

BACKGROUND: Dispensing doctors (DDs) have been found to prescribe significantly more drugs, more injections and more antibiotics per patient than non-dispensing doctors (NDDs). However, the rationality of prescription in relation to diagnoses and symptoms has not been studied. OBJECTIVES: To identify and assess differences in the rationality of cotrimoxazole prescription by DDs and NDDs evaluated by drug choice and dosage in relation to diagnoses and symptoms. METHODS: Cohort study of 28 private sector DDs and 25 NDDs in Zimbabwe, using retrospective data from 688 patient records. Drug choice and dose in relation to the recorded diagnoses and symptom(s) were assessed. A new method was developed and tested to measure rationality in a specific and realistic way. A 'correctness-score list' was developed based on a panel of four evaluators assessing the rationality of cotrimoxazole prescription in relation to diagnoses and symptoms. This list was then used as a reference for the assessment. RESULTS: The two groups of prescribers did not differ significantly with respect to rationality of drug choice. Both DDs and NDDs prescribed cotrimoxazole to patients for diagnoses and symptoms for which cotrimoxazole could not be justified (41.4%vs. 43.5%). DDs compared with NDDs used subcurative doses more often (26.4% of the encounters compared with 11.7%; P = 0.035) and correct doses less frequent (58.0% compared with 72.6%; P = 0.047). CONCLUSION: The prescription of cotrimoxazole by both DDs and NDDs was widely irrational. They prescribed cotrimoxazole too frequently, and DDs used subcurative doses to a wider extent. By this prescribing practice, both groups, but especially the DDs, contribute to increasing health hazards, cost and risk of developing bacterial resistance. The method for assessing rationality of drug prescribing was found feasible, and it is recommended that it be further tested and developed.

Adult↗
PubMed1979

The effect of a low-protein ration on milk yield and plasma metabolites in Friesian heifers during early lactation.

1. Sixteen first-calf Friesian heifers were used in a continous treatment design experiment. For 2 weeks after calving they were given a 750 g concentrate, 250 g hay/kg ration with 169 g crude protein (nitrogen X 6.25; CP)/kg dry matter (DM). They were then divided into two groups of eight and given a high-protein (223 g CP/kg DM) or low-protein (107 g CP/kg DM) ration at the rate of 10.8 kg concentrate + 3.6 kg hay for 8 weeks. 2. Milk yield and composition, live weight and blood composition were monitored throughout. A digestibility trial was carried out with six animals on each treatment. 3. The low protein ration reduced DM, organic matter, energy and fibre digestibility significantly (P less than 0.001) so that intakes of digestible energy were not equal and the low-protein group lost more weight than the high-protein group. 4. Milk yield and the fat content of milk were lower in heifers given the low-protein ration (P less than 0.01). The lactose content of the milk was not affected and protein content only slightly reduced (P less than 0.01) by low-protein feeding. When the heifers were all changed onto an adequate protein (190 g CP/kg DM) ration in mid-lactation, those which had previously been under-fed protein appeared to recover in milk yield to the point they might have been expected to reach is given an adequate-protein ration throughout. 5. Concentrations of urea (P less than 0.001) and albumin (P less than 0.05) were reduced by underfeeding protein, but albumin concentration was affected less by diet than by stage of lactation. Blood concentrations of total protein, glucose, sodium, potassium, calcium, inorganic phosphate, iron, copper, haemoglobin and packed cell volume were unaffected by treatment. Blood magnesium concentration was slightly lower (P less than 0.01) with low-protein feeding.

Animals↗
PubMed1976

[The effect of the raw protein supply on the lysine requirements of young pigs of 12-40 kg. 1. Report. Feeding studies with wheat-peanut extraction residue rations].

10 feedings trials were carried out with a total of more than 500 pigs weighing 12 to 40 kgs. To investigate the lysine needs of growing pigs, the animals were fed rations of wheat + extracted ground nut meal. Different food mixtures were tested containing 5 levels of crude protein (19%, 17%, 15%, 13% and 11% of the dry feed. Within each crude protein level 6 graded lysine supplements were added to the ration. The trial showed that the lysine requirements of the weaned pigs were in a decisive measure determined by the percentage proportion of crude protein contained in the ration. The crude protein portion may be calculated (for the liveweight range tested) by using the following regression equation: y=0.28+0.075x (y=lysine requirements expressed as % of the air-dried ration; x=percentage proportion of crude protein in the ration). Rations containing only protein sources of vegetable origin, with a minimum protein content of 15%, produced the same daily weight gains (520 g) as a standard diet, if the lysine demands were met through the supplementation of synthetic lysine.

Animal Nutritional Physiological Phenomena↗
PubMedDate not supplied

[Protein digestibility and the absorption of amino acids in various segments of the digestive tract of pigs. 3. Results of the fractionation of ileum chyme after feeding various rations].

Growing female pigs provided with re-entrant ileum resp. ileocecal cannulae received 6 different rations (fattening feed I and II for pigs, rations with dried skim milk, wheat gluten + lysine resp. wheat + wheat gluten + lysine, N-free mixture). The ileum chyme was separated into the fractions supernatant 1 and sediment 1 and by a treatment of supernatant 1 with trichloracetic acid and subsequent centrifuging into supernatant 2 and sediment 2. In the complete chyme as well as in all fractions the crude protein and amino acid contents were determined. The distribution in per cent of the crude protein and the amino acids over the fractions was calculated as well. The influence of the rations, in particular rations of dried skim milk, on the amino acid pattern of the complete chyme and the chyme fractions could be established. An influence of the rations could not be recognised on sediment 2 only, which indicates a uniform amino acid pattern of these probably endogenous proteins. The percentage of crude protein and amino acids in the fractions was also influenced by the rations.

Amino Acids↗