by Carolyn N. Kinder
Rationing organ transplantation has been a difficult process as it relates to justice or fairness. Rationing is a major concern because it adds a burden when allocating the already insufficient supply of organs for life-saving transplantation. However, justice is not the only issue, since allocating large resource commitments to people who are real sick, may not be efficient in producing good, because they are too sick to benefit from it. We must decide not only what is just, but also what is the right decision in producing justice, good health outcomes, and other unpredictable situations.
Some of the considerations based on other principles are deontological in character. Deontology ethics place emphasis on autonomy, justice and kind acts. This principle does not focus directly on the good consequences. In other words, you must never act wrongly in order to bring about good consequences. According to this ethics, one must treat every person as an end, and never as a means. As we deal with others we are to realize that they have their own goals, aims, and projects. We should not treat people as if they do not count, or exist to fulfill our purposes. The emphasis is on moral rules and duty. Its strength is providing a special status for humans.
In the formula for rationing, ethical resource allocation concerns who should get what kind of care when. We must consider how to get the maximum utility possible to service the general welfare of the society. Embedded in this notion is if there is enough utility to the group, the rights of individuals can always be sacrificed. In this case the right being sacrificed is an entitlement right, the right to the resources needed to have an opportunity for equality of well being as much as possible. In other cases the right may be a liberty right, for example, the right to refuse medical treatment (7).
The only solution to the huge gap between the number of organs available for transplantation and the number of patient waiting is to increase the number of suitable donors. Many potential donors are victims of accidents and violent crimes, and should indicate donor status in advance. In addition, the shortage of kidneys for organ transplantation has led to some unethical ways. Organ donors are selected from prisoners, street children, and brain damaged patients as a means of increasing the supply.
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For example, it has been proposed in the form of legislation that prisoners
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be allowed to donate organs and or tissues. Much of the legislation targets
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prisoners on death row. Some states legislatures in the U.S. haveinvestigated
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the possibility of condemned prisoners trading a kidney or bone their marrow for reduction
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in their sentence from death to life in prison (8).
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In Europe, one proposal is that all reasonable compassionate persons want their organs to be used to save others’ lives. Their organs would be automatically removed on their demise. However, those individuals who are not compassionate, would be allowed not to register their dissent.
In another proposal, it has been a mandatory universal declaration requiring all adults to at least register their wishes one way or another. This allows for a high degree of self-determination, but by requiring a decision, it is speculated that persons would be in favor of the donation. This is not the case in the U.S., neither presumed consent or mandatory declaration has been widely received as a solution to the critical organ scarcity, and voluntary donation remains the policy.
Ethical Dilemma of Rationing Effective But Expensive Treatments
One problem common to all health care systems is making a decision on how ethical it is to provide expensive halfway medical inventions. Managed care organization must make difficult decisions about health issues and who receive care. These decisions will affect everyone and money spent on one group or another.
Biotechnology has assisted in the creation of a variety of treatments that do not cure but allow individuals to live their lives with chronic but manageable conditions. For example, kidney dialysis is a technology that does not cure the disease, but allows a person to live by cleansing the blood of patients with a machine.
Halfway interventions are expensive. People who depend on halfway interventions live for a long time, and the cost of care increases over time. The question is should people be denied expensive halfway interventions and be confronted with possible premature death? or should they be provided with treatment knowing that it will endanger the fiscal resources for the majority (9)?
Should People Be Denied Expensive Hallfway Interventions?
We must look at two sources of justice in analyzing whether or not people should be denied expensive halfway interventions. First, we must find out the effectiveness of these interventions and secondly, their ability to protect fair equality of opportunity.
First, people with chronic kidney disease are given halfway interventions. They are given kidney dialysis, a technology that cleanses the blood so that the patient can live. Although, this intervention is effective in allowing people to live longer, they may have a low quality of life. People who have kidney disease and relevant need are not denied dialysis, regardless of limited public resources or whether they benefit or not. Managed care organizations will pay for kidney transplants, but do not pay for other major organ transplants (10).
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However, this is not the case with HIV or other diseases. The drugs given to HIV patient are highly effective. In addition, there have been widespread reports of improvements in quality of life with patient who has HIV. Many have enjoyed the happiness of a normal life. It would be unjust to deny an individual life, liberty and the pursuit of happiness, if the possibility exists for better health (11).
Second, the capacity to protect fair equality of opportunity is key to understanding the demands of health care justice. Given the effectiveness of the HIV protease inhibitors, individuals would have a good case on the grounds that they should have protection of fair equality and opportunity to enjoy normal functioning and a better life. This is not to say that there is a cure for H.I.V (12).
However, several options might be available to the managed care organization
in formulating a health policy to protect fairness. These options will help ensure that diseases with a similar clinical and cost profile be rationed in an equitable way. Other drugs might become available to improve cancer and other diseases that might need to be taken on a regular basis. They too will have the option of a more general term to trade marginal expensive procedures to marginal inexpensive benefits later in life.
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Option # 1: Postpone making any decision for a year. The main argument
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in support of this option is that we do not want to waste money on very
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expensive medical technology that might offer more than short-term hopes.
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This will give enough trial time to see if the treatment is effective, but there
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may still be a question about just caring (13).
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Option # 2: Fund the medical technology only to the extent that competing
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managed care plans fund them. This may bring about corporate interest
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and raise moral issues. If there are large corporations that offer options with all
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the managed care plans in a specific location, then there would be a risk that the
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first managed care plan to offer coverage of the technology would attract a high
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percentage of individuals. This would be an unfair burden placed on the
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managed health care providers. In addition, the issue of right or wrong will be
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weighted (14)
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Option #3: Let plan members themselves decide what the policy ought
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to be by voting or another process. This would be a democratic procedure
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that allows for community to make public self-imposed rationing decisions
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(15).
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Option #4: Let plan physicians make the relevant moral and clinical de-
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decisions for individual patients on the basis of their best professional
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judgment. This option might bring to bear unlimited clinical autonomy
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as it relates to unlimited cost and unlimited inequities (16).
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Option #5: Let companies that have contracts with our managed care plan
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decide whether or not to have coverage for their employees on the medical
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technology. This option will shift the moral responsibility to others whose
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self-interest is likely to bring about unjust results (17).
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Option 6: Fund the medical technology for all patients who believe it is
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in their best interest that they get treatment immediately. This would be
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the most expensive option. Justice might be sadly compromised (18).
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Option 7: Fund the medical technology for those whom best current
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medical evidence suggests are most likely to benefit significantly. This
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option is a limited, non-ideal, just-enough option (19).
A just and caring health care system should leave enough space so that the requirements of a competitive business environment could accommodate medical advancement without threatening the long-term fiscal viability of the plan. (20).
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Should People Be Provided With Treatment Knowing That It Will Endanger The Fiscal Resources of the Majority?
Overall, people should be provided with treatment knowing that it will endanger the fiscal resources of the majority if there is flexibility making good rational decisions with the presumtion of (1) effectiveness and (2) ability to protect equality of opportunity. Each person life is valuable, and priority should be given to saving lives. Resources will always be limited and people are forced into competing for resources.
