Health care technology and the inevitability of resource allocation and rationing decisions. Part II.
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Lewis and Charny have come under siege for suggesting remote questioning to decide appropriate medical care. While the criticisms are theoretically valid, the idea is so important practically that Lewis and Charny should be supported and their approach investigated as a way of making medical treatment at least more open and possibly more fair.
The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.
The paper analyses the factors involved in a series of decisions by the Newcastle Area Health Authority concerning the future of one of its hospitals, as an illustration of the way in which choices about priorities in the health service are actually made. There is no easy way to resolve the various conflicts of interest, notably in this case the competing demands of acute and chronic medicine. Difficult decisions are made more difficult, however, by the over-rigid division of medicine into compartments, by mistrust between the medical profession and administrators, and by the inordinately long time-scale of the decision-making process. It is suggested that there might be value in acknowledging explicitly that occasional examples of 'heroic medicine' must not be allowed too much influence in shaping public expectations. The paper results from the deliberations of a working group on current medical-ethical problems, set up under the auspices of the Northern Regional Health Authority (I).
Even though there is substantial pressure on physicians to significantly reduce the amount of public monies spent on geriatric health care, it is improper for physicians to let financial concerns take precedence over their obligations to care for the patients who seek their services and assistance. The doctor/patient relationship demands that the physician be faithful to the cause of meeting the needs of patients. This faith is kept by taking all necessary steps to respect and promote the autonomy of patients. This is best done by adhering to a commitment of pursuing a process of communication with patients that leads to the attainment of informed consent or refusal from patients. Two consequences likely to follow are protection of many patients from protracted, miserable deaths because of less use of invasive medical procedures, and subsequent financial savings from this lower degree of use.
The increasing complexity of health care systems in Europe, the financial limits of the public sector one hand, and a political consensus in favour of equal accessibility to services on the other, are at the origin of a widening gap between "individual" ethics (i.e. of health care professionals) and societal ethics. An additional conflict is that between equal accessibility and operational and distributive efficiency.
The decision that a particular intervention is not clinically indicated may conceal two quite different ethical assumptions. The first assumption is that the intervention is not of overall benefit to this patient. The second is that limited resources should not be used for this patient. These issues are discussed with reference to cardiac surgery in elderly patients with reference to the main theories of allocation: QALYs, needs theories, the sanctity of life theory, the lottery theory, and market forces.
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This paper addresses the question of the most appropriate theoretical account of the phenomena of orienting and habituation. Several lines of evidence are reviewed. First, it is argued that the effects of stimulus omission require a comparator theory in which it is asserted that responses to iterated events result from a comparison between predicted and actual stimulus input. Second, the data from studies in which paired stimulus events are employed seem, at least at first sight, to be best explained in terms of a comparator theory in which a key role is ascribed to associative processes. Third, secondary task probe reaction time data indicate that events that elicit orienting also command processing resources, and that habituation involves changes in the manner in which events are processed. Finally, recent data on the effects of intermodality change indicate that electrodermal responses are larger on the change trial than on the first habituation training trial; these results seem problematical for noncomparator theories. However, other data on the context-specificity of habituation and on the effects of stimulus miscuing cast doubt on the usefulness of an associative analysis as a general account of habituation phenomena. Nevertheless, the weight of evidence seems to indicate that an adequate theory of human habituation must include a comparison process and must acknowledge that orienting and habituation involve a re-allocation of attentional resources.