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PubMed2002

Disability versus futility in rationing health care services: defining medical futility based on permanent unconsciousness--PVS, coma, and anencephaly.

All societies must ration health care services in the face of unlimited demand. The concept of medical futility may appear to be an uncontroversial means by which to ration services. Depending upon how it is applied, however, limiting services based on alleged medical futility may violate prohibitions against disability-based discrimination. In particular, use of medical futility to require removal of life-sustaining interventions has been held to violate the Americans with Disabilities Act. The ADA protects both people with disabilities who are conscious and people in unconscious states, such as permanent vegetative state (PVS), coma, and anencephaly. Ultimately, as the number of people in permanently unconscious states increases, our society will have to recognize that consciousness is an essential characteristic defining human beings and determining whether a legal right to unlimited life-sustaining intervention should apply. This article proposes to define medical futility to preclude life-sustaining interventions after a stated period of permanent unconsciousness and to redefine the end of life consistently as neocortical death.

Anencephaly↗
PubMed2004

The effects of rational and experiential information processing of expert testimony in death penalty cases.

Past research examining the effects of actuarial and clinical expert testimony on defendants' dangerousness in Texas death penalty sentencing has found that jurors are more influenced by less scientific pure clinical expert testimony and less influenced by more scientific actuarial expert testimony (Krauss & Lee, 2003; Krauss & Sales, 2001). By applying cognitive-experiential self-theory (CEST) to juror decision-making, the present study was undertaken in an attempt to offer a theoretical rationale for these findings. Based on past CEST research, 163 mock jurors were either directed into a rational mode or experiential mode of processing. Consistent with CEST and inconsistent with previous research using the same stimulus materials, results demonstrate that jurors in a rational mode of processing more heavily weighted actuarial expert testimony in their dangerousness assessments, while those jurors in the experiential condition were more influenced by clinical expert testimony. The policy implications of these findings are discussed.

Adolescent↗
PubMedDate not supplied

The cost of rationing medical care by insurance coverage and by waiting.

This paper raises the question of the least-cost institutional mechanism to secure the value of certainty by reducing risk over the purchase of medical care. Two methods of reducing risk are evaluated: financing medical care with 'complete insurance', that is, ready access to medical care that is free at the point of purchase; and rationing by waiting time in a national health service that supplies a limited volume of medical care. The first system corresponds to the type of insurance held by most people in the United States, while the latter represents a stylized model of a national health service. The cost of over-utilization of services by insured consumers in the U.S. is substantial--larger on a per-family basis, and far larger for the nation, than the cost of under-utilization by those who lack insurance. The cost of rationing by waiting is estimated to be between $541 and $828 per family (in 1984 dollars). Thus, both systems involve costly mis-allocation of resources.

Actuarial Analysis↗
PubMed2001

Citizens, their agents and health care rationing: an exploratory study using qualitative methods.

This paper considers the application of the theoretical notion of a principal-agent relationship to societal health care decision making. Current literature sheds little light upon whether a citizen-agent relationship exists in health care, with ambiguity about whether citizens want agents to make rationing decisions on their behalf, and if so, who these societal agents might be. A qualitative approach, using semi-structured interviews as the main instrument of data collection and analysis by constant comparison, was used to explore these issues with groups of both citizens and their potential agents. The findings of the research suggest that citizens vary considerably in the extent to which they want to be directly involved in making rationing decisions. Important influences on this issue appear to be knowledge and experience, objectivity and the potential distress that denying care may cause. Agents, in contrast, view citizens as needing agents to make decisions for them and suggest that it is primarily the health authority's role to act in this capacity. It is, however, apparent that the citizen-agent relationship in health care is both imperfect and complex, with final decisions resulting from the interaction between the utility functions of the various actors in the health care system. In practice a system of equivocation can be envisaged in which different groups collude as they attempt to avoid the disutility associated with denying care, with the consequence that the impact of decisions taken on an explicitly societal or citizen basis may be relatively small.

Adult↗
PubMed1993

Rationing in The Netherlands: the liberal and the communitarian perspective.

In the discussion on rationing health care in The Netherlands, a fundamental tension emerges between two ethical perspectives: liberalism and communitarianism. A Dutch government committee recently issued a report opting for a community-oriented approach. This approach proves less communitarian as compared to the views on rationing elaborated by Callahan. Moreover, the community-oriented approach is conceptualised in such a way that it seems compatible with some basic aspects of the liberal account of a just society.

Advisory Committees↗
PubMed1999

Ethical issues in managed and rationed care for children with severe neurological disabilities: a questionnaire survey.

The attitudes of pediatric neurosurgeons to managed and rationed care for children with severe al neurological disabilities were surveyed as reflected in responses from International Society for Pediatric Neurosurgery (ISPN) members to a questionnaire. Of 399 ISPN members, 156 (39.1%) responded to the questionnaire. There were 15 questions, which were designed to explore what care is medically indicated, whether all medically indicated care should always be provided, and how this care should be managed or rationed. Most respondents agreed that these patients should receive the same level of medical care as a normally developing child. However, respondents felt that cardiopulmonary resuscitation (CPR) is not indicated if a child is not retrievable. Most respondents also felt that provision of care should be influenced by cost. The responses to the questions from ISPN members were compared with those from Child Neurology Society (CNS) members.

Adult↗
PubMed1998

[Cost-effectiveness--limits between optimization and rationing].

Although rationing is an important feature in the German health care system, this topic is not discussed in an explicit and structured way. Currently, most rationing decisions are not based on systematic data on costs and outcomes of diseases and medical interventions. A major task of future research will be to provide health policy makers with data on direct costs, indirect costs, effectiveness, and utility of medical interventions and to integrate these data into decision analysis models. Interdisciplinary work-groups should be set up, combining clinical and economic knowledge. On the other hand, official grants are needed to perform unbiased research in this field covering the various areas of medical care.

Cost-Benefit Analysis↗
PubMed1992

Scarcity in the intensive care unit: principles of justice for rationing ICU beds.

Difficult dilemmas arise when resources become scarce in intensive care units (ICUs). When there are fewer beds available than patients who need them, how are those beds to be distributed? In this report, I discuss such rationing dilemmas from the context of John Rawls' theory of justice. Principles of justice can be chosen by clinicians and used to set priorities in the distribution of scarce ICU beds. These principles consist of a ranking of patients based on available prognostic data. Such a ranking would be the most fair way of distributing scarce ICU beds within a Rawlsian conception of justice. It is a ranking that would be chosen by the patients themselves, were they able to consider the matter from a rational and impartial perspective.

Decision Making↗
PubMed1993

Queueing for coronary surgery during severe supply-demand mismatch in a Canadian referral centre: a case study of implicit rationing.

Queues for in-patient surgery are commonplace in universal health care systems. Clinicians and hospitals usually manage these waiting lists with informal criteria for determining patient priority--a form of implicit rationing. To understand the workings of implicit rationing by queue, we took advantage of a natural experiment in the Canadian province of Ontario. Unprecedentedly severe supply-demand mismatch led to long waiting lists for coronary surgery [CABS] in Ontario during 1987-88. The crisis was resolved by increased funding and widespread adoption of a multifactorial clinical index for patient priority that was developed by an expert panel in 1989. Thus, we audited randomly chosen charts of patients who underwent coronary angiography at four Toronto hospitals during the crisis period, and calculated urgency scores for each case based on the multifactorial index. From 413 charts, 193 eligible patients were identified who proceeded to CABS. Waiting times did correlate with urgency ratings (r = 0.42, P < 0.0001). However, mean wait from catheterization to CABS varied among hospitals by as much as 8 weeks (P < 0.0001 after controlling for urgency scores). At the hospital with shortest queues, waiting times were twice as long for patients catheterized by cardiologists off-site vs those referred by on-site practitioners (P < 0.0001, after controlling for urgency scores); a similar form of bias was found at a second coronary surgery centre (P = 0.056, after controlling for urgency scores). Over half the patients waited longer than the maximum suggested for their category by the expert panel.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiology Service, Hospital↗
PubMed1994

Discovering the right questions--our call to action--who will define health care rationing, and how?

Will the citizens and legislators of our country be accurately informed in enough detail to decide wisely on the proposed health care plans? If we cannot afford all health care for all people, how can we make the government use the words "rationing health care" and be certain that the rationing is done by the stakeholders (patients and providers)? Changes in the health care system are needed and it must be improved, but does that justify totally changing a system providing the best care in the world for 200 million people? Or should we build on and improve that which is good and extend it to the remaining 10-15% who are currently without insurance? Can the government guarantee good health? Does this imply we are to guarantee health, then food, and then housing and clothing? Or, rather, should we guarantee the right to pursue a job that allows the purchase of health care insurance, just as we have the right to purchase housing, food, and clothing? Can we guarantee health to our citizens, or must we guarantee the right to pursue good health? How much should we spend on health care? Is the health care industry a growth industry with the product a healthier population? If so, should it be punished or encouraged? Is what we spend out of line with what is spent on entertainment, tobacco, and alcohol? When viewed from that perspective is health care too expensive or a bargain? Will the individual citizen accept his/her individual obligation to change habits and lifestyle? Do the people of this country really want a health care service with the regulatory simplicity of the tax law, the frugality of the Pentagon, the efficiency of the Post Office, and the compassion of the IRS? To be consistent with the Vice President's efforts to downsize government should government involvement in health care be increased or decreased? Are the proper innovations underway on the state level? Is federal law necessary now at all, or should Washington just monitor the emerging new programs at the regional and state levels? If England and Sweden are backing away from socialism and starting to privatize, and if major cities in our own country are acknowledging governmental failure and inability to deliver cost-effective quality service for such simple things as trash collection and maintenance of park systems, how can our federal government run health care?(ABSTRACT TRUNCATED AT 400 WORDS)

Delivery of Health Care↗
PubMed1990

Rationing of health care and the end-stage renal disease program.

The potential impact of rationing health care on the end-stage renal disease (ESRD) program is considered. The possible implications of the recommendations emanating from the study being conducted by the Institute of Medicine of the National Academy of Sciences are also mentioned. Particular emphasis is given to the potential consequences of rationing health care on the elderly and on certain socioeconomic groups with ESRD.

Advisory Committees↗
PubMed1999

Rationing decisions: from diversity to consensus.

As rationing decisions become more of an immediate reality for healthcare practitioners it is important to design mechanisms that facilitate carefully deliberated outcomes. No individual can be expected to be able to cover wide debate on their own, so an exercise has been designed that helps generate consensus decisions from diverse opinions. The exercise was piloted with two groups, an undergraduate medical class and the members of a general practice. Though the aims were different for each group, the tool was useful to both for producing the desired outcomes. Expert and non-expert knowledge were drawn upon and rationing prioritisation lists regarding funding of infertility treatment were generated. A description of the exercise and the results produced by the two groups are provided, as well as the theoretical placement for the significance of forming consensus from diversity.

Consensus↗
PubMed1996

Implicit rationing criteria in non-small-cell lung cancer treatment.

Data collected from lung cancer patients attending the Victoria Clinic of the British Columbia Cancer Agency are used to investigate how resources are rationed in the treatment of non-small-cell lung cancer (NSCLC). An ordered logit model is estimated to analyse empirically the relationship between treatment selection and: tumour stage, size and differentiation; the Feinstein index; Karnofsky performance status (KPS); and the patient's age, gender and marital and smoking status. Implicit rationing is found to occur with respect to all of these factors except the Feinstein index, gender and marital status. With respect to age, KPS and smoker status the main empirical results are: (a) an increase in age from 50 to 85 reduces the expected treatment expenditure by 50-70%, depending on the patient's KPS and smoker status; (b) patients with a KPS less than 80 and of 80, receive 30-46% and 75-85%, respectively, of the expected treatment expenditure for patients with a KPS of 90 or 100, depending on age and smoker status; (c) the expected treatment expenditure for active smokers is about 71-86% of the expenditure for non- or former smokers depending on age and KPS.

Age Factors↗
PubMed1995

Health care rationing: nursing perspectives.

Ideas currently postulated around the way health care should be delivered and costs controlled, often referred to as health care rationing, are increasingly coming to dominate the agenda of health care in the 1990s. British nursing has yet to take a noticeably visible role in this debate, despite the fact that it poses a serious dilemma for a profession whose cultural ethos has been shaped by the concepts of universal access and comprehensiveness of care and is wedded to the idea of holism. In the USA debate amongst nurses is further advanced and whilst this discourse may be of limited value to British nursing, owing to a differing historical and cultural attitude to health care, recent changes to the organizational values in the NHS are leading to similar issues arising already faced by American nurses. This paper considers the broad parameters of the debate on health care rationing and examines how these parameters have been reflected within relevant North American and British nursing literature, pointing both to similar and differentiating factors between the two countries.

Beneficence↗
PubMed1989

Hypnosis and rational-emotive therapy--a de-stressing combination: a brief communication.

It has been suggested that teacher stress might be reduced through cognitive restructuring which is aimed at improving the rationality of their thinking. To test this hypothesis, 40 high school teachers were paired on their level of reasonable thinking, operationalized in terms of scores on the Teacher Idea Inventory (Bernard, Joyce, & Rosewarne, 1983), and allocated at random to one of 2 groups. They also completed the Face Valid Stress Test. The experimental group participated in 4 weekly treatment sessions involving a hypnotic induction and suggestions derived from key elements of Rational-Emotive Therapy. These focused on the reduction of what Ellis (Ellis & Grieger, 1977), the originator of this treatment, calls "irrational thinking." The control group spent the same amount of time discussing stress reduction methods. Both the Face Valid Stress Test and the Teacher Idea Inventory were re-administered at the end of this period and again 12 months after conclusion of the experiment. Results indicated that both the experimental and control groups significantly reduced their levels of irrational thinking and stress, although the former's improvement was more marked, particularly at the 12-month follow-up.

Combined Modality Therapy↗
PubMed1992

Justice and the moral acceptability of rationing medical care: the Oregon experiment.

The Oregon Basic Health Services Act of 1989 seeks to establish universal access to basic medical care for all currently uninsured Oregon residents. To control the increasing cost of medical care, the Oregon plan will restrict funding according to a priority list of medical interventions. The basic level of medical care provided to residents with incomes below the federal poverty line will vary according to the funds made available by the Oregon legislature. A rationing plan such as Oregon's which potentially excludes medically necessary procedures from the basic level of health care may be just, for the right to publically-sponsored medical care is restricted by opposing rights of private property. However, the moral acceptability of the Oregon plan cannot be determined in the absence of knowing the level of resources to be provided. Finally, Oregon to date has failed to include the individuals being rationed in discussions as to how the scarce resources are to be distributed.

Adult↗
PubMed1994

Publicity and pricelessness: grassroots decisionmaking and justice in rationing.

The "grassroots turn" in bioethical discussions about justice in allocation of health care resources has attracted a great deal of support; in the absence of a convincing theory of justice in rationing, democratic decisionmaking concerning priority setting emerges with a kind of inevitability. Yet there remain suspicions about this approach--most importantly, worries about the socially corrosive impact of explicit, public decisionmaking that in effect sets a price on the lives of persons. These worries have been quieted, particularly by the work of Leonard Fleck, but not altogether stilled. I explore more sympathetically the ideals to which concerns about public rationing somewhat dimly respond, and suggest constraints on priority setting discussions which might accommodate those ideals rather better.

Community Participation↗
PubMed1995

Decisions not to transplant: futility or rationing.

Since the 1980s, heart transplantation has become an acceptable treatment therapy for patients with end-stage congestive heart failure. In recent years, the demand for heart transplantation has exceeded the supply of available organs. Potential transplant candidates undergo rigorous screening to determine which patients will be offered transplantation as a treatment option. Heart transplant recipients are selected based on a determination of which patients will experience an improvement in symptomatology, functional class ability, and life expectancy after transplantation. Refusal of transplantation for an individual patient is usually framed in a futility argument: Either transplantation will not benefit the patient or the risks involved in undergoing the transplant are considered to outweigh the benefits. However, futility is an elusive and ambiguous concept. Furthermore, although authors, clinicians, and ethicists argue for the separation of futility and rationing issues, clearly it is not always possible to do so. The purpose of this article is to argue that many decisions to refuse heart transplantation are actually based on the rationing of organs and not on futility.

Ethics, Medical↗