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PubMed1997

Recognizing bedside rationing: clear cases and tough calls.

Under increasing pressure to contain medical costs, physicians find themselves wondering whether it is ever proper to ration health care at the bedside. Opinion about this is divided, but one thing is clear; Whether physicians should ration at the bedside or not, they ought to be able to recognize when they are doing so. This paper describes three conditions that must be met for a physician's action to quality as bedside rationing. The physician must 1) withhold, withdraw, or fail to recommend a service that, in the physician's best clinical judgment, is in the patient's best medical interests; 2) act primarily to promote the financial interests of someone other than the patient (including an organization, society at large, and the physician himself or herself); and 3) have control over the use of the beneficial service. This paper presents a series of cases that illustrate and elaborate on the importance of these three conditions. Physicians can use these conditions to identify instances of bedside rationing; leaders of the medical profession, ethicists, and policymakers can use them as a starting point for discussions about when, if ever, physicians should ration at the bedside.

Adult↗

PubMed2000

[Attitude of seniors to rationing in health care--before and after a lecture series].

UNLABELLED: Prior to the first lecture in the public series of lectures entitled "Rationing of Health Care: Are Elderly the Victims?" and before a lecture given to a Senior Citizens Association on the same subject, all participants were polled. The polling was repeated at the end of the lecture series. The initial participation totalled 69 with two-thirds women, average age 64 years (50% were from the health care or social welfare sector), and 57 retired business people (50% women). At the end, there were 45 listeners (average age 65 years), with 30 taking part in both surveys. The majority believed that rationing is already taking place, only 1/6 rejected such measures in principle. When asked, nearly all those surveyed were in favor of quality of life after treatment and life expectancy as criteria for the right to medical services. Personal criteria, such as nationality, social role, self-related causes and calendar age were rejected by the majority, although less clearly by the business people than by the general participants. This rejection became more marked after the lecture series. Those surveyed gave various specific judgements on decisions about the complex allocation of resources and favored decision-making by patients themselves unless they were senile. A large minority were opposed to very elderly patients making decisions themselves, even if they were not senile. CONCLUSION: The elderly persons polled demand that all rationalization measures be exploited before rationing is implemented. Rationing criteria must be of a universal nature and borne by the general public.

Adult↗

PubMedDate not supplied

Healthcare reform through rationing.

Currently, the U.S. government cannot afford to pay for or ensure access to healthcare without limitations for all its citizens, as healthcare has become so expensive. Therefore, implementation of a rationing program is likely in the future for the U.S. healthcare system. Key stakeholders in such an initiative include citizens, healthcare providers, and the government. Americans expect to have unlimited access to care, but they do not like its high cost. Healthcare providers focus on giving the highest quality of care, with costs as a secondary concern. As a payer, the government wants to provide broader access to healthcare and, at the same time, reduce healthcare expenditures. The current debate over healthcare rationing surrounds three key questions: (1) can medically necessary procedures be ethically denied, (2) do Americans have a right to unlimited access to healthcare regardless of the costs, and (3) what is the limit on the availability of healthcare resources for those with the ability to pay. Proposals for rationing include developing a program similar to the Oregon Health Plan, using the quality-adjusted life years method, promoting self-rationing to consumers, or encouraging healthcare providers to actively and openly participate in bedside rationing. These proposals are evaluated based on their economic efficiency, fairness, and utility. The Oregon Health Plan is recommended among these proposals as it benefits the stakeholders through the explicit and equitable allocation of scarce healthcare resources.

Health Care Rationing↗

PubMed1995

Age-based rationing of health care.

The U.S. has focused attention on the rising costs of health care coincident with the increasing age of the population. Arguments have been made to overtly ration care to older persons; however, general acceptance of the need to ration scarce resources, whether or not such a policy is actually formalized, can lead to covert rationing. Some overt rationing has already occurred, some of the data put forth to justify that rationing needs to be challenged, and ethical principles need to be applied to provide appropriate and perhaps less costly care.

Age Factors↗

PubMed1996

[Cost control in public health by rationing--what are the advantages and disadvantages?].

In Germany, the discussion on the pros and cons of rationing health care services in the statutory health insurance funds has just begun, but it will probably be of great importance in the years to come. Until now, it is mainly a political discussion with only very few researches participating. In order to enhance the matter-of-factness in this controversial debate, the experiences in the USA with rationing health care services are summarised, and in the second part a more general discussion is added on different forms and consequences of rationing. The present discussion in Germany is outlined in the third part of the paper. In our own evaluation two arguments are stressed: Firstly, the central argument that rationing of health care services is inevitable because health care costs are "exploding", has as yeb no firm empirical and theoretical basis. Secondly rationing by taking medically useful benefits from the schedule of benefits in the statutory health insurance funds is not compatible with the ethical principles governing these funds.

Cost Control↗

PubMed2004

Comparison of rational pharmacotherapy decision-making competence of general practitioners with intern doctors.

OBJECTIVE: The aim of this study was to compare rational pharmacotherapy decision-making competency of interns (final-year medical students) who had received rational pharmacotherapy education (RPE), with their classmates at another medical school and general practitioners (GPs) who had not been exposed to RPE. DESIGN: A written, objective, structured clinical examination (OSCE), consisting of open and structured questions, was given to all participants. The participants were expected to make a treatment plan and prescribe for simple, uncomplicated beta-hemolytic streptococcal tonsillitis and mild-to-moderate essential hypertension patients, explain their proposed treatment plans and reasons affecting their drug choice. After the OSCE, a questionnaire to assess knowledge of the rational use of drugs was given to the participants. RESULTS: Fifty RPE(+) interns, 54 RPE(-) interns and 53 GPs participated in the study. Mean scores of RPE(+) interns were higher than those of GPs, which were in turn found to be higher than those of RPE(-) interns for all cases. The RPE(+) interns scored the highest regarding all components of rational pharmacotherapy process for all cases of both indications. However, participants in all groups had higher scores for the structured questions compared with the corresponding open ones for both diseases. Prescription analysis also revealed better results for RPE(+) interns regarding the number of drugs/prescription and treatment costs. CONCLUSION: The present study demonstrated that the final-year medical students (interns) markedly benefited from undergraduate RPE at the medical school in developing rational prescribing skills compared with their classmates from a medical school with traditional pharmacology education. Interestingly, they got higher scores than not only RPE(-) interns, but also than the GPs participating in this study, indicating the urgent need for continuous medical education programs in this field throughout the country for practicing GPs.

Decision Making↗

PubMed2005

The effect of combat rations on bowel habits in a combat environment.

BACKGROUND: Combat rations have long been suspected to affect the bowel habits of deployed soldiers by causing significant constipation. This may create morbidity and result in decreased troop readiness. In a uniform population of deployed combat soldiers, we sought to determine the effect of combat rations on changes in bowel habits. METHODS: Over a 4-month period from December 2001 through March 2002, 118 soldiers were followed prospectively using a bowel habit diary. Soldiers were evaluated by age, race, gender, past medical history, ration intake, and medications including fiber use. Subjects were then screened for changes in diarrhea and constipation. We performed an analysis to determine predictors for changing habits. RESULTS: There were 108 males and 10 females. Mean follow-up was 42.6 +/- 23.1 days. Groups were comparable in demographics, time in the combat zone, and fluid/fiber intake (P = not significant [NS]). No change in habits were found in 58%, 19% had an increase in constipation, 13% had an increase in diarrhea, and 10% had increase in both diarrhea and constipation, while 8% had improvements. CONCLUSION: Combat rations and environment have variable effects on bowel habits, with no loss in workdays. Although 64% of subjects experienced either no change or improvement, and 36% had worsened symptoms, this appears unrelated to ration or fiber intake.

Adult↗

PubMed2006

Rational design of polymerase inhibitors as antiviral drugs.

Almost all viruses have polymerases which are suitable targets for antiviral drugs. The development of selective polymerase inhibitors started with screening of compounds in virus-infected cell cultures and the mechanism of action was investigated once an inhibitor had been found. Especially nucleoside analogs were screened as their triphosphates were potential substrates for polymerases. However, the stepwise phosphorylation by cellular, and sometimes viral, kinases to the active triphosphate prevented a truly rational design of polymerase inhibitors. Nucleotide analogs offers a type of compounds which could be designed in a more rational way than nucleoside analogs since the first, most selective, phosphorylation step is eliminated in the path to the active inhibitor. The development of pyrophosphate analogs made rational design possible since these compounds act directly on the viral enzyme, but the room for structural variation was limited. The non-nucleoside HIV reverse transcriptase inhibitors are direct inhibitors and can thus be designed in a truly rational way by use of structure information on the enzyme-inhibitor complex by use of X-ray and NMR. This rational design of allosteric inhibitors is also being used in the development of inhibitors to other viral polymerases.

Antiviral Agents↗

PubMed2003

Rationality and social behavior.

This article penetrates the relationship between social behavior and rationality. A critical analysis is made of efforts to classify some behaviors as altruistic, as they simultaneously meet criteria of rationality by not truly being self-destructive. Newcomb's paradox is one attempt to create a hybrid behavior that is both irrational and still meets some criterion of rationality. Such dubious rationality is often seen as a source of altruistic behavior. Group selection is a controversial topic. Sober and Wilson (Unto Others--The Evolution and Psychology of Unselfish Behavior, Harvard University Press, Cambridge, MA, 1998) suggest that a very wide concept of group selection might be used to explain altruism. This concept also includes kin selection and reciprocity, which blurs its focus. The latter mechanisms hardly need further arguments to prove their existence. This article suggests that it is group selection in a strict sense that should be investigated to limit semantic neologism and confusion. In evaluation, the effort to muster a mechanism for altruism out of group selection has not been successful. However, this is not the end to group selection, but rather a good reason to investigate more promising possibilities. There is little reason to burden group selection with the instability of altruism caused by altruistic members of a group having lower fitness than egoistic members. Group selection is much more likely to develop in combination with group egoism. A common project is supported by incitement against free riding, where conformist members joined in solidarity achieve a higher fitness than members pursuing more individualistic options. Group egoism is in no conflict with rationality, and the effects of group selection will be supported rather than threatened by individual selection. Empirical evidence indicates a high level of traits such as conformism and out-group antagonism in line with group egoism. These traits are also likely candidates for behavior favored by group selection since they homogenize the group and link the different individuals closer to one another and a similar fate.

Altruism↗

PubMedDate not supplied

[The dynamics of the content of ammonia and volatile fatty acids in the rumen fluid during the use of dry feed rations in the cow].

The development of the pH-value, the molar quota of volatile fatty acids and of the NH3 content in the change from silage rations to dried rations on the basis of pelleted feed and in dependence on the time after the beginning of feeding was tested in studies of the rumen fluid of four cows in order to explain the causes of the very low NH3 content of the rumen fluid in feeding experiments with rations based on pelleted straw-concentrate mixtures. An influence of the ration type and the time after the beginning of feeding on the molar quota of the individual volatile fatty acids and the NH3 content was ascertained. The ration type tested can cause an NH3 content in the rumen fluid below 1 mmol/l.

Ammonia↗

PubMed1997

[Influence of the ration content on the fecal phosphorus excretion of growing bulls varying in body weight].

Five smaller (body weight: 227.9 +/- 23.7 kg) and large growing bulls (435.2 +/- 14.3 kg per animal) each were fed with rations rich (chopped wheat straw:concentrate = 1:1) or poor in roughage (straw: concentrate = 1:4). Animals were kept in balance cages; 20 days adaptation period were followed by 10 days collection period. Body weight of bulls did not significantly influence apparent digestibility of rations. digestibility of organic matter of fibre rich ration was significantly lower (66.8%) than those of concentrate rich ration (74.4%). Feeding and body weight did not significantly influence metabolic parameters of mineral status. The fecal P-excretion amounted to 0.94 and 1.08 g per kg DMI in bulls fed with rations rich and poor in roughage. No influence of body weight was measured. Feeding and body weight did not significantly influence fecal P-excretion per kg DOMI (between 1.44 and 1.58 g P/kg DOM). For calculation of P-requirements for growing cattle fecal P-excretion amounted to 1.0 or 1.5 g P/kg DM and DOMI, respectively.

Animal Feed↗

PubMed1997

[Glycerol supplementation in broiler rations with low crude protein content].

In connection with the utilization of glycerol, which could become available as a by-product of the fuel production from rapeseed the influence of glycerol feeding with rations of low crude protein content was proved. 61 male day old broiler chickens received ad libitum 8 experimental rations based on maize and soybean meal. The experimental design included 3 factors: 15 or 18% CP; supplementation of essential amino acids or not and a content of pure glycerol of 0 or 10%. During the experimental feeding of 23 days body weight gain, feed conversion ratio, N-balance and the intake and excretion of glycerol was obtained. At the end of the trial the utilization of 15N-methionine and the glycerol content of blood plasma, liver and breast muscle was estimated. Due to the low crude protein content of the rations the body weight gain and N-balance was very low (BWG day 1 to 23: 8.6 to 17 g/animal.d; N-balance day 19 to 23: 0.4 to 1.0 g N/animal.d). The supplementation of essential amino acids was the factor with the highest improving effect on the body weight gain, feed conversion ratio and N-balance. Especially at the begin of the trial animals which received 10% glycerol had have an increased feed intake. The excretion of the supplemented glycerol by excreta amounted to 26% of the intake. However, the glycerol content of the rations did not effect body weight gain, feed conversion ratio, N-balance or utilization of 15N-methionine significantly. The assumption of a saving effect on glucoplastic amino acids due to glycerol feeding could not be manifested. In the mean feeding of glycerol elevated the glycerol level in blood plasma in comparison to the basal level up to 23 times (from 0.6 to 13.6 mumol/ml) and in the breast muscle up to 19 times (from 0.4 to 7.5 mumol/g). Nevertheless, these values were lower than the basal level of glycerol in the liver (17.1 to 19.0 mumol/g), which was significantly increased by glycerol feeding to 128%. Regarding the utilization of glycerol as a by-product of the production of renewable fuels it can be concluded that on the basis of the estimated parameters 10% pure glycerol in broiler rations instead of corn starch is without adverse effects.

Amino Acids, Essential↗

PubMed1986

The concept of rational suicide.

Suicide has been condemned in our culture in one way or another since Augustine offered theological arguments against it in the sixth century. More recently, theological condemnation has given way to the view that suicidal behavior must always be symptomatic of emotional disturbance and mental illness. However, suicide has not always been viewed so negatively. In other times and cultures, it has been held that circumstances might befall a person in which suicide would be a perfectly rational course of action, in the same sense that any other course of action could be rational: that it could be sensible, i.e., defensible by good reasons, or that it could be in keeping with the agent's fundamental interests. Indiscriminate use of modern life-sustaining technologies has renewed interest in the possibility of rational suicide. Today proponents of rational suicide tend to equate the rationality of suicide with the competence of the decision to commit suicide.

Altruism↗

PubMed1986

Rationality in medicine: an explication.

Various meanings of "rational" implicitly and explicitly suggested in this issue's articles are abstracted and stated. Two accounts of rationality are shown to be able to explain most uses of "rational": the "cool moment" account and a more objective account. The former is examined and modified, but still found inadequate. The objective account of rational is developed, taking "irrational" as the basic concept. "Irrational" is given content in terms of a list, and "rational" is subsequently defined as "not irrational". Reasons and motives are defined and distinguished. The advantages of the objective account are explored and some challenges to it are answered.

Consumer Behavior↗

PubMed2005

Utilizing different ratios of alfalfa and layer ration for molt induction and performance in commercial laying hens.

Molting is a common practice used by the commercial egg industry to rejuvenate flocks for a second or third laying cycle. During this time the hens rest from production, and the reproductive organs are rejuvenated to increase production and quality during the next laying cycle. Although feed withdrawal (FW) is the most popular and effective method of molt induction, it has come under scrutiny due to food safety issues and animal welfare issues. This study involved feeding alfalfa mixed with layer ration at different ratios to hens to determine their ability to induce molt. The treatment ratios were 100% alfalfa (A100), 90% alfalfa and 10% layer ration (A90), and 70% alfalfa and 30% layer ration (A70). In addition, a fully fed (FF) nonmolted control and a FW negative control were used. Alfalfa is an insoluble, high fiber feedstuff with low metabolizable energy. Egg production for A90 and FW treatments ceased completely by d 6, whereas birds fed A100 and A70 ceased egg production by d 8. Ovary and oviduct weight of hens fed all molting diets decreased (P < 0.05) by an average of 1.5 to 2.5% (BW basis) compared with FF control during the 9-d molt induction period. As the percentage of layer ration increased, feed intake also increased and percentage of BW loss decreased during the 9-d molt induction period. Hens molted by FW lost an average of 25.8% BW, whereas A70 hens lost 18.9% BW. Nonmolted hens (FF) and A70 treatment hens had significantly lower (P < 0.05) egg production when compared with all other treatments over the 39-wk postmolt period. FF treatment hens also had lower (P < 0.05) albumen heights when compared with all other treatments. From these results, alfalfa or alfalfa mixed with layer ration appears to be viable alternatives to conventional FW methods for the successful induction of molt and retention of postmolt performance.

Agriculture↗

PubMed2006

Rational solitons in deep nonlinear optical Bragg grating.

We have examined the rational solitons in the Generalized Coupled Mode model for a deep nonlinear Bragg grating. These solitons are the degenerate forms of the ordinary solitons and appear at the transition lines in the parameter plane. A simple formulation is presented for the investigation of the bifurcations induced by detuning the carrier wave frequency. The analysis yields among others the appearance of in-gap dark and antidark rational solitons unknown in the nonlinear shallow grating. The exact expressions for the corresponding rational solitons are also derived in the process, which are characterized by rational algebraic functions. It is further demonstrated that certain effects in the soliton energy variations are to be expected when the frequency is varied across the values where the rational solitons appear.

Journal Article↗

PubMed1995

Quality assurance and the myth of rationality.

Examines the extent to which quality assurance can be conceived as a rational endeavour, particularly in ethical terms. Examines the Weberian distinction between rationality as values as an "end in themselves" and values conceived in terms of a "means-ends" distinction. While the emergence and existence of quality assurance can be viewed from either of these two perspectives, both entail a number of problems. Suggests that quality assurance, while appearing rational, fails at a crucial point for two reasons. First, while rationality is a relational concept, quality within the health service does not appear to function in such a manner; and second that quality assurance often neglects to evaluate its own activities. Claims that in both instances quality assurance acts more in terms of its functional role than in terms of its rationality.

Ethics, Medical↗

PubMed1993

Effect of rational and irrational statements on intensity and 'inappropriateness' of emotional distress and irrational beliefs in psychotherapy patients.

Ellis's rational-emotive theory postulates that since irrational statements augment emotional distress, replacing irrational with rational statements should lessen distress. This hypothesis was tested in the initial stages of psychotherapy by having 13 and 14 clinical out-patients respectively repeat for one minute either rational or irrational statements about their major presenting psychological problem. The distinction by Ellis & Harper (1975) that 'inappropriate' emotions differ qualitatively from 'appropriate' emotions was also examined. Although the experimental intervention had no effect on a post-test measure of irrational beliefs, patients repeating rational statements had significantly lower appropriate and inappropriate negative emotions at post-test, suggesting that inappropriate emotions do not differ qualitatively from appropriate emotions and that making rational statements may lower emotional distress in patients. Patients reiterating irrational statements showed no change in emotions, implying that these kinds of irrational cognitions may have already been present.

Adult↗